Electronic nicotine delivery systems: emerging science foundation for policy

Since they were first marketed in China in 2004, electronic nicotine delivery systems (ENDS) have spread globally like wildfire. Their proponents, who refer to the products as “electronic cigarettes” or “E-cigs”, argue that by delivering nicotine to the lung, they are more effective and acceptable than nicotine replacement medicines, and should be readily available as cigarette substitutes. An internet search using terms such as “electronic cigarette” reveals that the products vary widely in form, names, and nicotine delivery claims and health claims. Flavours include “tobacco” as well as cherry and other candy-like flavours banned for use in cigarettes in the USA1 and recommended for banning by the World Health Organization (WHO).2 ENDS marketers claim benefits: “cancer causing chemicals found in tobacco cigarettes are not found in electronic cigarettes”, “not any toxins”, “no first or second hand smoke”, “tobacco-like taste and flavors”, “won't stain teeth or damage skin”, “increase productivity and promote the potential health benefits”, “its emissions are simply water vapor” and “quit smoking”.3–5 Many public health authorities caution that the risks and benefits of ENDS have not been adequately studied, that they may not deliver nicotine as claimed and may deliver more toxicants than claimed. There is also concern that ENDS may undermine smoking prevention, cessation and clean air laws.6 7 Some countries have banned ENDS until they are adequately studied (eg, Brazil, Canada, Uruguay, Singapore, Turkey).7 The foregoing has occurred in virtual absence of published data on the contents, emissions and effects of the products. For medicines, and even for foods with health claims, manufacturers must conduct studies of safety and efficacy. Little verifiable data support ENDS promotion—and some implied claims are profound: “you can keep smoking with little or no risk …