Wagener and colleagues examine concerns that have been raised about e-cigarettes, and argue that these have been overstated relative to the potential benefits of these new products . Their paper raises important questions about the possible role of e-cigarettes in tobacco control, and in particular in tobacco harm reduction. What place might e-cigarettes have in efforts to reduce the harm from smoking and what further evidence is required before policy-makers and regulators can reach informed conclusions about their safety and efficacy?
A key consideration is whether e-cigarettes can serve as a substitute for tobacco smoking. In order to avoid the health risks that are associated with cigarettes smokers need to quit, but many find it hard to do so. Current alternative nicotine delivery devices such as nicotine replacement therapy (NRT) products fail to deliver nicotine in the way that a cigarette does. For this, and a range of other reasons, most smokers do not use them when trying to stop even though NRT, when used correctly, can double a smoker's chances of achieving abstinence . In addition, most smokers do not use NRT as an aid to smoking reduction or temporary abstinence, even though recent evidence suggests that these products aid in cutting down and increase the chances of eventual cessation for those who engage in smoking reduction [3,4].
In contrast, the limited evidence we have about e-cigarettes suggests that users are treating them as a replacement for tobacco smoking and are using them to cut down and to quit, as outlined by Wagener and colleagues. This evidence should be treated with some caution, as it is drawn largely from surveys that may attract those who are positive rather than negative about the products [5,6]. However, if it can be confirmed in larger population studies or trials then these products may have a role to play in reducing smoking prevalence.
Where most of the remaining concerns lie is in relation to the safety and quality of e-cigarettes. There are also questions about the role of e-cigarettes as a potential gateway product into smoking for young people, and questions about the extent to which the tobacco industry may become involved in the manufacture of these products. By reviewing existing and forthcoming research and involving professionals and the public in their deliberations, these are questions that a range of organizations in different countries are now considering. This includes, for example, the Medicines Healthcare Regulatory Agency (MHRA) in the United Kingdom, which has recently completed a public consultation on nicotine-containing products that are not licensed as medicines . Responses to the consultation indicated that there was clear support for regulation of these products, particularly from public health bodies, while the importers and users of e-cigarettes were opposed to regulation in case it results in a ban on the sale of existing products. The MHRA's response has been to coordinate a period of further research and information-seeking regarding, in particular, the doses of nicotine that have a significant pharmacological effect and the impact of potential regulation on businesses and for public health. A final decision on the regulation of e-cigarettes as medicinal products in the United Kingdom is expected in spring 2013.