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E-Cigarettes: A Rapidly Growing Internet Phenomenon

Cyrus K. Yamin, BS; Asaf Bitton, MD, MPH; and David W. Bates, MD, MSc
[+] Article, Author, and Disclosure Information

From Harvard Medical School, Brigham and Women's Hospital, and Harvard School of Public Health, Boston, Massachusetts.

Acknowledgment: The authors thank Jack Henningfield, Adam Wright, and Ayal Bitton for feedback on earlier versions of this manuscript.

Potential Conflicts of Interest: None disclosed. Forms can be be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1447.

Corresponding Author: David W. Bates, MD, MSc, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613; e-mail, dbates@partners.org.

Current Author Addresses: Mr. Yamin and Drs. Bitton and Bates: Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613.

Author Contributions: Conception and design: C.K. Yamin, A. Bitton, D.W. Bates.

Analysis and interpretation of the data: C.K. Yamin, A. Bitton.

Drafting of the article: C.K. Yamin, A. Bitton, D.W. Bates.

Critical revision of the article for important intellectual content: C.K. Yamin, A. Bitton, D.W. Bates.

Final approval of the article: C.K. Yamin, A. Bitton, D.W. Bates.

Administrative, technical, or logistic support: A. Bitton, D.W. Bates.

Collection and assembly of data: C.K. Yamin, A. Bitton.

Ann Intern Med. 2010;153(9):607-609. doi:10.7326/0003-4819-153-9-201011020-00011
Text Size: A A A

Electronic cigarettes (e-cigarettes) aerosolize nicotine and produce a vapor that emulates that of cigarettes but purportedly has fewer traditional toxins than secondhand smoke. Although e-cigarettes are widely sold online and by retailers, new research suggests that they may contain unexpected toxins and may provide unreliable nicotine delivery. Many countries have already banned or strictly regulated e-cigarettes. Currently in the United States, e-cigarettes are exempt from regulation as drug-delivery devices. Meanwhile, the presence of e-cigarettes on the Internet, including in Web searches, virtual user communities, and online stores where people sell e-cigarettes on commission, is increasing rapidly. Physicians should be aware of the popularity, questionable efficacy claims, and safety concerns of e-cigarettes so that they may counsel patients against use and advocate for research to inform an evidence-based regulatory approach.


internet ; cigarettes


Grahic Jump Location
Schematic of an electronic cigarette.

Reproduced with permission from American Journal of Health-System Pharmacy. 2009;66:1740-2.

Grahic Jump Location




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More Pertinent Poll Question
Posted on November 16, 2010
Elaine D. Keller
The Consumer Advocates for Smoke-Free Alternatives Association
Conflict of Interest: None Declared

The poll posted with this article asked what doctors would do when faced with a patient who used e-cigarettes to reduce their smoking. However, consumer surveys show that the majority (ranging from 63% to 79%) of e-cigarette consumers completely replace their smoked cigarettes with the devices. See: http://www.biomedcentral.com/1471-2458/10/231 and http://tobaccoharmreduction.org/wpapers/011v1.pdf

Therefore, a more pertinent question would have been:

A patient tells you that after smoking for decades and trying to quit dozens of times without success, she finally managed to stop inhaling smoke a year ago by switching to e-cigarettes. What would you advise?

a. Switch to any of the products that didn't work before; maybe they will work this time.

b. Stop using e-cigarettes immediately, even if it means a relapse to smoking.

c. Congratulations on your accomplishment. Keep up the good work.

Conflict of Interest:

None declared

Response to Yamin re E-cigarettes
Posted on December 2, 2010
Joel L Nitzkin
JLN, MD Associates, LLC
Conflict of Interest: None Declared

The commentary by Yamin et al is truly remarkable. They readily admit that E-cigarettes are far safer than cigarettes, and then urge physicians to counsel patients against their use as a substitute for conventional cigarettes. Yamin et al did not consider the research already done by the E-cigarette industry, FDA, and others relative to the chemical quality of their products, user profiles, and marketing policy.

Questions related to the quality of manufacture or marketing of E- cigarettes can be resolved by FDA regulating them as the tobacco products. Under the new FDA tobacco law, FDA has all the authority it needs to assure quality and consistency of manufacturing and to regulate marketing as needed to prevent sales to minors. E-cigarettes are intended as a substitute for cigarettes for smokers unwilling or unable to quit, yet desiring to all-but-eliminate their exposure to the other toxic substances in cigarette smoke.1 They are marketed as tobacco products, not pharmaceuticals for smoking cessation therapy.

FDA's own studies of E-cigarettes show that they contain the same carcinogens in the same trace quantities as the Nicorette and other pharmaceutical nicotine replacement therapy products already approved by FDA (1).

From February of 2007 through February of 2010, I served as Co-Chair of the Tobacco Control Task Force of the American Association of Public Health Physicians. In that context I explored policy options for rapidly and substantially reducing tobacco-related illness and death among current American tobacco users. This research led to the conclusion that almost all tobacco-related illness and death in the United States is due to the smoking of cigarettes and that alternative smokeless tobacco and nicotine products, including but not limited to snus, E-cigarettes and the pharmaceutical NRT products, pose a risk of tobacco-related death less than 2% the risk posed by cigarettes (2,3). In this context, it seemed clear that a harm reduction initiative based on informing smokers of the difference in risk posed by the different types of tobacco/nicotine products, accompanied by effective FDA regulation of the manufacture and marketing of all such products held the best possible hope for securing rapid and substantial reductions in tobacco-related illness and death among current smokers while minimizing initiation of tobacco use by teens in the USA.

Pending effective regulatory action by FDA, physicians should consider E-cigarettes as an option for smokers who are unable or unwilling to quit or who have tried available pharmaceutical options without success.

Joel L. Nitzkin, MD


1. Nitzkin JL, jln-md@mindspring.com. Citizen Petition (to FDA) to Reclassify E-Cigarettes from "drug-device combination" to "tobacco product" [].

2. Nitzkin JL, Rodu B. AAPHP Resolution and White Paper: The Case for Harm Reduction for Control of Tobacco-related Illness and Death [http://www.aaphp.org/special/joelstobac/20081026HarmReductionResolutionAsPassed1.pdf].

3. Rodu B, Nitzkin JL, jln-md@mindspring.com. Update on the Scientific Status of Tobacco Harm Reduction, 2008-2010 Prepared for the American Association of Public Health Physicians [http://www.aaphp.org/special/joelstobac/2010/harmredcnupdatejuly2010.html]

Conflict of Interest:

None declared

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