We agree with many of the points raised by Dr Middlekauff.1 In comparison with traditional cigarettes it appears that electronic cigarettes (e-cigarettes) are less carcinogenic and their use in lieu of cigarettes would likely lead to less chronic cardiovascular and respiratory disease. In an ideal world, millions of traditional cigarette smokers would switch to the e-cigarette and the global burden of lung cancer, coronary disease, and COPD would dramatically decrease over time. Unfortunately, we do not live in an ideal world, and the dream that e-cigarettes will lead to a decrease in total tobacco consumption may be replaced with the nightmare that e-cigarettes may instead increase the total number of tobacco smokers. At the heart of the argument is the changing demographics of e-cigarette users. Although most states (though no federal laws) prohibit the sale of e-cigarettes to minors, e-cigarettes and nicotine solutions (many with enticing added flavors) are easily purchased online, and the age of the first time e-cigarette user is decreasing. A report from the California Department of Public Health stated that eighth and 10th graders now use e-cigarettes two times more than they do traditional cigarettes, 17% of 12th graders use e-cigarettes, and e-cigarette use among younger adults has tripled in the last year.2 The theoretical concern over e-cigarettes being a “gateway” to tobacco consumption is no longer theoretical, it is a reality. In fact, a recent study reported that 43% of teens using e-cigarettes had a positive intention to use traditional cigarettes in the future.3 Perhaps the best proof of e-cigarettes being a gateway for traditional cigarettes is the fact that “big tobacco” has gotten into the e-cigarette business in a big way.