Table 1.

Ethical considerations surrounding the availability and use of e-cigarettes

Ethical considerations	Supporting arguments	Opposing arguments	Questions to direct future research
Tobacco harm reduction
Potential for smoking cessation	E-cigarettes may be as effective as the nicotine patch.	Inconclusive evidence of efficacy for smoking cessation.	What is the efficacy of nicotine and non-nicotine e-cigarettes for smoking cessation and reduction?
Potential for smoking reduction	Demonstrated in multiple studies.	Unlikely that cigarette reduction results in significant health benefits.	What is the long-term impact of dual use of e-cigarettes and tobacco cigarettes on health outcomes?
Product safety
Potential for long-term adverse effects	Unknown impact of long-term propylene glycol inhalation.	No documented serious adverse events to date.	What are the long-term safety implications of nicotine and non-nicotine e-cigarette use?
	Propylene glycol inhalation causes short-term respiratory irritation.
Autonomy to use a product of unknown risk	Ethical imperative given informed consent.	Public health concerns trump individual rights.	How should consumer rights be weighed against public health concerns?
Use among non-smokers
Potential to lead to nicotine addiction	Perceived harmlessness may lead never smokers to initiate e-cigarettes.	No evidence for increased nicotine addiction to cause net public health harms.	What is the long-term health impact of nicotine addiction?
Potential gateway effect	Nicotine acts as a priming agent for the brain.	Unclear implications for transitioning to tobacco cigarettes.	How many non-smokers initiating e-cigarettes transition to other tobacco products, including cigarettes?
Use among youth
Potential to lead to nicotine addiction	Minors require protection.	No evidence of increased nicotine addiction causing net public health harms.	How many youth initiating e-cigarettes report continuous long-term product use (1 year or longer)?
	E-liquid flavorings are attractive to youth.
Potential gateway effect	Nicotine is a priming agent for the brain.	Unclear implications for transitioning to tobacco cigarettes.	How many youth initiating e-cigarettes transition to other tobacco products, including cigarettes?
Nicotine poisoning among children	Increased calls to poison control centers.	None.	To what extent can the risk of nicotine poisoning among children be mitigated?
	E-liquid flavors are appealing to youth.
Use in public places
Potential for passive vaping	Stem cell cytotoxicity.	Limited evidence that passive vaping poses significant health concerns.	What is the long-term impact of passive vaping and second-hand vapor exposure?
	Aerosolized nicotine emissions.
Renormalized smoking culture
Potential to subvert decades of anti-smoking efforts	Increased acceptability of smoke-like vapor and smoking behavior.	No evidence that e-cigarettes would be conflated with tobacco cigarettes.	How are the increased awareness and use of e-cigarettes affecting perceptions of cigarette smoking?
Market ownership
Unethical collaboration with the tobacco industry	Public health endorsement of e-cigarettes increases tobacco company market share.	Possible necessity to collaborate with the tobacco industry to achieve public health gains.	What are the public health implications of tobacco industry ownership of major e-cigarette brands?