Any dispassionate appraisal of e-cigarettes must acknowledge that much more is unknown than known—most of the iceberg remains underwater.
However, despite all this uncertainty, some have rendered global and fairly Manichean pronouncements regarding the threats and benefits of e-cigarettes. Unfortunately, we are largely ignorant not only about the effects of e-cigarettes, but also about the long-term consequences of such public pronouncements. Black and white perspectives on e-cigarettes were clearly manifest in the divergent reactions to the electronic cigarette and vaping product–associated lung injury crisis of 2019,1 reactions that often preceded meaningful evidence.
What are some of the fundamental questions that we cannot answer with confidence?
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What will be the fate(s) of the dual users of e-cigarettes and cigarettes in terms of cigarette cessation, ultimate return to exclusive smoking, and smoking reduction? And what are the health consequences of long-term dual use relative to exclusive smoking and complete abstinence?
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How will more restrictive access policies to e-cigarettes affect youth uptake of these products? How will the use of e-cigarettes by youth relate to future harms, including their prevalence of future cigarette use?
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How effective are e-cigarettes in increasing cigarette cessation and long-term abstinence in those making aided and unaided quit attempts? How do they compare with the most effective Food and Drug Administration pharmacotherapies for cessation: varenicline and combination nicotine replacement therapy?2–4
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What are the effects of e-cigarette availability on population-based smoking quit attempt rates? Do they increase or discourage quit attempts? Does their use precipitate relapse back to smoking among individuals who had successfully quit combustible tobacco use?
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How will the public health effects of e-cigarette availability and use be affected by secular changes such as the recently enacted federal under-21 age ban on the sale of all tobacco products (including e-cigarettes)? If some e-cigarettes gain Food and Drug Administration approval for a harm reduction indication, how will this affect public health?
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How will e-cigarette products change over time and how will these changes affect public health? Could future e-cigarettes be developed that retain e-cigarette appeal but yield less compulsive use?
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How will rates of e-cigarette use be affected by the COVID-19 pandemic? Does e-cigarette use confer added risk for COVID-19 infection and complications?
Certainly, something is known about many of these topics. However, clearly too little is known to make definitive judgments. Modeling of outcomes can address such topics, but it would be based on fairly incomplete evidence.
Timothy B. Baker, Michael C. Fiore – JAMA Network – June 5, 2020.
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