Electronic cigarettes controversy Electronic cigarettes (EC) are a consumer product appealing to smokers looking for a safer way to obtain what they want from their cigarettes. From what we know about EC ingredients, toxicology and the chemical and physical processes involved, they can be expected, outside pregnancy, to be at least 95% less harmful than cigarettes [1]. There is now a sufficient body of evidence available on several aspects and effects of EC for recent reviews to conclude that health care professionals and public health bodies should encourage smokers who cannot stop smoking using available treatments, or do not want to do so, to switch to EC [2],[3]. Yet at the same time, the World Health Organisation (WHO) have labelled EC a threat to public health, issued a strong advice to smokers not to use them [4], and urges policy makers to limit their use by prohibition or strict regulation [5]. This and other negative campaigns are starting to have an alarming effect of persuading smokers that EC are as harmful as cigarettes [6] and discouraging them from making the switch [7],[8]. This commentary argues that EC have a potential to generate substantial public health benefits and that discouraging smokers from using them and regulating EC as severely as cigarettes, or even more severely, is detrimental to public health. There are manifest humane and logical reasons to encourage smokers who cannot or do not want to stop smoking but want to limit the damage smoking may do to their health to switch to EC. Here is the straightforward case: There are currently two main products competing for smokers’ custom. One, the conventional cigarette, is responsible for disease and premature death in a substantial proportion of its users. It also continues to recruit new customers from among non-smoking children who try it. The other, EC, is orders of magnitude safer. On current evidence it only appeals to smokers and generates negligible rates of regular use among non-smoking children who try it. Which one would you prefer your nicotine addicted father to use? And if your children were to try a nicotine product, which of these two would you prefer that they lay their hands on?

Evidence and agendas For the past few years, scientific journals have been publishing a large volume of commentaries on the EC phenomenon. Most of these focus on hypothetical concerns. Although all commentators now acknowledge that EC are safer than cigarettes, EC are typically presented as a competitor to smoking cessation medications that is possibly less safe and that can somehow increase cigarette use, rather than as a consumer product that competes with cigarettes, and that can make its deadly competitor obsolete. Some medical organisations which are supposed to protect public health, such as WHO, go further and actively discourage smokers from using EC while lobbying for restricting EC use by regulation. The WHO stance is underpinned by a review they commissioned [9] that has been criticised for an unorthodox use of evidence [10] and illustrates well the anti-EC arguments. Findings that EC vapour contains traces of toxicants is interpreted as a sign of danger and even as a threat to bystanders, even if the levels of these chemicals are well within limits considered safe in the air we breathe [2],[11]. Surveys showing that a small proportion of children experiment with EC are presented as a sign of the ‘gateway’ risk despite the fact that virtually no non-smokers progress to daily EC use and that smoking in youth is declining [12]. Where it fits with the negative agenda, trying EC once in the past month is labelled as ‘current use’ which by analogy with ‘current smoking’ is typically interpreted as daily use. Surveys which include only smokers who did not find EC helpful and exclude EC users who stopped smoking are presented as a proof that EC are unhelpful. ‘Dual use’ is presented as a sign of danger despite the fact that it leads to reduced toxin intake [2]. The toxicity of nicotine is exaggerated [13] and the evidence that it makes little if any contribution to smoking related disease and death [14],[15] is ignored. Concerns about the twisting of evidence for ideological ends have generated an exchange of letters by large groups of researchers and activists [16]-[18]. Given the visibility and influence of the activists and medical organisations opposing EC use, there is a risk that these campaigns will discourage or even bar large numbers of smokers around the world from the unquestionable benefits of switching from smoking to vaping. Indeed, alarming signs are emerging that smokers who could benefit from switching to EC now increasingly believe EC are dangerous and they might as well stick to the conventional cigarettes [6]-[8].

Why is there a controversy? EC are a disruptive technology, threatening sales of tobacco products as well as sales of stop smoking medications and so commercially motivated opposition can be expected. The hostility to EC from some tobacco control activists, however, is puzzling. Future textbooks are likely to discuss this phenomenon at length. Here is one hypothesis. The field of public health is not always rational. Ideology and morality can play at least as big a role as evidence and logic. Public health policies struggle with ideology in areas ranging from abortion to harm reduction strategies in drug addiction and sexually transmitted diseases. One of the possible explanations of the EC controversy is that for some tobacco control activists, any nicotine use is ‘drug abuse’ and abhorrent even if it were to carry no physical health risk. When encountering evidence that EC are much safer than cigarettes, do not attract non-smokers, and promise to reduce smoking-related morbidity, people with this ‘moral stance’ look for objections and counterarguments. Evidence is not needed to discover the truth as the truth is ‘self-evident’ and there is a higher purpose. Evidence is just a tool to gain converts. Nicotine use should be eradicated, not allowed to morph into an activity akin to drinking coffee. An earlier version of the WHO Report to the Framework Convention on Tobacco Control (FCTC), now off-line, betrayed its missionary ethos when it stated that the group’s target is nicotine addiction (that is, nicotine use) ‘independently from its source’ (that is, whether it impacts physical health or not). Nicotine use, of course, can have negative consequences even if it does not affect physical health. A proportion of users become dependent. However, compared with disease and death caused by combustible non-nicotine chemicals in tobacco smoke, this is a minor consideration. Worries about nicotine use stripped of the health risks of smoking are on par with worries about drinking coffee. Some coffee drinkers do become dependent and spend a fair amount of money and time on their habit, but this does not constitute a major public health issue. It definitely does not justify denying smokers health benefits of stopping smoking just because they would continue to use nicotine and so their conversion to the true virtue would be incomplete.