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Point and Counterpoint |

Rebuttal From Drs Avdalovic and MurinRebuttal From Drs Avdalovic and Murin FREE TO VIEW

Mark V. Avdalovic, MD, MAS; Susan Murin, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine; and VA Northern California Health Care System.

CORRESPONDENCE TO: Mark Avdalovic, MD, MAS, Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis School of Medicine, 4150 V St, PSSB 3400, Sacramento, CA 95817; e-mail: mark.avdalovic@ucdmc.ucdavis.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(3):584-585. doi:10.1378/chest.15-0539
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We agree with many of the points raised by Dr Middlekauff.1 In comparison with traditional cigarettes it appears that electronic cigarettes (e-cigarettes) are less carcinogenic and their use in lieu of cigarettes would likely lead to less chronic cardiovascular and respiratory disease. In an ideal world, millions of traditional cigarette smokers would switch to the e-cigarette and the global burden of lung cancer, coronary disease, and COPD would dramatically decrease over time. Unfortunately, we do not live in an ideal world, and the dream that e-cigarettes will lead to a decrease in total tobacco consumption may be replaced with the nightmare that e-cigarettes may instead increase the total number of tobacco smokers. At the heart of the argument is the changing demographics of e-cigarette users. Although most states (though no federal laws) prohibit the sale of e-cigarettes to minors, e-cigarettes and nicotine solutions (many with enticing added flavors) are easily purchased online, and the age of the first time e-cigarette user is decreasing. A report from the California Department of Public Health stated that eighth and 10th graders now use e-cigarettes two times more than they do traditional cigarettes, 17% of 12th graders use e-cigarettes, and e-cigarette use among younger adults has tripled in the last year.2 The theoretical concern over e-cigarettes being a “gateway” to tobacco consumption is no longer theoretical, it is a reality. In fact, a recent study reported that 43% of teens using e-cigarettes had a positive intention to use traditional cigarettes in the future.3 Perhaps the best proof of e-cigarettes being a gateway for traditional cigarettes is the fact that “big tobacco” has gotten into the e-cigarette business in a big way.

Dr Middlekauff1 highlights the potential of e-cigarettes as a “clean nicotine delivery device” and draws a comparison with the US Food and Drug Administration-approved nicotine inhaler. A key difference is that the constituents of the nicotine inhaler were well characterized, and the devices had undergone safety and efficacy testing prior to marketing. Recent research reported in the New England Journal of Medicine demonstrated that the formaldehyde exposure from an e-cigarette was many times higher than that of a traditional cigarette, leading to a higher cancer risk specific to this known carcinogen.4 This is one of many studies that have called into question the safety of the e-cigarette aerosols, which are currently unregulated as to content, additives, and even nicotine concentration.

We completely concur with Dr Middlekauff that e-cigarettes should be required to meet product and safety standards and be subject to premarketing and postmarketing Food and Drug Administration testing. We would further add that promotion of these devices must be limited, and sales to minors strictly forbidden. Until such safeguards are in place and we have additional data on the health effects of both e-cigarette and dual e-cigarette/traditional cigarette use, it remains inappropriate to advocate for these devices.

References

Middlekauff HR. Counterpoint: does the risk of electronic cigarettes exceed potential benefits? No. Chest. 2015;148(3):582-584.
 
Chapman R. State Health Officer’s Report on E-Cigarettes: A Community Health Threat. Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2015.
 
Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2015;17(2):228-235. [CrossRef] [PubMed]
 
Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med. 2015;372(4):392-394. [CrossRef] [PubMed]
 

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References

Middlekauff HR. Counterpoint: does the risk of electronic cigarettes exceed potential benefits? No. Chest. 2015;148(3):582-584.
 
Chapman R. State Health Officer’s Report on E-Cigarettes: A Community Health Threat. Sacramento, CA: California Department of Public Health, California Tobacco Control Program; 2015.
 
Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res. 2015;17(2):228-235. [CrossRef] [PubMed]
 
Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med. 2015;372(4):392-394. [CrossRef] [PubMed]
 
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