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Salud Pública de México

versión impresa ISSN 0036-3634

Salud pública Méx vol.61 no.4 Cuernavaca jul./ago. 2019  Epub 31-Mar-2020 

Cartas al editor

Response to “New tobacco products, a threat for tobacco control and public health of Mexico"

Riccardo Polosa, MD, PhD1  2 

Salvatore Urso, MSc2 

Konstantinos E Farsalinos, MD, MPH3  4  5 

1Department of Clinical and Experimental Medicine, University of Catania. Catania, Italy.

2Center of Excellence for the Acceleration of Harm Reduction (Coehar), University of Catania. Catania, Italy.

3Department of Cardiology, Onassis Cardiac Surgery Centre. Kallithea, Greece

4Department of Pharmacy, University of Patras. Patras, Greece.

5National School of Public Health. Athens, Greece.

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.


1. Reynales-Shigematsu LM, Barrientos-Gutiérez I, Zavala-Arciniega L, Arillo-Santillán E. Nuevos productos de tabaco, una amenaza para el control de tabaco y la salud pública en México. Salud Publica Mex. 2018;60(5):598-604. https:// [ Links ]

2. Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP, 2016 [cited October 7, 2018]. Available from: Available from: Links ]

3. McNeill A, Brose LS, Calder R, Bauld L, Robson D. Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. London: Public Health England, 2018 [cited October 7, 2018]. Available from: Available from: publications/e-cigarettes-and-heated-tobaccoproducts-evidence-reviewLinks ]

4. National Academies of Sciences, Engineering and Medicine. Public health consequences of e-cigarettes. Washington DC: The National Academies Press, 2018. [ Links ]

5. Polosa R, Urso S, Farsalinos KE. Response to “New tobacco products, a threat for tobacco control and public health of Mexico” [internet]. Greece; c2015-2016 [updated 2019 Apr 26; cited 2018 Oct 7]. E-cigarrete research [about 7 screens]. Available from: Available from: whats-new/2019/269-mexico-ecigLinks ]

6 . Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers-Smith K, Bisal N, et al. A randomized trial of e-cigarettes versus nicotine replacement therapy. N Engl J Med. 2019;380:629-37. https:// [ Links ]

7. Norma Oficial Mexicana NOM-028-SSA2-2009 Para la prevención, tratamiento y control de las adicciones. México: Conadic, 2009 [cited October 7, 2018]. Available from: Available from: http://www.conadic. ]

Declaration of conflict of interests. Riccardo Polosa has received lecture fees and research funding from manufacturers of stop smoking medications (Pfizer and GlaxoSmithKline) as well as manufacturers of drugs for the management of smoking-related diseases (CV Therapeutics, NeuroSearch A/S, Sandoz, MSD, Boehringer, Ingelheim, Novartis, Duska Therapeutics and Forest Laboratories). He has also received support from The Consumer Advocates for Smoke-free Alternatives (CASAA) for publication and open access costs of one paper. He has also served as a consultant for Pfizer, Global Health Alliance for treatment of tobacco dependence, ECITA (Electronic Cigarette Industry Trade Association, in the UK), Arbi Group Srl., and Health Diplomats (consulting company that delivers solutions to global health problems with special emphasis on harm minimization). Lectures fees from a number of European electronic cigarette industry and trade associations (including FIVAPE in France and FIESEL in Italy) were directly donated to vapers advocacy no-profit organizations. He is also currently involved in the following pro bono activities: scientific advisor for LIAF, Lega Italiana Anti Fumo (Italian acronym for Italian Anti Smoking League) and for The Consumer Advocates for Smoke-free Alternatives (CASAA); Chair of the European Technical Committee for standardization on “Requirements and test methods for emissions of electronic cigarettes” (CEN/TC 437; WG4). Salvatore Urso has no conflict of interest to report. Konstantinos E Farsalinos has no conflict of interest to report for the past three years. For the past five years, two of his studies were funded by the non-profit association AEMSA and one study was funded by the non-profit association Tennessee Smoke-Free Association.

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