An email originating from a senior journalist at a national newspaper reached me indirectly this morning. The newspaper had sent position statements from nine anti-vaping ‘experts’ asking someone (not visible to me) for a reaction to twelve ‘observations and opinions’ advanced by members of this group. The newspaper proposed to publish these in an article soon after. I thought it may help readers if I provided some responses to these twelve points myself.
I will refer to the nine activists mentioned in the email as ‘experts’ or the ‘expert group’, though not because I think they are experts. They are the following:
Professor Simon Capewell, Liverpool University (Professor Public Health and Policy) [spelt ‘Capeman’ in the email]
Professor Anna Gilmore, Bath University (Professor of Public Health and Director of Tobacco Control Research Group)
Professor Mike Daube, Professor of Health Policy, Curtin University, Perth, Australia and Director of the Public Health Advocacy Institute and the McCusker Centre for Action on Alcohol and Youth
Professor Stanton Glantz, Director Center for Tobacco Control Research and Education, California University
Professor Martin McKee, Professor of European Public Heath, London School of Hygiene & Tropical Medicine and former President of the Faculty of Public Health
Dr Gabriel Scally, President of Epidemiology and Public Health, Royal; Society of Medicine
Professor John Ashton, former president of public health at the Royal Colleges of Physicians and former president of UK Public Health
John Dicey, Global CEO Allen Carr’s EasyWay
Robin Ireland, former chief executive of the Health Equalities Group
If any of these individuals would prefer to distance themselves from any or all of the statements circulated by the newspaper and attributed to them, I would of course be happy to make that clear.
Update 2nd March: The Telegraph has published articles based on views drawn from this group. Not all the group above are quoted and not all the ‘observations and comments’ listed in the email made the cut but the broad thrust is the same.
What do experts think?
If curious readers would like a concise expert statement that takes a completely different view to the one sold to this newspaper, then this letter from 72 international experts to the WHO in October 2018, would provide a fair perspective.
What should a journalist watch out for?
Obviously, no self-respecting journalist or editor would wish to be played by an activist campaign agenda, so I draw the newspaper’s attention to the familiar tactics of opponents of e-cigarettes. To stay one step ahead of the bullshit produced in this field, a journalist can read my post: Ten perverse intellectual contortions: a guide to the sophistry of anti-vaping activists
According to the journalist:
The experts have offered the following observations and opinions which we intend to report
Is it just me, or does this seem like an unusual model of journalism? Do newspapers usually oblige campaigners with an unchallenged publishing platform for their fringe contrarian views, at least without payment? Or is this something else?
What next? Should we expect anti-vaxxers or climate change deniers to be granted uncontested column inches for their supposedly expert views?
The twelve “observations and opinions”
The newspaper apparently wants to publish these as arguments from authority, as if this group is so eminent that it need not justify its positions. That is simply absurd, as we shall see. The deliberate selection of these views would, in my view, also imply that the newspaper was standing behind their views – a form of editorial-by-proxy. While it would be accurately reporting the views of the individuals whose views it chose to present, such selective reporting would raise concerns about the newspaper’s broader commitment to accuracy.
Now let’s move on to look at the twelve ‘observations and opinions’ expressed.
1. E-cigarettes and heat not burn products are a “Trojan Horse” which allow tobacco companies to enter lucrative advertising and sponsorship deals in areas where they are banned for promoting cigarettes
This is a ridiculous statement. First, the e-cigarette market emerged from outside the tobacco industry and remains largely in the hands of non-tobacco companies. The heat-not-burn market is all tobacco companies by definition as these are tobacco products. In both cases, the aim of companies is to provide products that are alternatives to cigarettes and do much less harm – and that is unambiguously a good thing. It has nothing to do with marketing cigarettes. The case for advertising these low-risk products is very strong: it is the same as the case for anti-smoking advertising – to persuade people not to smoke.
In fact, advertising in this area is very tightly controlled and probably to the point of being counterproductive. Preventing the advertising of these newer products amounts to a regulatory protection for the incumbent cigarette trade.
The European Union Tobacco Advertising Directive, 2003/33/EC, bans most TV, radio, internet, press and other transboundary advertising, promotion or sponsorship that has the direct or indirect effect of promoting a tobacco product – so if the intent is to promote cigarettes, it is illegal in the EU in these media. In the UK, it is illegal to advertise cigarette brands on a non-cigarette product – so-called ‘brand-sharing’ (see Brand-sharing regulations, 2004) . Even where this is permitted, it may encourage smokers to try something new and less harmful through the connection with a familiar brand – so it is not even possible to argue that this would be bad if it happened.
Heat-not-burn advertising is treated in the same way as cigarette and other tobacco advertising in the EU. However, in Japan, where HnB advertising is not banned, there was a dramatic 27% decline in cigarette consumption between early 2016 and early 2018, largely attributable to the rapid uptake of HnB products. This worked because consumers knew about these new products.
E-cigarette advertising is tightly controlled under Article 20.5 of the Tobacco Products Directive, and can only be placed on fixed locations, like billboards or shops – it is banned on TV, radio, internet, magazines, press and publications etc. Even this limited form of fixed location e-cigarette advertising is subject to similar controls to the advertising of alcohol in the UK (i.e. controls on location, content, marketing claims made in ads).
E-cigarette and Heat-not-Burn advertising, to the extent that it is permitted at all, is exactly what it appears to be: adverts for alternatives to cigarettes. It really is not a Trojan horse for anything.
2. The tobacco companies are attempting to re-cast themselves as a champion of public health via initiatives such as Foundation for a Smoke Free World when in fact the new nicotine products simply create new markets for nicotine addiction and undermine progress in reducing tobacco use.
The primary reason that public health has taken a strong interest in tobacco control for six decades is because of the intolerable toll of cancer, cardiovascular disease and debilitating respiratory conditions like COPD – and countless other harmful effects – caused by smoking. These lethal conditions are overwhelmingly caused by smoke – the toxic products of combustion of burning dried and cured tobacco leaf. Products that are ‘smoke-free’ pose far lower risks to health – if any. The purpose of the FSFW is to support research that will inform a transition from smoked products to smoke-free products among those who still wish to use (or are dependent on) nicotine. This is a worthy goal and expressed in the objectives of the Foundation:
The purpose of the Foundation for a Smoke-Free World is to improve global health by ending smoking in this generation. Ending smoking means eliminating the use of cigarettes and other forms of combustible tobacco worldwide.
As we pursue this goal, we will also identify and provide support to address the unique needs of the developing world associated with global efforts to end smoking.
Our task is urgent. More than a billion people still smoke worldwide, and more than seven million smokers die each year.Foundation for a Smoke-Free World, About Us. [link]
What precisely is wrong with that?
The tobacco company that has supported this foundation, Philip Morris International, is engaged in an effort to change its business model from selling combustible to non-combustible products. It’s easy to dismiss statements by tobacco companies, but in this case, there is a compelling commercial logic to it. It is now technically achievable, given continuing advances in key technologies like batteries and vapour aerosol. In taking this approach, it is recognising what is likely to become a profound shift in consumer preferences. Oddly enough, consumers prefer not to die in agony from cancer or live in misery with COPD, but many do like smoking or mild recreational drug nicotine. The new products are a disruption to a long-established market based on the most harmful products. It should not be a surprise that companies should wish to get out of the ‘merchant of death’ business if they can make it work for customers and shareholders.
Despite widespread knowledge of the risks of smoking, around 1 in 7 Brits and around 1 in 4 EU citizens still smoke regularly. As smoking prevalence declines, it has tended to consolidate in poorer groups in society or those with mental health problems or other substance use issues. These groups find it harder to quit smoking. So smoke-free alternatives – for harm reduction purposes – become more important as the smoker population become more marginalised.
This defensive and backwards-looking attitude towards disruption and innovation in this field is truly pitiful. I think that anyone in public health has a ‘duty of curiosity‘, given all the life and pain at stake. But far too many have had closed minds from the outset. I discuss the unthinking knee-jerk rejection of the Foundation in a post: Foundation for a Smoke-Free World – the mob behaviour of tobacco control
3. E-cigarettes could be as bad, if not worse, than cigarettes for causing lung and cardiovascular disease and in respect of gum disease they are equally as bad as cigarettes
This is an astonishing claim that no genuine experts support and most would reject as grossly irresponsible. Given it is asserted without evidence, it is difficult to know on what it is based. It likely arises from a highly misleading interpretation of in vitro cell studies, in which cells outside the body, and therefore without their normal defence and repair mechanisms, have been exposed to e-liquids – sometimes extreme exposures have been used. It is a completely unrealistic and inappropriate way to assess the impact on human health, as David Abrams and colleagues point out here:
Some scientists and advocates have expressed concerns regarding potential cardiovascular and respiratory risks of e-vapor in certain cell preparation and acute physiological exposure studies (Glasser et al., 2017; Glantz and Bareham, 2018a). Extrapolation from many of these studies appears to be questionable when the studies imply direct causal links to long-term human harms equal to or greater than smoking or make no direct comparison with smoking so relative harms can be compared. Although nicotine use poses some risk for smokers with existing cardiovascular disease, risk is small relative to the risk posed by smoking cigarettes (Benowitz and Fraiman, 2017; Benowitz and Burbank, 2016; Niaura, 2016; Farsalinos, 2017; Fagerstrom et al., 2015; Fagerstrom and Bridgman, 2014).
Abrams DB, Glasser AM, Villanti AC, Pearson JL, Rose S, Niaura RS. Managing nicotine without smoke to save lives now: Evidence for harm minimization. Prev Med (Baltim). Academic Press; 2018 Jun 23; [link]
Scientists have measured the exposures to the most important toxins as found in users’ blood or urine and concluded that exposures are either below the limit of detection or one to three orders of magnitude lower than for smoking.
The assessment of Public Health England (here) and the Royal College of Physicians remains the most reliable. The RCP (London) states:
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”.Royal College of Physicians (London) Nicotine without smoke: tobacco harm reduction 28 April 2016 [link]
The third “observation and opinion” is the most dangerous and reckless of the falsehoods emanating from this group. If taken seriously, it would add further to the confusion and misperceptions that smokers have about the risks of e-cigarettes, decrease the likelihood they would switch to vaping, increase the likelihood they would continue to smoke – and therefore suffer disease or die as a result. Any newspaper should approach this claim with great scepticism before promoting this idea as any kind of expert consensus to its readers.
In my view, exaggerating the risks of much safer products like e-cigarettes is ethically and consequentially symmetrical to downplaying the risks of more dangerous products like cigarettes. The tobacco companies used to do the latter, certain public health activists have taken to doing the former.
4. E-cigarettes are particularly dangerous for young people due to the detrimental effects of nicotine on the developing brain
This claim has become particularly popular in the United States. However, it relies on conflating different ideas, and almost entirely on rodent studies.
It is clear that nicotine has effects on the brain of anyone using it – as does alcohol and caffeine and almost anything else. It is also clear that nicotine can be dependence-forming. There is no dispute about this. However, this claim has been used to suggest that nicotine creates some sort of mental impairment or detriment. The trouble with the claim is that this has not been found in the multiple generations of young people who consumed nicotine as smokers.
Put simply, after all these decades, where are all the brain-damaged smokers and ex-smokers?
5. E-cigarettes are developing new generations of youngsters who are addicted to nicotine
This is another extreme claim and reflects a tendency for some in public health to proceed straight to a moral panic, if they can. First of all, it is hard to see how vaping meets the definition of addiction at all. The US National Institute of Drug Abuse (NIDA) defines it as follows:
Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal.NIDA, Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) [link]
What are the harmful consequences? Where is vapers’ social dysfunction. Before they can make this claim, the authors need the following:
- What do they mean by ‘addicted’? Once that is clear, is vaping addictive, and if so, for what proportion of users?
- How much youth vaping is intensive (e.g. frequent use daily starting soon after waking) and how much is occasional or just adolescent experimentation?
- Of the intensive use, how much of that is among people who smoke or would otherwise smoke – and the vaping may be displacing the smoking. In fact, the available evidence from the UK and US suggests that more frequent vaping is highly concentrated in smokers.
- Is vaping displacing other risk behaviours and beneficial as a result?
- How much do we worry about adolescent vaping compared to other youth risk behaviours like drink-driving, underage sex, drug use?
They simply do not have the answers to these questions, and to the extent that we do have answers, they provide reassurance not a reason to promote a moral panic. I have written about the so-called epidemic of youth vaping in the United States: The great American youth vaping epidemic. Really?
In the UK, we do not have this: Regular e-cigarette use remains low among young people in Britain. I suspect that the American moral panic about youth vaping is self-propelling. Through a massive media onslaught by activist groups and public officials, adolescents have been alerted to a new product that adults think should only be for adults. What could possibly go wrong?
6. It is not credible to claim that e-cigarettes are 95 per cent safer than cigarettes – Prof Martin McKee states that “We are having more and more evidence of damage to lungs, the heart and cardiovascular system.”
There is nothing to support Professor McKee’s contention – other than discredited claims made by a few maverick scientists. Again, as no evidence is presented to support this contention, it is hard to know what this assertion it is based on. In contrast, PHE contracted independent experts in the relevant disciplines and they set out the basis for its assessment in its 2018 evidence review. At no point does this assessment assert that e-cigarettes are harmless. It concludes with its key findings as follows (page 174), pointing out (first bullet) that cancer risk may be 99.5% less than smoking:
- One assessment of the published data on emissions from cigarettes and EC calculated the lifetime cancer risks. It concluded that the cancer potencies of EC were largely under 0.5% of the risk of smoking.
- Comparative risks of cardiovascular disease and lung disease have not been quantified but are likely to be also substantially below the risks of smoking. Among EC users, two studies of biomarker data for acrolein, a potent respiratory irritant, found levels consistent with non-smoking levels.
- There have been some studies with adolescents suggesting respiratory symptoms among EC experimenters. However, small scale or uncontrolled switching studies from smoking to vaping have demonstrated some respiratory improvements.
- EC can release aldehydes if e-liquids are overheated, but the overheating generates an aversive taste.
- To date, there is no clear evidence that specific flavourings pose health risks but there are suggestions that inhalation of some could be a source of preventable risks.
- To date, the levels of metals identified in EC aerosol do not give rise to any significant safety concerns, but metal emissions, however small, are unnecessary.
- Biomarkers of exposure assessed to date are consistent with significant reductions in harmful constituents and for a few biomarkers assessed in this chapter, similar levels to smokers abstaining from smoking or non-smokers were observed.
- One study showed no reductions across a range of biomarkers for dual users (either for nicotine replacement therapy or EC dual users).
- To date, there have been no identified health risks of passive vaping to bystanders.
- Reporting of some academic studies has been misleading.
The final point is, of course, directed at media-focussed academic activists who have been misusing the science to spread alarm and fear.
What, specifically, does Professor McKee believe is wrong with this assessment? And not only wrong but so wrong that he can claim (point 3) that respiratory and cardiovascular risks are equivalent to or worse than smoking? How he has concluded that whatever observations he has chosen from the literature that show some effects of vaping mean that lifetime risks of vaping exceed 5% of that of smoking? There is no evidence of any material harm from vaping at present and good evidence of harm reduction in smokers who switch. So what is the basis of his dispute with PHE’s experts, other than it is inconvenient to his anti-vaping abstinence-only position?
7. WHO states that there is “very little science to support the claim that e-cigarettes help people give up smoking”
I have been unable to source or date this quote, but it is not impossible that someone in WHO would say such a thing. That does not make it correct: WHO is a largely dysfunctional bureaucracy with an offshoot that provides secretariat functions for a convention. It is not the place you would look for evidence. A blistering critique of WHO’s 2016 paper on e-cigarettes (or “ENDS”) by experts at the UK Centre for Tobacco and Alcohol Studies (UKCTAS) shows just how poor its work on ENDS has been. The summary of the critique refers to the WHO view at the time on whether e-cigarettes (ENDS) help smokers to quit:
Discounting the evidence that ENDS do help smokers quit. The WHO paper does not properly assess the role that ENDS play in quitting smoking and uncritically repeats several methodological errors found in the literature. Taking the totality of evidence including controlled trials, observational studies, changes in population smoking and ENDS use, the experience of nicotine replacement therapy, and widely reported user experience, there is confidence that ENDS are helping many smokers to quit smoking and not having negative effects like renormalising smoking, reducing quit rates or creating gateway effects.UKCTAS, Commentary of WHO paper on electronic nicotine delivery systems, 2016 [link][PDF]
In fact, there is considerable evidence supporting the argument that vaping reduces smoking. In 2017 evidence to the Australian government, Colin Mendelson and I set out some of the studies: Do vapour products reduce or increase smoking?
More recently, a randomised controlled trial found that e-cigarettes are almost twice as effective as nicotine replacement:
The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group.Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Feb 14;380(7) [link]
It might be objected that most smokers are not in a randomised controlled trial, but encouraging results were also found with a study of over-the-counter purchases of NRT and e-cigarettes and found far better performance that the ‘approved’ smoking cessation measures.
People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum.Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014 1;109(9):1531–40. [link] Press release 20 May 2014 [link]
This adds to a large volume of individual experience and rapid declines in smoking where vaping has taken off. There is little doubt that vaping replaces smoking.
8. Research by Kings College London and Cancer Research UK found that British children who had vaped were 12 times more likely to go to smoke than those who had never tried e-cigarettes.
This is a link to the study in question: East K, et al, 2018 [link]
Point 8 is an almost childish attempt to pull a fast one on the newspaper’s readers. It appears that the reader is being encouraged to think that someone who vapes is 12 times as likely to smoke because they vaped first. That would be quite wrong.
The concept behind this reported observation is known as ‘common liability’. This means that whatever it is that inclines a young person to smoke also inclines them to vape – this could include genetics, parental behaviour, mental health, self-esteem, social circle, school and community norms – and many other factors. You would expect smoking and vaping behaviours to be seen in the same individuals. And this is good: it means the most likely e-cigarette users would be people who are likely to smoke in the absence of e-cigarettes. It therefore opens the possibility of eventual diversion from smoking and harm reduction. Of course, the authors make this clear:
Although this study controlled for a variety of factors previously associated with smoking and e-cigarette use to enhance approximation of the models, there are still several factors that were not included that may contribute to the observed association between these products . Examples may include curiosity, sensation seeking, liking, or disliking the effects of smoking/e-cigarettes, expectancies of smoking/e-cigarettes, mental ill health, and use of other drugs . Furthermore, there are likely to be contributing factors that cannot be easily measured in surveys such as biological or genetic vulnerabilities, although drug use and parent’s smoking and e-cigarette use may act as an indicator of these.East K, Hitchman SC, Bakolis I, Williams S, Cheeseman H, Arnott D, et al. The Association Between Smoking and Electronic Cigarette Use in a Cohort of Young People. J Adolesc Health.; 2018 May 1;62(5):539–47. [link]
The survey also deals with ‘ever use’ not current or regular vaping or smoking – just having tried it once. In this case, the underlying common liabilities are even more difficult to pin down – they might just indicate a youthful tendency to experiment. Of course, the authors point this out:
Therefore, although the present study found an association between ever smoking and ever e-cigarette use, these cannot be generalized to current or regular use, and it cannot be determined whether e-cigarette experimentation leads to regular smoking.
If responsible experts wish to avoid confusing or misleading readers, they would explain that the technical words in this statement do not mean that vaping causes smoking, even if that’s what it sounds like in non-technical English. That, at least, is what the experts who wrote the study did.
9. The tobacco industry is pretending to be part of the solution but instead are part of the problem as e-cigarettes are just another method by which people become addicted to nicotine
The tobacco industry is acting rationally in the interests of its shareholders and within the law – something that is (or should be) true for pretty much any company. However, in this case, the companies – driven by consumers and competition – are in a disrupted market which is changing in a way that is potentially highly beneficial to consumers and public health through a transition from combustible to non-combustible products.
See my post, Pariahs, predators or players? The tobacco industry and the end of smoking for views on what is going on in the industry.
In fact, the main risk to these encouraging marketplace developments is excessive regulation of reduced-risk products. This can easily have the effect of protecting the cigarette trade from the competition. I have set out harmful unintended consequences from excessive regulation here. We should also note the work of anti-vaping activists trying – for inexplicable reasons – to ensure that smokers do not switch from cigarettes to vaping products that will do them much less harm. The tobacco policy expert, David Sweanor, describes them as Big Tobacco’s Little Helpers.
10. In respect of British American Tobacco – your statements on smokeless tobacco about how you have “no wish to aid or hasten any decline in cigarette smoking” were a precursor to your approach to e-cigarettes
I don’t really know what this question means or who it was directed at – certainly not me. However, I do think I can provide a helpful response.
The country with the lowest rate of smoking in the European Union by some distance is Sweden at 5% daily smoking and 7% current smoking. The reason for this is that many Swedes use smokeless tobacco or snus instead of smoking. That has greatly contributed to reducing tobacco-related death and disease. The chart shows smoking prevalence and tobacco-related deaths.
In Norway, daily smoking among young women had fallen to 1% by 2017 – again the reason is snus.
The experience of smokeless tobacco in Scandinavia and Nordic countries in fact provides ‘proof of concept’ for the idea of tobacco harm reduction – for reducing cigarette use through switching to low risk alternatives.
11. E-cigarettes have been shown to reduce cessation rates and slow down the long term decline in smoking
One can only guess the source, but this probably refers to a ‘meta-analysis’ of smoking cessation studies undertaken by one of the group. The informed criticism of that analysis is withering, and I have documented some of it here: Who will be duped by error-strewn ‘meta-analysis’ of e-cigarette studies? According to an expert submission from what was then the Legacy Foundation and is now the Truth Initiative – commenting on an earlier draft of the paper.
While the majority of the studies we reviewed are marred by poor measurement of exposures and unmeasured confounders, many of them have been included in a meta-analysis that claims to show that smokers who use e-cigarettes are less likely to quit smoking compared to those who do not. This meta-analysis simply lumps together the errors of inference from these correlations. As described in detail above, quantitatively synthesizing heterogeneous studies is scientifically inappropriate and the findings of such meta-analyses are therefore invalid. (emphasis added)
The UK expert reaction was no less unkind: “not scientific”, “grossly misleading”, “a major failure of the peer review system” are amongst the comments from Professor Robert West, Professor Ann McNeill, Professor Peter Hajek, Linda Bauld of Cancer Research UK and Roseanna O’Connor of Public Health England.
A more formal critique of the studies that purport to show vaping increases smoking dismissed the meta-analysis and other similar attempts:
Only a small proportion of studies seeking to address the effect of e‐cigarettes on smoking cessation or reduction meet a set of proposed quality standards. Those that do are consistent with randomized controlled trial evidence in suggesting that e‐cigarettes can help with smoking cessation or reduction.Villanti AC, Feirman SP, Niaura RS, Pearson JL, Glasser AM, Collins LK, et al. How do we determine the impact of e-cigarettes on cigarette smoking cessation or reduction? Review and recommendations for answering the research question with scientific rigor. Addiction. 2017 Oct 3; [link]
In fact, in both the United States and the United Kingdom, the rate of decline in smoking has accelerated since e-cigarettes emerged.
12. Tobacco companies are funding scientific research about e-cigarettes and heat not burn products in an attempt to influence public opinion and showcase favourable results
This is plain wrong and shows that they have little understanding of the industry. The companies undertake very substantial R&D programmes but mainly for reasons other than influencing public opinion. The following are the more important reasons.
- To satisfy the demands of sceptical regulators, like the Food and Drug Administration of the United States.
- To discharge a duty of care, to meet general product safety obligations and to ensure they have minimised product liability risks.
- For development reasons: to understand their products and to make higher quality and improving products.
- To be able to make truthful and evidence-based claims about their products. In this case, with a view to persuading smokers to use them instead of cigarettes.
The scientific programmes of the tobacco companies are legitimate and of high quality – they have to be, as they attract very strong scrutiny. If they were not doing this work, there would be a serious cause for concern.
What do others say?
Many within the mainstream of public health are starting to recognise the great potential of e-cigarettes and tobacco harm reduction.