On 2017 Jan 21, Clive Bates commented:

How did the author manage to publish a paper with the title "E-cigarettes: Are they as safe as the public thinks?", without citing any data on what the public actually does think? There is data in the National Cancer Institute's HINTS survey 2015. This is what it says:

Compared to smoking cigarettes, would you say that electronic cigarettes are…

• 5.3% say much less harmful
• 20.6% say less harmful
• 32.8% say just as harmful
• 2.7% say more harmful
• 2.0% say much more harmful
• 1.2% have never heard of e-cigarettes
• 33.9% don’t know enough about these products

Which brings me to the main issue with the paper. The author claims that there is insufficient knowledge to determine if these products are safer than cigarettes. This is an extraordinary and dangerous claim given what is known about e-cigarettes and cigarettes. It is known with certainty that there are no products of combustion of organic material (i.e tobacco leaf) in e-cigarette vapour - this is a function of the physical and chemical processes involved. We also know that products of combustion cause almost all of the harm associated with smoking. There is also extensive measurement of harmful and potentially harmful constituent of cigarette smoke and e-cigarette aerosol showing many are not detectable or present at levels two orders of magnitude lower in the vapour aerosol (e.g. see Farsalinos KE, 2014, Burstyn I, 2014). So the emissions are dramatically less toxic and exposures much lower.

The author provides a familiar non-sequitur: "There are no current studies that prove that e-cigarettes are safe". There never will be. Firstly because it is impossible to prove something to be completely safe, and almost nothing is. Secondly, no serious commentators claim they are completely safe, just very much safer than smoking. Hence the term 'harm reduction' to describe the benefits of switching to these products.

This view commands support in the expert medical profession. The Royal College of Physicians (London) assessed the toxicology evidence in its 2016 report Nicotine without smoke: tobacco harm reduction and concluded:

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. (Section 5.5 page 87)

This is a carefully measured statement that aims to provide useful information to both users of the products and health and medical professionals while reflecting residual uncertainty. It contrasts with the author's information leaflet for patients, which even suggests there is no basis for believing e-cigarettes to be safer than smoking:

If you are smoking and not planning to quit, we don't know if e-cigarettes are safer. Talk to your health care provider.

But we do know beyond any reasonable doubt that e-cigarettes are very much safer - the debate is whether they are 90% safer or 99.9% safer than smoking. Regrettably, only 5.3% of American adults correctly believe that e-cigarettes are very much less harmful than smoking, while 37% incorrectly think they are as harmful or more harmful (see above). The danger with these misperceptions of risk is that they affect behaviour, causing people to continue to smoke when they might otherwise switch to much safer vaping. The danger with a paper like this and its patient-facing leaflet is that it nurtures these harmful risk misperceptions and becomes, therefore, a vector for harm.

To return to the author's title question: E-Cigarettes: Are They as Safe as the Public Thinks?. The answer is: "No, they are very much safer than the public thinks".

On 2017 Jan 21, Clive Bates commented:

How did the author manage to publish a paper with the title "E-cigarettes: Are they as safe as the public thinks?", without citing any data on what the public actually does think? There is data in the National Cancer Institute's HINTS survey 2015. This is what it says:

Compared to smoking cigarettes, would you say that electronic cigarettes are…

• 5.3% say much less harmful
• 20.6% say less harmful
• 32.8% say just as harmful
• 2.7% say more harmful
• 2.0% say much more harmful
• 1.2% have never heard of e-cigarettes
• 33.9% don’t know enough about these products

Which brings me to the main issue with the paper. The author claims that there is insufficient knowledge to determine if these products are safer than cigarettes. This is an extraordinary and dangerous claim given what is known about e-cigarettes and cigarettes. It is known with certainty that there are no products of combustion of organic material (i.e tobacco leaf) in e-cigarette vapour - this is a function of the physical and chemical processes involved. We also know that products of combustion cause almost all of the harm associated with smoking. There is also extensive measurement of harmful and potentially harmful constituent of cigarette smoke and e-cigarette aerosol showing many are not detectable or present at levels two orders of magnitude lower in the vapour aerosol (e.g. see Farsalinos KE, 2014, Burstyn I, 2014). So the emissions are dramatically less toxic and exposures much lower.

The author provides a familiar non-sequitur: "There are no current studies that prove that e-cigarettes are safe". There never will be. Firstly because it is impossible to prove something to be completely safe, and almost nothing is. Secondly, no serious commentators claim they are completely safe, just very much safer than smoking. Hence the term 'harm reduction' to describe the benefits of switching to these products.

This view commands support in the expert medical profession. The Royal College of Physicians (London) assessed the toxicology evidence in its 2016 report Nicotine without smoke: tobacco harm reduction and concluded:

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. (Section 5.5 page 87)

This is a carefully measured statement that aims to provide useful information to both users of the products and health and medical professionals while reflecting residual uncertainty. It contrasts with the author's information leaflet for patients, which even suggests there is no basis for believing e-cigarettes to be safer than smoking:

If you are smoking and not planning to quit, we don't know if e-cigarettes are safer. Talk to your health care provider.

But we do know beyond any reasonable doubt that e-cigarettes are very much safer - the debate is whether they are 90% safer or 99.9% safer than smoking. Regrettably, only 5.3% of American adults correctly believe that e-cigarettes are very much less harmful than smoking, while 37% incorrectly think they are as harmful or more harmful (see above). The danger with these misperceptions of risk is that they affect behaviour, causing people to continue to smoke when they might otherwise switch to much safer vaping. The danger with a paper like this and its patient-facing leaflet is that it nurtures these harmful risk misperceptions and becomes, therefore, a vector for harm.

To return to the author's title question: E-Cigarettes: Are They as Safe as the Public Thinks?. The answer is: "No, they are very much safer than the public thinks".