Balfour et al.1 argued for balancing the risks and benefits of e-cigarettes, based on the value of e-cigarettes as cigarette smoking‒cessation aids for adult smokers. In particular, they cited our meta-analysis of e-cigarettes and smoking cessation2 to support their statement, “Other researchers have found regular and frequent e-cigarette use to be associated with increased smoking cessation, while infrequent use was not.”1(p1663)
Like the discussion by Balfour et al. of the health effects of e-cigarettes, including the effects of nicotine on children,3 this statement is a highly selective reading of our article.
Specifically, although it is correct that we found that daily e-cigarette use was associated with significant increases in cigarette cessation (odds ratio [OR] = 1.529; 95% confidence interval [CI] = 1.158, 2.019), we also found that nondaily use was associated with significantly less quitting (OR = 0.514; 95% CI = 0.402, 0.656). Most importantly, among all users, there was no significant association between e-cigarette consumer product use and quitting (OR = 0.947; 95% CI = 0.772, 1.160), the key conclusion in our article.
Balfour et al. ignored this primary conclusion and instead focused on criticizing our earlier meta-analysis,4 which was superseded by the new article2 that was based on more than twice as many studies and was specifically designed to address the limitations of the earlier work.
We did find that the randomized controlled trials of free e-cigarettes provided in smoking-cessation trials (often combined with counseling) were associated with increased cessation.2 As Balfour et al.,1 Samet and Barrington-Trimis,3 and we2 recognized, randomized controlled trials are relevant for assessing medicines, not consumer products. Indeed, Balfour et al. recognized, “Noteworthy is the lack of trials by e-cigarette manufacturers in pursuit of regulatory agency approval to use e-cigarettes for smoking cessation, likely reflecting the profitability of selling e-cigarettes as consumer products, rather than medicinal devices.”1(p1663) These randomized controlled trials are not, however, relevant to the US Food and Drug Administration Center for Tobacco Products’ decision of whether to authorize sale of e-cigarettes as consumer products in the United States.
Balfour et al. ignored our primary conclusions: “As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population” and, so, “E-cigarettes should not be approved as consumer products.”2(p.e1)
CONFLICTS OF INTEREST
The author reports no conflicts of interest.
REFERENCES
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