With so much confusion around electronic cigarettes, Mary Isokariari examines the health and legislation associated with the product.

The controversy surrounding e-cigarettes has been fuelled by public concern and media speculation over the health risks and regulation of these products.
Since e-cigarettes use battery-powered cartridges to produce a nicotine-laced vapour instead of tobacco smoke.  According to a 2014 report from Smoking England, they are at least 20 times safer than smoking cigarettes.
The sector has grown rapidly over the past few years and is estimated to be worth £91.3 million a year. 
According to a survey published by Action on Smoking and Health in July 2014, there are now 2.1 million users of e-cigarettes in Great Britain. And around one third are now ex-smokers.
Although some people use them to stop smoking, they are yet to be regulated in the same way as products like nicotine patches. Other people use them as a way to carry on smoking while avoiding cigarette smoke.
The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing nearly six million people a year.
There are 10 million adult cigarette smokers in the UK and approximately one billion globally. 
Smoking tobacco is the greatest single cause of avoidable ill-health and death, accounting for 80,000 deaths each year in England alone.
E-cigarettes are considered to be a powerful response to help smokers quit. 
University College London (UCL) experts said over 6,000 premature deaths a year could be prevented for every million British smokers who give up tobacco for e-cigarettes.
This would add up to more than 54,000 lives saved every year if all the UK's nine million smokers switched.
There is currently no legal restriction placed on the age at which e-cigarettes may be sold, the majority of these products carry a voluntary age warning that they are not for sale to under 18s.  
Officials say this represents a serious legal loophole at a time when e-cigarettes are becoming increasingly popular with teenagers.
Public Health England (PHE) and Trading Standards Institute recently revealed the results of an investigation, which found retailers were selling e-cigarettes to young people. 
Out of 574 visits made by young people in March 2014, successful purchases were made on 227 occasions (40%).
Professor Kevin Fenton, National Director of Health and Wellbeing, PHE, said the Department of Health was committed to maximising and managing the risks of e-cigarettes.
He added:  “With effective and appropriate regulation, we believe these products can have a real and lasting benefit to public health by helping people to quit tobacco.
“However, we are aware of concerns about young people’s access to e-cigarettes. The report finds that despite age of sale warnings, many retailers are selling e-cigarette products to young people. This is unacceptable.
“This study shows that the government and regulatory authorities need to work closely with retailers in advance of any regulations to ensure that retailers are aware of their legal responsibilities.”
Opponents in favour of tougher restrictions believe e-cigarettes act as a 'gateway' into tobacco; might discourage people from quitting smoking and 'renormalise' smoking in society. 
The World Health Organisation (WHO) has taken a hard line against e-cigarettes, calling for a ban on their use in indoor public places, amid a lack of conclusive evidence about their health effects. 
In the report on electronic nicotine delivery systems (ENDS) published in August, the WHO also suggested restrictions on advertising and on sales to under-18s.
Professor Peter Hajek from the Tobacco Dependence Research Unit at Queen Mary University of London said there was no evidence for the 'gateway' hypothesis.
He said: “There is minimal or no uptake of vaping in non-smokers who experiment with e-cigarettes. In contrast, some 50% of non-smoking youth who experiment with conventional cigarettes become daily smokers.”
Hajek along with other world leading tobacco experts writing in the journal Addiction published on July 31st, attacked the criticisms of e-cigarettes in a review of the WHO's report calling its findings as “misleading.”
Co-author Hajek said: “Smokers should be encouraged to switch from dangerous conventional cigarettes to much safer e-cigarettes. A population level switch would generate huge public health benefits. Alarmist regulation is slowing down this process and protects the market monopoly of conventional cigarettes.”
“There are currently two products competing for smokers’ custom. One, the conventional cigarette, endangers users and bystanders and recruits new customers from among non-smoking children who try it.”
He added: “The other, e-cigarette, is orders of magnitude safer, poses no risk to bystanders, and generates negligible rates of regular use among non-smoking children who try it. 
“The WHO recommendations blur these differences and if followed, will cripple the competitiveness of e-cigarettes and help to maintain the market monopoly of conventional cigarettes.”
The latest research by Action on Smoking and Health (ASH) found that e-cigarettes do not encourage child smoking which has been an area of public concern for some.
ASH compiled the data, which was analysed by Public Health England revealed that experimenting with electronic cigarettes is “closely linked” to current smoking habits.
A report commissioned by the PHE, which was published in May, said it was currently difficult to regulate the marketing of e-cigarettes. 
It stated both independent manufacturers and those owned by the tobacco industry were "investing in almost every conceivable form of promotion from print media to television, sport sponsorship, celebrity endorsement and social media." 
PHE claimed that e-cigarettes marketed as lifestyle products available in a wide range of flavours and packaging more likely to appeal to children and young people. This prompted calls for a consultation by the Advertising Standards Authority (ASA) in the UK.
VIP, which is one of the leading brands for e-cigarettes, said its products featured the 'Not for under 18s symbol', contained a nicotine health warning and were not intended as a replacement therapy. 
Press advertising always contained the following message:  “VIP makes no claim that our products help to quit smoking. VIP is intended for use by existing smokers aged 18 or over as an alternative to tobacco cigarettes. Not to be used by children.” 
A spokeswoman said: “We have voluntarily signed up to this as part of being an ECITA member and we ensure all our staff are trained within our kiosks to age check customers as well to ensure sales are not made to under age persons. We have implemented this before it becomes enforceable in 2015.
She added: "Currently there are no clearly defined rules for advertising and we work very closely with Clear cast when putting together out TV adverts as the ASA have changed what can and can’t be used – for instance we were the first Ecig ad to actually verbalise e cigarettes and e liquids after complaints to the ASA that it wasn’t stated they then allowed us to use this. 
“We also are now able to show the product providing it does not look like a traditional cigarette and also our last TV ad. For TV we are post watershed and we always state that the product contains nicotine and show the ‘no under 18s’ info. This area is clearly evolving as the use of e-cigarettes is increasing.”
A spokesperson for manufacturer Philip Morris said: “We believe all advertising should clearly communicate the relative risk profile of e-cigarettes to adult smokers. Restrictions should limit the exposure of advertising to minors and any appeal to non-smokers. Furthermore, they should clearly state that nicotine is an addictive substance and that these products are not risk-free.” 
However, blu-eCigs, the best-selling American e-cigarette brand, which is now available nationwide, said it only broadcasted after 9pm and "target publications with a readership, which is 85% adult." 
A spokeswoman said: “blu-eCigs products are not medicinal products or a form of nicotine replacement therapy for adult smokers; they provide a modern alternative to traditional cigarettes. We welcome reasonable regulation of electronic cigarettes that is grounded in sound science, however it is premature to draw any conclusions such as this at this stage as other publicly available studies state precisely the opposite.” 
Currently e-cigarettes are subject to general consumer protection laws.
New powers in the Children and Families Act 2014 allow for the introduction of a ban on selling e-cigarettes to under 18s. 
The same legislation will make it illegal for adults to buy electronic cigarettes and normal cigarettes for children, but this is yet to be enacted.
In 2010, the Medicines and Healthcare products Regulatory Agency (MHRA), encouraged companies to submit medicine license applications voluntarily or e-cigarettes to be approved as medicines. 
The European Union is revising the Tobacco Products Directive so that electronic cigarettes below a certain nicotine threshold can be sold with health warnings covering 30% of the pack. Above this nicotine threshold, e-cigarettes will have to be authorised by MHRA as over-the-counter medicines in the UK. 
This will come into effect from May 2016 with mandate requirements such as advertising restrictions in line with existing tobacco advertising rules.  
The Tobacco Products Directive say strengthening rules on tobacco products is to assure a high level of public health due to new scientific evidence, the explosion of e-cigarettes and strongly flavoured tobacco products, which have emerged on the market.