What are the respiratory effects of e-cigarettes?BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5275 (Published 30 September 2019) Cite this as: BMJ 2019;366:l5275
All rapid responses
The harm of e-cigarettes must be compared with the alternative for most users: continued tobacco smoking.
Gotts et al. show that e-cigarettes pose a risk to respiratory health. It is now clear that people who have never smoked cigarettes should not use e-cigarettes, and that those who do – approximately 0.5% of never smokers – should stop using them.
However, the great majority of regular e-cigarette users are current- or ex-smokers, most of whom are using e-cigarettes to cut down or used them to stop smoking completely. Therefore, the most relevant public health consideration is the harm of e-cigarettes compared with the alternative for most users: continued tobacco smoking. This requires a dispassionate look at and accurate reporting of the available evidence.
While cessation is not the focus of the review, the abstract misleadingly reports "their effectiveness as a smoking cessation intervention…[is] highly controversial". Yet, neither the Cochrane review or NASEM report on the topic are cited.[4,5] Even before the publication of a large RCT in the NEJM, which demonstrated that participants who were offered e-cigarettes had two-fold higher quit rates than those given nicotine replacement therapy, the NASEM report concluded “there is moderate evidence from randomized controlled trials that e-cigarettes with nicotine are more effective than e-cigarettes without nicotine for smoking cessation”. These findings are supported by two studies that used population data from the UK and US, published in the BMJ.[7,8]
The authors state that, “current knowledge of these effects is insufficient to determine whether the respiratory health effects of e-cigarette are less than those of combustible tobacco products.” Yet, they often report on the absolute harm of e-cigarette use, without the comparison with smoking. For instance, the authors include research showing that e-cigarette aerosol can contain the known carcinogens and toxicants acetaldehyde, acrolein, diacetyl, and formaldehyde. Yet they neglect various studies showing that these chemicals are present at far lower levels in e-cigarette vapour than in cigarette smoke, when used under realistic conditions.
There is also an omission of relevant research on biomarkers of toxicant and carcinogen exposure. This work is especially useful for assessing the effect of e-cigarette use on respiratory health because, unlike animal and cell models, these studies measure toxicant exposure among real-world e-cigarette users. This research shows that long-term e-cigarettes users have substantially lower levels of these biomarkers. In fact, they have similar levels to NRT-only users, including for metabolites of acrolein, a known respiratory irritant, and NNK, a potent carcinogen linked to lung cancer. This provides reassurance that, when compared with smoking, e-cigarette use puts one at far lower risk of developing lung diseases associated with inhalation of these toxicants.
Further research and monitoring of the possible health effects of e-cigarettes is essential but so also are accurate statements on comparative safety. Already, the majority of smokers in England believe e-cigarettes are at least as harmful as cigarettes, a declining proportion are using them to support quitting and a growing number attempt to quit without any aid. Each year, cigarettes kill 5.2 million of the 1.1 billion smokers worldwide, and another million die from second-hand exposure. Misleading statements about the comparative safety of e-cigarettes may not only influence policy in a way that is not supported by evidence, but may also deter people who have struggled to stop smoking deadly cigarettes from using an effective method at helping them quit.
1. Gotts JE, Jordt S-E, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019;366:l5275. doi:10.1136/bmj.l5275
2. McNeill A, Brose LS, Calder R, Bauld L, Robson D. Vaping in England: An Evidence Update February 2019. London; 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploa....
3. Action on Smoking and Health. Use of E-Cigarettes (Vaporisers) among Adults in Great Britain.; 2019. https://ash.org.uk/information-and-resources/ash-fact-sheets/. Accessed October 24, 2019.
4. Stratton K, Kwan L, Eaton D. Public Health Consequences of E-Cigarettes. (Eaton DL, Kwan LY, Stratton K, eds.). National Academies of Sciences (US); 2018. doi:10.17226/24952
5. Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead L, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016. doi:10.1002/14651858.CD010216.pub3
6. Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of E-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779
7. Zhu SH, Zhuang YL, Wong S, Cummins SE, Tedeschi GJ. E-cigarette use and associated changes in population smoking cessation: Evidence from US current population surveys. BMJ. 2017;358. doi:10.1136/bmj.j3262
8. Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ. 2016;354:i4645. doi:10.1136/bmj.i4645
9. Farsalinos KE, Gillman G. Carbonyl Emissions in E-cigarette Aerosol: A Systematic Review and Methodological Considerations. Front Physiol. 2018;8:1119. doi:10.3389/fphys.2017.01119
10. Chang CM, Edwards SH, Arab A, Del Valle-Pinero AY, Yang L, Hatsukami DK. Biomarkers of Tobacco Exposure: Summary of an FDA-Sponsored Public Workshop. Cancer Epidemiol biomarkers Prev. 2017;26(3):291-302. doi:10.1158/1055-9965.EPI-16-0675
11. Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med. 2017;166(6):390. doi:10.7326/M16-1107
12. West R, Proudfoot H, Mohr G, Beard E, Brown J. Electronic Cigarettes in England - Latest Trends from the Smoking Toolkit Study.; 2019. http://www.smokinginengland.info/sts-documents/. Accessed October 24, 2019.
13. Gakidou E, Afshin A, Abajobir AA, et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1345-1422. doi:10.1016/S0140-6736(17)32366-8
Competing interests: No competing interests
Adolescents and Clinicians need appropriate and clear guidance on electronic cigarette (vaping) use and its potential benefits and harm to help them make the right decisions.
We thank The BMJ and Gotts and his colleagues for their timely important contribution to e-cigarette prevention (1). Even though e cigarette industry is aggressively advocating and promoting nicotine vaping as a safest tobacco cessation tool “few adolescents try to quit smoking using any sort of cessation aid or professional intervention and the efficacy of e-cigarettes in improving smoking cessation in youth is equivocal”(2).
It is interesting to know even reputed medical journals (3) have explicitly stated that there is growing evidence to support e-cigarettes and their effectiveness and safety for smoking cessation and harm reduction, and unfortunately these statements does not reflect the current best evidence and the efficacy of e-cigarettes for successful smoking cessation is inconclusive (4, 5).
We certainly agree that these inconsistent conclusions reflect uncertainty about the long term health effects of e-cigarettes, their effectiveness as smoking cessation agents, and their effect on children (1). Moreover, industry funding is strongly associated with finding no harm of e-cigarettes, compared with studies without a potential conflict of interest (1).
We strongly believe that the enthusiasm for a new therapeutic tool for tobacco addiction needs to be supported by best evidence. Despite lack of evidence of effectiveness, some clinicians are, in fact, advising smokers to use them (6). Also, many clinicians feel that they lack sufficient knowledge about the e-cigarette and express interest in learning more (6).
Therefore, the physicians need evidence-based information (in straight forward simple language) to help them appropriately address e-cigarettes in primary care (7, 8. 9). It is crucial that the British Medical Association (BMA) provides clinicians with evidence-based guidance on e-cigarettes (1).
It is also true that many adolescents face tough choices regarding tobacco, alcohol and drug use due to peer pressure and lack of accurate information. Adolescents need appropriate and clear guidance on electronic cigarette use and its potential benefits and harm to help them make the right decisions. Empowering adolescents to embrace healthy behaviors is very significant and we believe it is an important social responsibility. We thank The BMJ for continued advocacy in support of the adolescent health and well-being (1). Getting adolescents involved in this prevention program is crucial and the key to success.
We urge The BMJ to take a leadership role in a world-wide comprehensive school prevention program. We could perhaps tailor e-cigarette prevention programs similar to the old combustible cigarette prevention education programs. We need an effective social media campaign to enhance adolescents’ knowledge about the ingredients in e-cigarettes, their potential adverse effects and the known health hazards of prolonged use and misuse. There also needs to be a strong public education and awareness campaign to counter common myths and misconceptions (e.g., like e-cigarettes are a therapeutic tool).Comprehensive global prevention programs targeting adolescents are urgently needed. They need to be launched with the collaboration of schools, school boards, school administrators, parents, caregivers and youth organizations.
It is urgently needed to introduce a brief online training module as part of continuing medical education (CME) on how to use every opportunity of “teachable moments in the respective clinical practice”. “Teachable moments” has been commonly described as an opportunity to facilitate education and patient behavior change. Every clinical visits potentially could be an instance of a ‘‘teachable moment’’ to help educate young patients with vaping related potential serious health problems and motivate behavioral change. It is important that the training module should develop in consultation with the World Medical Association as well as the BMA. It is also important to involve adolescents in the process. Educational tool may be designed taking in to consideration of the context of interactive clinical scenarios.
(1). Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019 Sep 30;366:l5275. doi: 10.1136/bmj.l5275. Review.
(2). Wolfenden L, Stockings E, Yoong SL. Regulating e-cigarettes in Australia: implications for tobacco use among young people. Med J Aust 2017; 208 (1):1. || doi: 10.5694/mja17.00787
(3). Warner KE, Schroeder SA. FDA's Innovative Plan to Address the Enormous Toll of Smoking. JAMA. 2017 Nov 14;318(18):1755-1756. doi: 10.1001/jama.2017.14336.
(4). Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG. A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med. 2018;14;378(24):2302-2310. doi: 10.1056/NEJMsa1715757.
(5). Hartmann-Boyce J, Begh R, Aveyard P. Electronic cigarettes for smoking cessation. BMJ. 2018;360:j5543.PubMedGoogle ScholarCrossref
(6). Steinberg MB, Giovenco DP, Delnevo CD. Patient-physician communication regarding electronic cigarettes. Prev Med Rep. 2015; 2;2:96-8. doi: 10.1016/j.pmedr.2015.01.006. eCollection 2015.
(7). Doescher MP, Wu M, Rainwater E, Khan AS, Rhoades DA. Patient Perspectives on Discussions of Electronic Cigarettes in Primary Care. J Am Board Fam Med. 2018;31(1):73-82. doi: 10.3122/jabfm.2018.01.170206.
(8). Pepper JK, Gilkey MB, Brewer NT. Physicians' Counseling of Adolescents Regarding E-Cigarette Use. J Adolesc Health. 2015;57(6):580-6. doi: 10.1016/j.jadohealth.2015.06.017.
(9). Bandara NA, Mehrnoush V. E-Cigarettes, Incentives, and Drugs for Smoking Cessation.N Engl J Med. 2018 Sep 6;379(10):991. doi: 10.1056/NEJMc1809349.
Competing interests: No competing interests
The “vaping associated respiratory syndrome”  is a new phenomenon that needs further research and rethinking. Prima facie it seemed that, being devoid of tar and other noxious components of the tobacco qualm, e-cigarettes would be not carcinogenic and less harmful for the airways than combustible cigarettes. The argument in favour of the use and sale of e-cigarettes is simple: they are safer than cigarettes, and, potentially, they can help smokers to quit . As a stress coping strategy, an e-cigarette seems to be preferable to other tobacco products and, in some circumstances, to an alcoholic drink . The fact that e-cigarettes are promoted by the tobacco industry does not necessarily mean that they are harmful. Excessively restrictive policies on e-cigarettes up to prohibitions in some countries are hardly justified.
A significant disadvantage of e-cigarettes is a potential relapse of the nicotine dependence i.e. that some former smokers would restart, which might be associated with cardiovascular and other health risks especially for aged individuals. Moreover, e-cigarette use among young people is a risk factor for subsequent initiation of combustible cigarettes . For people with nicotine dependence combined with chronic respiratory diseases, a change from tobacco smoking to e-cigarettes may be favourable bearing in mind the final goal of smoking cessation .
1. Gotts JE, Jordt S-E, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ 2019;366:l5275.
2. Allwood B. Electronic cigarettes: The potential benefits outweigh the risks. S Afr Med J 2013;103(11):883.
3. Jargin SV. Re: Big Tobacco lights up e-cigarettes. BMJ Rapid Response 03 June 2013 https://www.bmj.com/content/346/bmj.f3418/rr/648280
4. Jargin SV. Electronic cigarettes: pros and cons. Ukrainian Med J online 2017 (in Russian) https://www.umj.com.ua/article/112422/elektronnye-sigarety-plyusy-i-minusy
Competing interests: No competing interests
Letter to the Editor,
In view of the deleterious effects noted by Gotts et al., one wonders why Public Health England continues to promote the usage of e-cigarettes to help smokers of cigarettes quit.
We in the healthcare profession are bound by the ethical principle of Do No Harm. Given the evidence presented in this review, using e-cigarettes to stop smoking introduces new unintended negative health consequences, not only those mentioned in the article, but possibly a new form of addiction which there is no known evidence-based means for e-cigarette cessation.
There are currently various means of helping cigarette smokers quit without the added risks mentioned in the article. The usage of nicotine replacement medications or other non-nicotine medications couples with effective counselling can greatly increase success in cessation of cigarette smoking without smokers adding to the list serious adverse risks of diseases mentioned in your article, including a new addiction.
Public Health England should reverse its decision because of the harm we now know and probably continue to discover as we navigate through this new industry induced world-wide epidemic.
Not only will we experience health related negative consequences due to the introduction of this novel technology, but we may have inadvertently introduced a new addiction –vaping - which presently there is no known evidence-based cessation methods to help those who are considering stopping vaping. It may turn out that vaping is much harder to stop, which, I believe, was not properly considered by those who advocate e-cigarettes as means of cigarette harm reduction intervention.
Competing interests: No competing interests