A response to our critique of the WHO-commissioned report on e-cigarettes verifies all our concerns mentioned in the critique


By Dr Farsalinos

Yesterday, a response to our critical assessment of the WHO-commissioned report on e-cigarettes was uploaded in the University of California San Francisco (UCSF) blog. Unfortunately, I cannot follow this blog because I find the censorship (and inability to respond just because the blog moderators do not like a different opinion) insulting. However, I was informed by few people about this response, so I had a look.

The response, which is longer than our Addiction manuscript, raises several issues about the safety of electronic cigarettes. But if you search for the evidence presented, there are only 2 studies mentioned: 1. The paper by Kosmider et al., finding that under certain conditions and with certain liquid composition, it is possible that levels of formaldehyde and acetaldehyde exceed those of tobacco cigarettes. 2. The paper by Goniewicz and Lee, finding nicotine (but not TSNAs as stated in the response) in an experimental chamber within 1 meter away from vapor generation position, 2 minutes after the vapor was generated. The rest of the presentation is based on newspaper or electronic news-media articles, letters by attorney generals (as if they have the knowledge or expertise to judge the harmful potential of e-cigarettes compared to tobacco) and reports by various organizations. I forgot to mention the abstract from the latest European Respiratory Congress, showing the potential of e-cigarettes to induce asthma and emphysema in mice, although the author of the response failed to mention that the exact opposite findings were observed in humans. Of note, last year the same congress presented a study showing that elevation in exhaled carbon monoxide levels after e-cigarette use (P1053), which is simply impossible to happen.

The most important conclusion from this response is that it verified all our arguments and our concerns presented in the Addiction paper. There is something you will never find in the text of this response: comparing e-cigarettes with tobacco cigarettes (the only exception was in the Kosmider et al paper mentioned above). Ironically, this is exactly what the smokers want and need to know. Moreover, this response is not in reality addressing our critique simply because you will not find a single section in our paper where we support that e-cigarettes are harmless. On the contrary, the whole text is based on the relative harm potential compared to tobacco cigarettes, and we were very careful in our expressions: “…e-cigarettes potentially offer a much less harmful form of nicotine delivery”, “It is not clear whether use of e-cigarettes by adolescent smokers and non-smokers inhibits or promotes smoking”, “E-cigarettes tested so far deliver much lower levels of toxins than conventional cigarettes”, “…an understanding of the toxicology of these chemicals indicates a risk to users much lower than from tobacco cigarettes”.

It is not hard to understand that our approach was based on the comparative measure of harm from e-cigarette and tobacco cigarette use. This is usually avoided, not only in this UCSF-uploaded response, but in almost every report which has been constructed with the purpose of misleading the public. Why? Because it is easy to create confusion, by selectively presenting the potential adverse effects of a product without mentioning any potential benefits. Is it appropriate to inform smokers that the levels of carbonyls emitted from e-cigarettes can (under certain conditions) be similar to or higher than smoking, but to hide from them that exposure to nitrosamines is at levels similar to NRTs (>1000 times less than smoking) and that carbon monoxide and polycyclic aromatic hydrocarbons are infinitely lower (i.e. absent)? It is easy to intimidate smokers by saying that they will be exposed to lead (Pb) and nickel (Ni) from e-cigarettes, unless you tell them that even in extreme consumptions the levels are still lower compared to the permissible daily exposure from inhalational pharmaceutical products. Would any smoker ever try an oral smoking cessation medication if the only information provided would be that they can cause seizures, depression and suicidal ideation?

Of course we continue our research efforts because we need to learn more about e-cigarettes. Of course we are concerned about some issues, such as e-liquid composition (despite the lack of combustion and the absence of cured tobacco) and temperature of e-cigarette use (despite being almost 5 times lower than smoking), not because e-cigarettes may be more harmful than smoking but because we want to find ways to make e-cigarettes even less harmful than they currently are. This is what every smoker deserves, instead of being discouraged by selective (mis)presentation of science and evidence, with a polemic and falsely-alarming language. Obviously, every non-smoker also deserves to know that the e-cigarette is not a safe new habit for everyone to adopt but a tobacco harm reduction product. Some people were surprised that we had the courage to stand up against established associations, organizations and scientists, and were even more surprised that we did it through a peer-reviewed publication. In fact, our position concerning e-cigarettes is identical to the recommendation of the American Heart Association (AHA): “If a patient has failed initial treatment, has been intolerant to or refuses to use conventional smoking cessation medication, and wishes to use e-cigarettes to aid quitting, it is reasonable to support the attempt”. What AHA and other scientific associations fail (or avoid) to admit is that this group represents the majority of smokers.


P.S. Within this report, I saw a response from the author of the ASHRAE study about my comment. I will prepare a separate response to this.



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