0
Point and Counterpoint |

Rebuttal From Dr MiddlekauffRebuttal From Dr Middlekauff FREE TO VIEW

Holly R. Middlekauff, MD
Author and Funding Information

From the Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA.

CORRESPONDENCE TO: Holly R. Middlekauff, MD, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 LeConte Ave, CHS A2-237, Los Angeles, CA 90095; e-mail: hmiddlekauff@mednet.ucla.edu


FUNDING/SUPPORT: Dr Middlekauff is supported by the Tobacco-Related Disease Research Program Exploratory/Developmental Research Award [TRDRP-XT 320833] and the American Heart Association, Western States Affiliate, Grant-in-Aid [15GRNT22930022].

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has 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):585-586. doi:10.1378/chest.15-0541
Text Size: A A A
Published online

Drs Avdalovic and Murin1 raise an important question: What do we say to our patients and others who inquire about electronic cigarettes (e-cigarettes)? I disagree with their dogmatic stance that in the absence of definitive proof that e-cigarettes are safe, we must assume that they are not. The science indicates that a more nuanced response will best serve the health interests of these patients.

e-Cigarettes are not cigarettes at all, since they do not contain tobacco and they are not combusted. Essentially, they are a new form of nicotine inhaler. Failure to acknowledge this fact has led to an emotion-based, not evidence-based, response to e-cigarettes. Combustible-tobacco cigarettes have been, and remain, the number one preventable cause of heart disease and lung cancer, responsible for one-half million premature tobacco-related deaths each year in the United States, and 6 million worldwide. Despite evidenced-based campaigns for smoking cessation, smoking rates remain steady in the United States and are actually increasing in less affluent countries.

With this in mind, when a patient addicted to combusted-tobacco cigarettes asks about e-cigarettes, I would avoid dogmatic statements and instead offer cautious optimism that although we do not know everything about e-cigarettes, most indicators suggest that they are vastly safer than lethal tobacco cigarettes.2,3 e-Cigarettes may not be entirely harm-free, but they are comparatively safe, or “safe enough.” After all, the package insert for the US Food and Drug Administration (FDA)-approved Nicotrol inhaler, which delivers aerosolized nicotine, carries the warning of an increased incidence of bronchospasm, accelerated hypertension, and palpitations, but despite these warnings, Nicotrol was considered “safe enough” for FDA approval, and the medical profession was not alarmist. Being overly cautious or downright pessimistic about e-cigarettes could lead to the withholding of an imperfect yet preferable alternative to the continued use of toxic combusted-tobacco cigarettes. The Cochrane Review4 concluded that, “There is evidence from two trials that e-cigarettes help smokers to stop smoking long-term…help [smokers] to reduce cigarette consumption…[and] No evidence emerged that short-term e-cigarette use is associated with health risk”; of course, the evidence is incomplete, and studies are ongoing.

On the other hand, in response to a curious nonsmoker who believes e-cigarettes are safe and is considering using them, my response would be, “Don’t.” Although e-cigarettes are much preferable to toxic tobacco cigarettes, they do, like tobacco cigarettes, contain nicotine. Nicotine is not the cause of heart disease or lung cancer, but it is a powerfully addictive drug. e-Cigarettes also contain small quantities of other compounds that remain undefined, since e-cigarettes are currently unregulated by the FDA.

In fact, the current lack of FDA regulation of e-cigarettes, including their manufacture, marketing, and distribution, is probably the greatest public health issue regarding e-cigarettes upon which we, as health advocates, should act. Rather than demanding an all-out ban on e-cigarettes reminiscent of the ill-fated prohibition of alcohol, we should actively support regulation. For example, opportunities to respond to the FDA’s requests for comments on its proposal to deem e-cigarettes subject to FDA regulation should not be wasted.5 Similarly, we owe it to patients to explain carefully the complexities of the current controversy surrounding e-cigarette use, allowing patients to make informed decisions based on the available science.

Acknowledgments

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Avdalovic MV, Murin S. Point: does the risk of electronic cigarettes exceed potential benefits? Yes. Chest. 2015;148(3):580-582.
 
Zeller M, Hatsukami D; Strategic Dialogue on Tobacco Harm Reduction Group. The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US. Tob Control. 2009;18(4):324-332. [CrossRef] [PubMed]
 
Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf. 2014;5(2):67-86. [CrossRef] [PubMed]
 
McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12:CD010216. [PubMed]
 
Food and Drug Administration. Deeming tobacco products to be subject to the federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act: regulations on the sale and distribution of tobacco products and required warning statements for tobacco products: proposed rule. Fed Regist. 2014;79:23141-23207.
 

Figures

Tables

References

Avdalovic MV, Murin S. Point: does the risk of electronic cigarettes exceed potential benefits? Yes. Chest. 2015;148(3):580-582.
 
Zeller M, Hatsukami D; Strategic Dialogue on Tobacco Harm Reduction Group. The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US. Tob Control. 2009;18(4):324-332. [CrossRef] [PubMed]
 
Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf. 2014;5(2):67-86. [CrossRef] [PubMed]
 
McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12:CD010216. [PubMed]
 
Food and Drug Administration. Deeming tobacco products to be subject to the federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act: regulations on the sale and distribution of tobacco products and required warning statements for tobacco products: proposed rule. Fed Regist. 2014;79:23141-23207.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543