In a submitted to the FDA, Dr. Stan Glantz has asserted that in terms of pulmonary effects, the use of electronic cigarettes may not be any less hazardous than smoking conventional cigarettes.

Here, they find a correlation between e-cigarette use and higher and more sustained levels of smoking. But because this is a cross-sectional study, they cannot determine which came first. In other words, what is the direction of the causal relationship? Does the e-cigarette use precede, and cause, the smoking? Or does the smoking precede, and cause, the e-cigarette use?

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