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These are all the standard criticisms we anticipated from e-cigarette advocates.  Here are the responses:

1. We did not say the association was causal.  In fact we took care not to.  What we did say is that the observed association is exactly what you would expect based on the demonstrated biological and clinical effects of e-cig exposure on the cardiovascular system.

2. The quiestion used to assess whether people had a heart attack is the standard question used on federal and other surveys and, as described in the paper, has been validated against medical records years ago.  That is why the CDC, FDA/NIH PATH study, and others use it.

3.  Issues of bias are also addressed in the paper.  Simply saying there is bias does not demonstrate that it exists.  Critics need to present evidence that such assertions are actually correct.  The one source of bias that is important -- and which is discussed in the paper -- is the fact that some of the heart attacks occurred before the advent of e-cigarettes biases the risk estimates to the null, i.e., means that we are probably underestimating the effect of e-cigarette use on heart attack risk.

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