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E-cigarettes attract low risk adolescents to smoking, say researchers

BMJ 2017; 356 doi: (Published 24 January 2017) Cite this as: BMJ 2017;356:j368

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Re: E-cigarettes attract low risk adolescents to smoking, say researchers

Professor Hajek’s response is somewhat disappointing, firstly, as it is unreferenced, and secondly, as it contains statements which are arguably either erroneous or comfortably open to challenge and comment. For example, he states:

1) “the continuous decline in smoking shows that e-cigarettes are not expanding smoking.”

This is, unfortunately, erroneous. In the U.S. recent CDC data demonstrates an abrupt plateau, and if not, a small rise in the numbers of high school children smoking tobacco in this age group in 2015 (1). This data ceases, ostensibly at least, the continuous decline in smoking in this age group that Professor Hajek claims, and is, therefore, unusual enough to be both extremely noteworthy and concerned about. A sudden cessation in the decline in youth smoking rates could be caused by several factors, simultaneously, one of them being a transition from e-cigarettes to conventional cigarettes in the “at low-risk of starting smoking” youth population. There is a growing body of evidence to substantiate the existence of a “Gateway Effect”, though its population magnitude is difficult to precisely calculate (2).

2) “While some smokers find e-cigarette satisfactory and switch to vaping, . . .”

It appears, in fact, to be only a significant minority of e-cigarette users that successfully switch completely to vaping, with the majority either stopping using them altogether or continuing to use them alongside conventional cigarettes i.e. “Dual Use”: they are not currently the “Disruptive Technology” that some are claiming them to be (3). This should come as no surprise, as the strongest scientific efficacy evidence we currently have, the Cochrane Review Update of November 2016, to which Professor Hajek was a co-author, merely concludes that, at best:

“There is evidence from two trials that ECs help smokers to stop smoking in the long term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards.”

Crucially, furthermore, regarding “dual use”, which is the predominant use of e-cigarettes currently, as Professor Robert West puts it:

“ . . . I think as far as using an e-cigarette to reduce your harm while continuing to smoke is concerned there really isn’t good evidence that it has any benefit" (5)

Moreover, it has recently been proposed that one causative factor for the first recorded increase in U.S. tobacco consumption since 1973, which has been identified to have occurred in 2015, could be continued dual use by smokers that do not quit completely.

3) “. . . the majority of non-smokers who experiment with e-cigarettes only try them once or twice and virtually none progress to daily use.”

This is not because of low experimentation rates, but probably because of the inferior nicotine delivery from e-cigarettes compared to cigarettes (7), hence they are not “satisfying” or pleasant to the user.

Unfortunately, due to their comparative ease of use as a nicotine delivery device i.e. “Put it in your mouth . . . light it up . . . and your gonna get your fix . . .” (8), their complex scientific design to efficiently deliver nicotine to the brain in seconds (9), utilising hundreds of different additives to mask the products of combustion and “impact boost” the effects on nicotine (10), cigarettes are still proving, mostly, to be more “satisfying” (as Professor Hajek puts it) to users than e-cigarettes. Hence, again, most users currently either stop using e-cigarettes completely, or continue to dual use.

2) Wills TA. E-Cigarettes and Adolescents’ Risk Status. Pediatrics. 2017;139(2):e20163736
6) Wang et al. Morbidity and Mortality Weekly Report 2016; 65(48): 1357-1363

Competing interests: No competing interests

28 January 2017
David W Bareham
Specialist Respiratory Physiotherapist
Chartered Society of Physiotherapy
Lincolnshire Community Health Services, Louth County Hospital, High Holme Road, Louth, Lincolnshire, LN11 0EU