Dear Editor: The position article by Reynales-Shigematsu and colleagues¹ on the public health impact in Mexico of combustion-free electronic nicotine delivery systems (ENDS) fails to present a balanced overview of the risk-benefit ratio of these new technologies, grossly misrepresents the existing evidence, and ignores the broad consensus that these products are much less harmful than cigarettes.^2,3,4

The work cited by the authors (references 8-21) on exposure risks from e-cigarette aerosol emissions report misleading results that do not reflect normal conditions of use.5 The authors claim that trial of e-cigarettes is propitiating tobacco initiation among Mexican adolescents, citing a longitudinal cohort study on Mexican high school students (reference 31) which actually disproves this claim, as it reported that the association between e-cigarette trial at baseline and past 30 day smoking at follow-up was not even statistically significant.⁵ The authors dismiss the utility of ecigarettes in smoking cessation, but their cited references do not support this claim.5 Further, a recent high quality randomized controlled trial⁶ has shown e-cigarettes to be twice as effective in smoking cessation compared to nicotine replacement therapies. A detailed critique of the position article is available.⁵

Following the authors, ENDS can only be part of a harm reduction strategy for Mexico if they immediately promote total smoking abstinence, as well as complete absence of dual usage and recruitment of non-smokers.⁷ However, these are maximalist and unrealistic conditions that no new harm reduction product can fulfill. A more realistic approach to harm reduction yields concrete benefits: the recreational usage of e-cigarettes, endorsed by health institutions in the United Kingdom under a consistent Tobacco Control strategy, has contributed to a significant decay of smoking prevalence with negligible usage by non-smokers of all ages.^2,3

By presenting ENDS as a threat to public health (consequently recommending their regulation as combustible tobacco products), Reynales- Shigematsu and colleagues are depriving 15 million Mexican smokers of key information on a plausible harm reduction alternative that can vastly improve their health. As an unintended consequence, this misinformation will keep them smoking.