Picking Sides Divides Public Health Researchers on Weighing Benefits and Risks of E-cigarettes

Within the public health field, there has been a substantial controversy over the benefits and the risks of e-cigarettes, with some focusing on the potential use of e-cigarettes as a cessation tool while others highlight the alarming rates of e-cigarette use among youth. This has led to a divide within the public health community, with individuals feeling the need to voice their stance. This division is also notable globally: many in the United States focus more on the potential health harms for youth, while in other nations, such as the United Kingdom, the risk is viewed to be balanced with the potential benefits for combustible tobacco users trying to quit. 

In August of 2021, 15 past presidents of the Society for Research on Nicotine & Tobacco (SRNT) decided to voice their opinions regarding e-cigarettes. Balfour et al. (2021) largely covered both sides of the topic and aptly name the article, “Balancing Consideration of the Risks and Benefits of E-Cigarettes.” 2 One of the major takeaways stated is that the “singular focus of US policies on decreasing youth vaping” 2 (p.1661) has been interfering with the larger goal of tobacco control to reduce smoking and smoking attributable mortality.1 Meaning that by focusing so much on the impacts of e-cigarettes on youth, there is a disregard for the potential benefits of e-cigarettes as a cessation tool for adults smoking combustible tobacco products, which is a larger population with more deaths attributed to their tobacco use.   


As of May 2022, the Balfour et al article has been cited 35 times. Interestingly this article has sparked numerous letters to the editor. For the American Journal of Public Health (AJPH) publication, individuals are allowed to submit letters to the editor up to 3 months after the article’s appearance with text being limited to 400 words. These letters are meant to be commentaries and critiques of the work presented in the original article.  

One such letter to the editor criticized the authors of Balfour et al. (2021) by stating that the article largely focused on the benefit vaping can have on public health which essentially placed all 15 authors on the advocate side of e-cigarettes.3 Instead, it was suggested that having authors of “both” sides of the e-cigarette debate would have aided in their argument being more balanced.3 Maziak (2022) further criticized that the Balfour et al. (2021) article’s discussion and interpretation of the gateway potential of e-cigarettes leading to later cigarette smoking was underdeveloped.3 Specifically, Maziak expressed that the Balfour article subjected prospective studies to greater scrutiny than the studies challenging the gateway theory,3 but Balfour disputed that they provided enough evidence for readers.4 Maziak also claimed that “adolescents are a vulnerable population without much legal and political voice.”3(p.e1) This statement was additionally countered by Balfour asserting that similar statements can be made about marginalized adult smokers, including those of the African American and LGBTQ community.2,4   

Another letter to the editor was provided by Glantz (2022) with a concern regarding Balfour citing their co-authored meta-analysis on e-cigarettes and smoking cessation in support of the statement “other researchers have found regular and frequent e-cigarette use to be associated with increased smoking cessation, while infrequent use was not.” 2(p.1663), 5 Glantz indicated that Balfour cited a 2021 article to provide evidence to support the statement, but then focused on a 2016 article written by Glantz and colleagues when criticizing the literature.5-7 Specifically, the 2016 meta-analysis' main finding was that e-cigarettes are associated with significantly less quitting among smokers while the 2021 article presented twice as many studies and was specifically written to address the limitations of the 2016 article.5-7 Furthermore, Glantz felt that Balfour misrepresented the data by selectively focusing on specific populations (daily e-cigarette users or nondaily use) instead of the main finding that there was no significant association between e-cigarette use and cigarette cessation among all e-cigarette users.5 Balfour responded back indicating that merging these two distinct groups of e-cigarette users did not make sense as it obscured significant findings.8 Balfour highlights that daily and more frequent e-cigarette users may be more motivated to quit smoking cigarettes versus infrequent e-cigarette users, so combining these data points is not useful.8 Glantz also pointed out the recommendation that “e-cigarettes should not be approved as consumer products,”6(p.e1) which Balfour ignored, countering that they wrote the article to provide a review of current evidence, not to take a side regarding e-cigarettes.8  

Overall, it is clear that the Balfour article has created a lot of discussion around the topic of considering the benefits and risks of e-cigarettes. The area of e-cigarettes will likely continue to be a point of different opinions, especially now that there are a few modified risk tobacco products that have met the requirement of the FDA authorization of marketing application by demonstrating that “the product will or is expected to benefit the health of the population as a whole.”9(p.1) As we learn more about e-cigarettes and modified risk tobacco products, public health professionals must weigh the benefits and risks for the entire population and not narrowly focus on specific populations.  


1. Dockrell, M., & Newton, J. N. (2021). Tobacco control leaders call for a balanced assessment of the risks and benefits of nicotine vaping. American Journal of Public Health, 111(9), 1570–1571. https://doi.org/10.2105/AJPH.2021.306458   

2. Balfour, D., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R. (2021). Balancing consideration of the risks and benefits of e-cigarettes. American Journal of Public Health, 111(9), 1661-1672. https://doi.org/10.2105/AJPH.2021.306416  

3. Maziak, W. (2022). Unbalanced authorship cannot produce balanced consideration of e-cigarettes. American Journal of Public Health, 112(1), e1–e2. Acceptance Date: September 16, 2021. DOI: https://doi.org/10.2105/AJPH.2021.306554  

4. Balfour, D., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R (2022). Balfour et al. respond. American Journal of Public Health. 112(1), e2–e3. Acceptance Date: September 16, 2021. DOI: https://doi.org/10.2105/AJPH.2021.306555   

5. Glantz, S.A. (2022). E-cigarettes as consumer products. American Journal of Public Health. 112(1), e4–e5. Acceptance Date: September 24, 2021. DOI: https://doi.org/10.2105/AJPH.2021.306569  

6. Wang, R.J., Bhadriraju, S. & Glantz, S.A.(2021). E-cigarette use and adult cigarette smoking cessation: A meta-analysis. American Journal of Public Health, 111(2), 230–246. https://doi.org/10.2105/AJPH.2020.305999  

7. Kalkhoran, S. & Glantz, S.A. (2016). E-cigarettes and smoking cessation in real-world and clinical settings: A systematic review and meta-analysis. The Lancet Respiratory Medicine,4(2), 116–128. https://doi.org/10.1016/ S2213-2600(15)00521-4   

8. Balfour, D., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R (2022). Balfour et al. respond. American Journal of Public Health. 112(1), e5–e6. Acceptance Date: September 24, 2021. DOI: https://doi.org/10.2105/AJPH.2021.306570 

9. U.S. Food and Drug Administration. Modified Risk Tobacco Products. https://www.fda.gov/tobacco-products/advertising-and-promotion/modified-...