We welcome the lively discussion among readers of Deutsches Ärzteblatt International that our article has triggered (1). We would like to add a factual rectification: in our study, prior consumption of e-cigarettes did not only predict the trying-out of conventional cigarettes but also the transition from experimental to daily smoking.

The five readers’ contributions primarily discuss the potential use of e-cigarettes as a smoking cessation aid. In our view, current empirical data do not allow any valid conclusions about the utility/benefits of e-cigarettes. The 2016 Cochrane analysis was based on only two randomized controlled studies (2). In the context of a new, large and comprehensive, pragmatic study of occupational smoking cessation measures (quitting smoking in the workplace), providing e-cigarettes at no cost helped only very few employees to give up (3). The latest meta-analysis on the efficacy of e-cigarettes as a smoking cessation aid was published in 2018 and concluded that using e-cigarettes reduces the chance of successfully quitting smoking by 39% (4). In order to minimize the harms of smoking, the UK is focusing on e-cigarettes. Advertising is therefore prohibited for tobacco products but allowed for e-cigarettes. At the population level, a strong increase in consumption of e-cigarettes was observed in England between 2006 and 2016, but no reduction in the number of conventional cigarettes smoked on a daily basis (5).

An initial study on the suitability of e-cigarettes as smoking cessation aids in young adults recruited 5128 Swiss men aged 20 (6). An observational study conducted over 15 months investigated whether consumers of e-cigarettes differed from non-consumers in terms of the number of cigarettes smoked, successful quitting, or attempts at quitting. A beneficial effect of e-cigarette consumption was not seen at follow-up—neither in view of smoking cessation nor of a reduction in cigarette consumption.

In our study, 215 10th grade students smoked conventional cigarettes every day at the time of the first data collection. Of this baseline total, 200 had also consumed e-cigarettes at the first data collection (93.0%). At follow-up, 10 of the previously daily smokers reported that they did not consume conventional cigarettes at all, which equates to a smoking cessation rate of 4.7%. Of the 10 adolescents who had quit smoking conventional cigarettes, nine had consumed e-cigarettes and one had’not. The relative smoking cessation rate in the group of e-cigarette consumers was therefore 4.5% and in the group of non-e-cigarette consumers, 6.7%. Three of the nine adolescents with e-cigarette experience had consumed e-cigarettes in the 30 days before the follow-up data collection. The one student without e-cigarette experience was completely smoke-free, that is, he wasnnot consuming e-cigarettes at follow-up either.

We obviously welcome every smoker who manages to give up smoking by using e-cigarettes. The consumption of e-cigarettes is, however, not risk-free for health, because a large number of ultrafine particles as well as nicotine are being inhaled, which may cause pulmonary or systemic inflammatory reactions, which in turn encourage atherosclerosis and raise the risk for cardiovascular and respiratory disorders (7). About two thirds of smokers died from such disorders (4). The medium term and long term sequelae of e-cigarette consumption and the passive burden on third parties owing to aerosolized e-cigarette liquids have not been studied at all to date. For us, the question therefore arises whether it is justifiable from an ethical perspective to recommend to 18 million smokers in Germany a measure that is currently not guideline-conform nor evidence-based.

DOI: 10.3238/arztebl.2018.0479b

Prof. Dr. phil. Reiner Hanewinkel

PD Dr. phil. Matthis Morgenstern

Institut für Therapie- und Gesundheitsforschung

IFT-Nord gGmbH, Kiel

hanewinkel@ift-nord.de

Michaela Goecke, M.A.

Bundeszentrale für gesundheitliche Aufklärung, Köln

Conflict of interest statement

The authors declare that no conflict of interest exists.

1.
Morgenstern M, Nies A, Goecke M, Hanewinkel R: E-cigarettes and the use of conventional cigarettes—a cohort study in 10th grade students in Germany. Dtsch Arztebl Int 2018; 115: 243–8 VOLLTEXT
2.
Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P: Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2016; 9: CD010216 CrossRef
3.
Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG: A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med 2018; 378: 2302–10 CrossRef MEDLINE
4.
Glantz SA, Bareham DW: E-Cigarettes: use, effects on smoking, risks, and policy implications. Annu Rev Public Health 2018; 39: 215–35 CrossRef MEDLINE
5.
Beard E, Brown J, Michie S, West R: Is prevalence of e-cigarette and nicotine replacement therapy use among smokers associated with average cigarette consumption in England? A time-series analysis. BMJ open. 2018; 8: e016046 CrossRef MEDLINE
6.
Gmel G, Baggio S, Mohler-Kuo M, Daeppen JB, Studer J: E-cigarette use in young Swiss men: is vaping an effective way of reducing or quitting smoking? Swiss Med Wkly 2016; 146: w14271 CrossRef
7.
National Academies of Sciences, Engineering, and Medicine: Public health consequences of E-cigarettes. Washington, DC: The National Academies Press 2018.
1.Morgenstern M, Nies A, Goecke M, Hanewinkel R: E-cigarettes and the use of conventional cigarettes—a cohort study in 10th grade students in Germany. Dtsch Arztebl Int 2018; 115: 243–8 VOLLTEXT
2.Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P: Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2016; 9: CD010216 CrossRef
3. Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG: A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med 2018; 378: 2302–10 CrossRef MEDLINE
4.Glantz SA, Bareham DW: E-Cigarettes: use, effects on smoking, risks, and policy implications. Annu Rev Public Health 2018; 39: 215–35 CrossRef MEDLINE
5.Beard E, Brown J, Michie S, West R: Is prevalence of e-cigarette and nicotine replacement therapy use among smokers associated with average cigarette consumption in England? A time-series analysis. BMJ open. 2018; 8: e016046 CrossRef MEDLINE
6.Gmel G, Baggio S, Mohler-Kuo M, Daeppen JB, Studer J: E-cigarette use in young Swiss men: is vaping an effective way of reducing or quitting smoking? Swiss Med Wkly 2016; 146: w14271 CrossRef
7.National Academies of Sciences, Engineering, and Medicine: Public health consequences of E-cigarettes. Washington, DC: The National Academies Press 2018.

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