Unbalanced Authorship Cannot Produce Balanced Consideration of E-Cigarettes

I read with interest the analysis piece by Balfour et al., recently published in AJPH.¹ In this piece, the authors correctly invited a balanced consideration of e-cigarettes among their opponents and proponents. Yet in the introduction, they declared that “[m]any, including this article’s authors, believe that vaping can benefit public health, given substantial evidence supporting the potential of vaping to reduce smoking’s toll.”^1(p1662) This statement basically places all of the authors in the “proponent group.”

Although evidence is always the guide, balanced authorship can ensure a fair selection and interpretation of evidence, which I believe eluded this piece. An example of this unbalanced analysis of the evidence can be found in the authors’ discussion of the “gateway” potential of e-cigarettes, that is, e-cigarette use among adolescents leading to later cigarette smoking. Here the authors presented and discussed several studies for and against the gateway effect among youths. Yet, only studies suggesting a gateway effect were subjected to scrutiny by the authors in terms of their limitations, despite the fact that they were for the most part based on stronger longitudinal designs than the studies presented to refute the gateway effect.¹ They also ignored studies that addressed their critiques of the gateway effect—by having a longitudinal design, adjusting for other tobacco and substance use, and examining regular cigarette smoking rather than experimentation—and still revealed the same association (see, e.g., Osibogun et al.²).

Furthermore, the authors presented the “gateway” and “common liability” as alternative explanations to the association between e-cigarette use and later cigarette smoking, when in reality they are likely to be complementary.^3,4 As Eric and Denise Kandel put it, “Common factors will explain the use of drugs in general, and specific factors will explain why young people use specific drugs and do so in a particular sequence.”^4(p942) Regardless of the strength and interpretation of evidence for and against the gateway effect, the fact that studies challenging the effect were given a free pass relative to the close scrutiny of the gateway studies is telling. Finally, the authors’ dichotomy of adult smokers versus youth nonsmokers, whose interests need to be balanced, ignores the fact that adolescents are a vulnerable population—without much legal and political voice—who have nevertheless been thrown into the midst of this “social experiment of vaping” without their knowledge or consent.