Intended for healthcare professionals

Head To Head

Should electronic cigarettes be as freely available as tobacco? Yes

BMJ 2013; 346 doi: (Published 14 June 2013) Cite this as: BMJ 2013;346:f3845
  1. Jean-François Etter, professor
  1. 1Institute of Social and Preventive Medicine, Faculty of Medicine, University of Geneva, Switzerland
  1. Jean-Francois.Etter{at}

The Medicines and Healthcare Products Regulatory Agency has decided to license electronic cigarettes as medicines from 2016. Simon Chapman (doi:10.1136/bmj.f3840) agrees with regulation, seeing e-cigarettes as another way for big tobacco to try to make nicotine addiction socially acceptable again, but Jean-François Etter says restrictions will result in more harm to smokers

At last smokers have a safer alternative to tobacco. The law in most countries allows the presence of nicotine only in tobacco and in drugs (for example, nicotine replacement therapy patches and gum), effectively prohibiting competitors to tobacco and drug companies from entering the drug market. Because drugs that contain nicotine are unattractive and not very effective,1 people addicted to nicotine tend to use tobacco. Arguably, the laws regulating nicotine cause millions of deaths and unjustifiably protect existing nicotine suppliers at the expense of more innovative competitors, who could devise safer products.

However, electronic cigarettes are about to change this. These products are very successful: sales of e-cigarettes in the United States have doubled every year since they were introduced in 2007.2

Harms of regulation

Until recently, e-cigarettes were able to fly under the legislative radar and the sale of nicotine containing e-cigarettes, although not in compliance with legislation, was tolerated in many countries. But this tolerance is about to end. Unfortunately, governments, legislators, and regulation agencies want to over-regulate these products. Regulators are inherently risk averse, and presented with a new product with an incompletely documented risk profile they will zealously apply a precautionary principle. Examples of this approach include bans on e-cigarettes in several countries; the proposed European Union directive to limit the nicotine concentration in e-cigarettes to 2 mg/mL (which is much too low); the regulation of e-cigarettes as drugs; and the prohibition of use in public.3 4

This approach is excessively cautious and harmful to public health. It makes no sense to cripple a safer product by excessive regulation, allowing a dangerous one to maintain its monopoly.

The spectacular success of e-cigarettes must and will trigger a public debate on the place of nicotine in society and in the law. The tremendous toll of disease and death caused by tobacco must remain a central element in this debate, and the risks of e-cigarettes must be compared with the risks of smoking. Because they are currently used by current and former smokers, either for enjoyment or to reduce or quit smoking, and rarely, if at all, by people who have never used tobacco,5 e-cigarettes do not need to be absolutely safe, they need only to be safer than tobacco. Even if some risks are identified in the future, e-cigarettes will remain orders of magnitude safer than tobacco cigarettes.6

To ensure that as many smokers as possible switch from smoking to “vaping,” e-cigarettes must not be regulated more tightly than tobacco cigarettes. They should not be regulated as drugs either because they are not drugs as long as vendors make no health claims. The regulation of e-cigarettes should cover only quality control (to ensure that they do not deliver unexpected substances), and the marketing and sales to minors, to ensure that e-cigarettes are not advertised or sold to those who do not use tobacco. Any tighter regulation will act as a barrier to e-cigarette use and ensure that the death toll caused by smoked tobacco continues.

No evidence that e-cigarettes promote smoking

Prohibitionists claim that e-cigarettes are a gateway to smoking for young non-smokers. Currently, no evidence supports this hypothesis. On the contrary, if e-cigarettes protect adult smokers from smoking, they probably also protect adolescents. However, tobacco companies, adept at targeting young consumers, are entering the e-cigarette market, and there is reason to fear that if smokers switch massively to e-cigarettes the pool of nicotine users will eventually need to be refilled with new, young consumers. This is why the marketing and sale of e-cigarettes to young non-smokers should be controlled, but teenage smokers should be allowed to switch to e-cigarettes. In a society where nicotine is widely available, some young people will inevitably try nicotine, and it is preferable for them to use e-cigarettes rather than tobacco cigarettes. Prohibition of e-cigarette sales to minors would not only be difficult to enforce but force new nicotine users to use tobacco.

Paradoxically, the most vocal opponents to e-cigarettes are found among tobacco control activists. They dislike a product that resembles tobacco cigarettes or disapprove of a smoking cessation tool that, being used without their participation or approval, threatens their status. Also, many experts refer to wariness among the public health community after it was fooled by “light” cigarettes—when the tobacco industry deceptively manipulated cigarettes to decrease the amounts of toxic compounds measured by smoking machines. It took many years to show that light cigarettes were in fact as dangerous as regular cigarettes.7

However, e-cigarettes are not a marketing ploy, and their success is explained primarily by their intrinsic qualities. If e-cigarettes are allowed to reach their full potential and become as satisfactory as smoking, there will be little incentive for smokers to continue to smoke. Even if some former smokers remain addicted to the nicotine delivered by e-cigarettes, this is not a public health problem because e-cigarettes have not been proved to be toxic. Thousands of former smokers are addicted to nicotine gum,8 9 and this is not a public health problem either. If governments, parliaments, regulation agencies, and experts are able to restrain their yearning to restrict access to e-cigarettes, these products are likely to represent a revolution in public health.


Cite this as: BMJ 2013;346:f3845


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: JFE was reimbursed by a manufacturer of e-cigarettes and e-liquids for travelling to London and to China to visit e-cigarette factories but received no honoraria for these meetings. JFE has written a book about e-cigarettes.

  • Read Simon Chapman’s side of the debate at doi:10.1136/bmj.f3840.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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