But there is another important factor that Glantz is forgetting. In the existing studies, the smokers examined had simply cut down on the amount they smoked without substituting another source of nicotine. Therefore, they were highly likely to be compensating by inhaling much more heavily on the cigarettes that they smoked. In contrast, when dual users of e-cigarettes and cigarettes cut down substantially on their smoking, they are doing so by substituting non-tobacco, nicotine cigarettes. One would expect much less, if any, compensation. Thus, the studies that Glantz cites are not quite as relevant as they would otherwise be.

The truth is that there are major advantages and disadvantages of both surveys and clinical trials to examine the potential benefits of electronic cigarettes. Both types of study designs have inherent biases which can produce results that are more "favorable" or "unfavorable." This is why the methodology of published research needs to be examined so carefully. It is not so simple as to dismiss RCT evidence and accept survey evidence. One needs to consider the strengths and limitations inherent in both approaches. And at the end of the day, the only defensible approach, I believe, is that both types of studies are necessary, and we must carefully interpret and synthesize the findings from studies of multiple designs, using the totality of the evidence to make final judgments about the benefits of electronic cigarettes.

The letter concludes: "I really hope you will reconsider your approach – it does not serve public health or the public interest. It is wrong simply to assume that e-cigarettes will play no part in reducing the expected one billion 21st Century deaths from smoking. The evidence that there is, taken as a whole, is actually very encouraging, and certainly not a reason to mount a ‘dirty tricks campaign’ against these products. In any event, there is never a case to mislead the public, policy-makers and legislators even if you are convinced the end justifies the means, which in this case it does not."

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