Since the adoption of Annex VI of the International Convention on the Prevention of Pollution from Ships, 1973/78, the International Maritime Organization has gradually expanded the scope of ship emission regulation to include VOCs, SOx, NOx, particulate matter and, more recently, greenhouse gas emissions. This regulatory effort has not been integrated and displays some inconsistency and even fragmentation, resulting in different levels of environment protection for different regions and even potential conflicts between standards. The regulation of use and carriage of heavy sulphur fuel oil may lead to increase of clean fuel use and thereby produce more CO2 emissions. Designation of emission control areas under Annex VI has benefitted public health in the Baltic, North Sea and North American waters, but not Arctic waters and coastal communities adjacent to international trade routes elsewhere. This chapter discusses the prospects and pitfalls of ship emissions regulation and argues for the development of an integrated approach consistent with the IMO’s own principles of regulation and enhancement of air emission standards in Arctic waters.