Balancing Risks and Benefits of E-Cigarettes in the Real World


We appreciate the assessment by Balfour et al. of the use, risks, and potential of e-cigarettes.1 

Although in our view they downplayed the literature on use among youths and what is known about the risks of these products, they correctly qualified what can be concluded from the current science on the benefits of e-cigarettes with words such as “may” and “potential.”

Various scientists will prioritize different aspects of the body of literature, including what they see as notable strengths and weaknesses of specific studies as well as the totality of the evidence, particularly when a systematic review approach is not employed. Here we raise a few additional key points.

We challenge the public health and scientific community to move away from characterizing scientists as “opponents” or “supporters” of e-cigarettes for three primary reasons.

First, many investigators believe that e-cigarettes have potential benefits for smokers in theory; what matters is how these products perform at the individual and population levels in practice and their effects on reducing tobacco-related disparities. These effects depend in large part on how the products are regulated and marketed.

Second, e-cigarettes comprise a heterogeneous class of products, and thus their short- and long-term harms and benefits are likely to vary according to device characteristics (e.g., power, modifiability, manufacturing quality), composition of the liquid (e.g., nicotine concentration, nicotine salt or base, flavor chemicals), how people actually use them, and how individual companies advertise and promote them.

Third, the “opponents/supporters” terminology highlights division rather than the many areas in which there is agreement. Most scientists would agree that balancing the risks and benefits of e-cigarettes for the individual cigarette smoker is critically important. Most would also agree that tobacco-naive youths should not start using e-cigarettes, not only because of concerns about whether they will go on to use cigarettes but also because of the unknown short- and long-term effects of e-cigarettes on health.

We agree also that much more needs to be done in the United States and in countries around the world to reduce the burden of combustible products quickly and decisively and to help smokers quit. However, highlighting e-cigarettes and harm reduction as the only solution disregards the critical utility of proven, established, science-supported interventions. We strongly encourage the scientific community to consider how e-cigarettes (in all of their heterogeneity of design and use patterns) perform in the real world when making conclusions about their effects and move away from the opponents/supporters false dichotomy.


Joanna E. Cohen’s effort in preparing this letter was supported by her professorship fund. Suchitra Krishnan-Sarin’s effort was supported by National Institutes of Health (NIH) grant U54DA036151. Thomas Eissenberg’s research is supported by the National Institute on Drug Abuse and the Center for Tobacco Products of the US Food and Drug Administration (FDA; award U54DA036105). Thomas J. Gould is supported by funding from the NIH (grants DA041632 and DA048166). Micah L. Berman receives funding from the National Cancer Institute (grant K07CA197221) and the American Heart Association. Also, he has received contract research funding from the Truth Initiative and the World Health Organization. Aruni Bhatnagar’s research is supported by the National Heart, Lung, and Blood Institute (grant HL120163). Lucy Popova receives funding from the NIH and the FDA (grants R01DA047397 and R01CA239308). Andy S. L. Tan is supported by funding from the NIH (grants R01CA237670, R21DA052421, 1OT2HL161568, R01DA054236, and R01CA224545). Eric Soule’s effort is supported by grant R15ES032138 from the National Institute of Environment Health Sciences, grant R21CA239188 from the National Cancer Institute and the Center for Tobacco Products, and grant U54DA036105 from the National Institute on Drug Abuse and the FDA. Pamela M. Ling receives funding from the National Cancer Institute (grants R01-CA87472 and R01-CA141661) and from the NIH and FDA (grant U54HL14712). She also receives grant funding from the Tobacco-Related Disease Research Program and the Truth Initiative. Richard O’Connor receives funding from the NIH and FDA (grants U54CA228110, P01CA217806, P01CA200512, R37CA222002, and R21ES030028).

Read full article here.

Joanna E. Cohen et al. – American Journal of Public Health – 2022-02-01.

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