Intended for healthcare professionals

Analysis Essay

E-cigarettes: the best and the worst case scenarios for public health—an essay by Simon Chapman

BMJ 2014; 349 doi: (Published 09 September 2014) Cite this as: BMJ 2014;349:g5512
  1. Simon Chapman, professor of public health
  1. 1School of Public Health, University of Sydney 2006, Australia
  1. simon.chapman{at}

Considerable energy is going into envisioning the likely benefits and harms of the proliferation of e-cigarettes, the use of which is growing exponentially in some countries. Simon Chapman reflects on two possible long term patterns of use and argues that we must not repeat the mistakes with the way in which tobacco was sold and marketed

The World Health Organization’s recent report on electronic nicotine delivery systems repeatedly notes the poverty of evidence to guide policy. It recommends that governments regulate the products, their promotion, and where they can be used in public as well as supporting research into their safety and efficacy in smoking cessation.1 2 The report is due for consideration at the sixth conference of the parties to the WHO Framework Convention on Tobacco Control, which will be held on 13-18 October 2014 in Moscow.

In this essay, I consider the best and worst case scenarios for e-cigarettes; claims that they assist in smoking cessation and their value if users continue to smoke; and, finally, the tobacco industry’s interests in these products.

Best case scenario

The best outcome with e-cigarettes would be a massive, rapid migration of smokers into vaping, akin to the magnitude of the replacement of film by digital cameras. Unparalleled declines in diseases caused by smoking would occur, starting with cardiovascular and respiratory diseases and followed years later by cancers caused by smoking. Overwhelmingly, vapers would be smokers whose principal motivation was smoking cessation. Although some might vape and smoke (“dual users”) temporarily, nearly all would completely quit smoking.

Uptake of vaping among former smokers and never smoking children would be extremely low, and longitudinal studies of children who started vaping would show negligible transition to smoking. Like adults, children would use e-cigarettes as a gateway out of smoking, not into it.

Continuing research would affirm …

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