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2 <br />Table of Contents <br />1 Background ................................................................................................................... 3 <br />1.1 What are e-cigarettes? .................................................................................................................. 3 <br />1.2 How have e-cigarettes come about? ............................................................................................. 3 <br />1.3 How much are e-cigarettes used? ................................................................................................. 3 <br />2 The public health case – tobacco harm reduction ......................................................... 4 <br />2.1 Challenging the burden of smoking ............................................................................................... 4 <br />2.2 Benefits of vaping to a smoker ...................................................................................................... 4 <br />2.3 Do e-cigarettes help people to quit smoking? .............................................................................. 5 <br />2.4 What is the potential? ................................................................................................................... 6 <br />3 What are critics concerned about? ............................................................................... 7 <br />3.1 Risks arising from exposure to vapour .......................................................................................... 7 <br />3.1.1 Nicotine .................................................................................................................................. 7 <br />3.1.2 Nicotine poisoning .................................................................................................................. 7 <br />3.1.3 Ultrafine particles ................................................................................................................... 8 <br />3.1.4 Formaldehyde ......................................................................................................................... 8 <br />3.1.5 Carcinogens and toxicants ...................................................................................................... 8 <br />3.1.6 Heavy metals .......................................................................................................................... 9 <br />3.1.7 Lung irritation ......................................................................................................................... 9 <br />3.2 Risks to the population .................................................................................................................. 9 <br />3.2.1 Renormalising smoking .......................................................................................................... 9 <br />3.2.2 Reduced quitting .................................................................................................................. 10 <br />3.2.3 Gateway effects .................................................................................................................... 10 <br />3.2.4 Understanding and defining gateway effects ...................................................................... 11 <br />3.2.5 Kiddie flavours to appeal to children.................................................................................... 12 <br />3.3 Seeing through controversy ........................................................................................................ 13 <br />3.4 The case of snus – a cautionary tale ............................................................................................ 13 <br />3.5 Concern about the tobacco industry ........................................................................................... 13 <br />3.6 Disruptive technology also challenges public health .................................................................. 14 <br />4 Regulatory issues ........................................................................................................ 15 <br />4.1 Poor regulation is the primary risk to public health .................................................................... 15 <br />4.2 Unintended consequences of regulation will dominate ............................................................. 15 <br />4.2.1 The risk of user countermeasures to overcome poor regulation ........................................ 16 <br />4.3 The current approach of key regulators is arbitrary and disproportionate ................................ 16 <br />4.3.1 UK approach ......................................................................................................................... 16 <br />4.3.2 European Union approach .................................................................................................... 16 <br />4.3.3 United States approach ........................................................................................................ 17 <br />4.3.4 Australia and Canada and other countries with de facto bans ............................................ 18 <br />4.3.5 The World Health Organisation ............................................................................................ 18 <br />4.4 A better approach to regulation .................................................................................................. 18 <br />4.5 Elements of an appropriate regulatory regime ........................................................................... 19 <br />About the author .............................................................................................................. 20 <br />