Perhaps opinion articles do not require the sort of rigorous peer-review process required of other types of articles in NEJM.
Cobb and Abrams make it clear that they view the e-cigarettes as a medicinal product, aimed at performing the same function as FDA-approved "smoking cessation" treatments: weaning the user down and off nicotine altogether. However, the products were never intended to treat the disease of nicotine addiction. By providing a less hazardous source of sufficient nicotine, the devices serve as an acceptable replacement for inhaling deadly tobacco smoke.
Cobb and Abrams are either unaware of, or refuse to believe, research showing that some smokers will never be able to give up using nicotine without experiencing severe problems. When these smokers quit using nicotine, they experience persistent difficulties with memory, attention, and concentration. Many also experience mood impairments that are corrected only when they resume using nicotine. A major U.S. government study released in 2006 showed that fewer than 50 percent of people become symptom-free on antidepressants, even after trying two different medications.
So what exactly do Cobb and Abrams expect these people to do?
Becoming smoke-free by switching to an alternative such as an e-cigarette or smokeless tobacco will save their lives. Becoming abstinent from nicotine will destroy the quality of their lives without adding any health benefits. Decades of research in Sweden show that smokers who switch to snus (a spit-free type of smokeless tobacco) have the same health-adjusted life expectancy as smokers who quit nicotine use altogether.
The authors claim, "Smokers attempting to use e-cigarettes as quitting aids will most likely find them ineffective." The research says otherwise. Population surveys indicate that electronic cigarettes are much more effective than currently available smoking cessation treatments. Heaver et al. surveyed over 300 e-cigarette consumers and found that 79% were using the e-cigarette as a complete replacement for smoking, 17% had significantly reduced the number smoked, and only 4% still smoked as much as before. The most recent published survey by Etter and Bullen surveyed 3,587 subjects, median age 41, of which 2,850 used e-cigarettes with nicotine, and 112 used e-cigarettes without nicotine. Among 2,896 daily users, 2,234 (77%) no longer smoked at all, and the median duration of smoking abstinence was 152 days.
These statistics indicate that Cobb and Abrams are mistaken about e-cigarettes functioning as a bridge product that delays smoking abstinence. Contrast the e-cigarette success rates with the products being recommended by Cobb and Abrams. A comprehensive review of approved nicotine replacement therapy (NRT) products found a success rate of 7% at six months, which dropped to 5% at 12 months, and to 2% after 20 months.
All population surveys of e-cigarette users show that they tried pharmaceutical nicotine products in the past, multiple times, without lasting success. Cobb and Abrams want e-cigarette users to stop using the one thing that finally did work, and go back to products that never worked in the past. That recommendation is unsound, to put it mildly.
Cobb and Abrams seem to be stuck in a time-warp when it comes to e-cigarette safety. They keep bringing up the FDA’s 2009 testing without acknowledging any of the following facts:
- An approved nicotine patch contains the same amount of ‘carcinogens’ as the FDA found in e-cigarettes.
- A quantity of 0.01 ml of diethylene glycol is totally harmless.
- FDA found nothing at all harmful in the vapor.
More recent testing confirms the absence of substances that could endanger health. Zachary Kahn of U.C. Berkeley and Dr. Michael Siegel of Boston University School of Public Health reviewed 16 studies that comprehensively characterized the content of e-cigarette liquid and vapor and determined "few, if any, chemicals at levels detected in electronic cigarettes raise serious health concerns." They concluded, "a preponderance of the available evidence shows them to be much safer than tobacco cigarettes and comparable in toxicity to conventional nicotine replacement products."
If e-cigarettes are so ineffective, why do they work so well for so many people? If the products are as unsafe as Cobb and Abrams try to imply, how do they explain the fact that there have been no serious adverse events reported during the four years the products have been sold in the United States? Why do they prefer that smokers switch to products such as Chantix that has caused suicides, violent behavior, murders, and heart attacks, or to Zyban/Wellbutrin that is also linked to suicides as well as to seizures?
There is no evidence whatsoever that young people are using e-cigarettes as a starter product. The only isolated reports of someone under 18 trying the products have involved young smokers looking for a way to quit.