Please cite this article in press as: Caponnetto, P., et al. What to consider when regulating electronic cigarettes: Pros, cons and unintended consequences. International Journal of Drug Policy (2015), http://dx.doi.org/10.1016/j.drugpo.2015.03.001 ARTICLE IN PRESS G Model DRUPOL-1533; No. of Pages 6 International Journal of Drug Policy xxx (2015) xxx–xxx Contents lists available at ScienceDirect International Journal of Drug Policy j ourna l h om epage: www.elsevier.com/locate/drugpo Commentary What to consider when regulating electronic cigarettes: Pros, cons and unintended consequences Pasquale Caponnetto a,b,∗ , Daniela Saitta b , David Sweanor c , Riccardo Polosa a,b a Centro per la Prevenzione e Cura del Tabagismo, Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”, Via S. Sofia 78, 95123 Catania, Italy b Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Via Palermo 636, 95121 Catania, Italy c Faculty of Law, University of Ottawa, 75 Laurier Avenue East, Ottawa ON K1 N 6N5, Canada a r t i c l e i n f o Article history: Received 9 November 2014 Received in revised form 3 March 2015 Accepted 7 March 2015 Keywords: Electronic cigarettes Regulation Public health a b s t r a c t Many public health experts, medical research societies, large health organizations and policy makers have expressed concerns about the increased popularity of electronic cigarettes and have pushed for more restrictive measures ranging from complete bans to tight regulations of these products either as medicines or as tobacco products. But these concerns have never been adequately qualified nor quantified. Without judicious assessment and thorough evaluation, regulations may have unintended consequences that can do more damage than good in public health terms. In this article, we will appraise the existing prominent regulatory frameworks for e-cigarettes, namely, general consumer product, medicinal product and tobacco product regulation, to highlight their pros and cons. Moreover, we provide concrete examples of the unintended consequences which may arise from inappropriate regulatory action. © 2015 Published by Elsevier B.V. Introduction Electronic cigarettes (e-cigarettes) are battery-operated devices designed to turn a liquid solution into an aerosol (“vapor”) to simu- late the act of smoking. The base of the liquid solution is propylene glycol and/or vegetable glycerin. The liquid also contains water and flavorings, and may or may not contain nicotine. Puffing activates a heating element in the atomizer and the resulting vapor is inhaled. The original models were designed to closely resemble a regu- lar cigarette, down to an orange LED at the tip that glows when the consumer activates the unit by inhaling. Now, however, many dif- ferent models are available. Some look like traditional cigarettes, cigars, or pipes. Others look similar to a pen, and some even look like small flashlights. Some have LED lights, and some do not. Some are single-use disposables, or use prefilled cartridges, and others have refillable cartridges. They come in numerous shapes and sizes and have different features as a very large number of companies seek a marketplace advantage in catering to those who wish to dis- tance themselves from anything resembling a traditional cigarette ∗ Corresponding author at: Centro per la Prevenzione e Cura del Tabagismo, Azienda Ospedaliero-Universitaria “Policlinico-V. Emanuele”, Via S. Sofia 78, 95123 Catania, Italy. Tel.: +39 0953781537; fax: +39 0953781567. E-mail address: p.caponetto@unict.it (P. Caponnetto). or want a longer battery life, and/or better performance, and/or the personal satisfaction of having cutting-edge technology. The success of e-cigarettes as a tobacco cigarette substitute is such that these products have been rapidly gaining on conventional cigarettes (Adelman, Grainger, Ayala, & Paxton, 2013). According to a recent Wells Fargo prediction analysis, e-cigarette consump- tion could surpass conventional cigarettes within the next decade (Mangan, 2013). The popularity of e-cigarettes’ appears in large part to be related to the fact that they share many similarities with smoking in the behavioural aspect of use (Caponnetto, Campagna, Papale, Russo, & Polosa, 2012; Caponnetto, Russo et al., 2013). Users are predominantly smokers, who report using them long term to reduce cigarette consumption or quit smoking, to relieve tobacco withdrawal symptoms, and to continue having a ‘smoking’ experi- ence (Farsalinos, Romagna, & Tsiapras, 2013; Farsalinos, Romagna, & Tsiapras, 2014), but with much reduced health risks (Farsalinos & Polosa, 2014). Data from clinical trials (Bullen, Howe, & Laugesen, 2013; Caponnetto, Campagna, & Cibella, 2013; Polosa, Caponnetto, & Morjaria, 2011; Polosa, Morjaria, & Caponnetto, 2013) have confirmed that e-cigarettes may help smokers quit smoking or reduce their tobacco consumption long term, thus reducing over- all exposure to toxins and carcinogens. Moreover, the popularity of e-cigarettes appears to be associated with the fact that they can be used in many smoke-free areas, their prices are competitive, and they are perceived as a much less harmful smoking alternative http://dx.doi.org/10.1016/j.drugpo.2015.03.001 0955-3959/© 2015 Published by Elsevier B.V.