Ethical considerations of e-cigarette use for tobacco harm reduction
Franck et al. Respiratory Research
Ethical considerations of e-cigarette use for tobacco harm reduction
Caroline Franck 1
Kristian B. Filion 0 1 2
Jonathan Kimmelman 5 6
Roland Grad 4
Mark J. Eisenberg 0 1 3 7
0 Department of Epidemiology , Biostatistics and Occupational Health , McGill University , Montreal, QC , Canada
1 Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University , Montreal, QC , Canada
2 Division of Clinical Epidemiology, McGill University , Montreal, QC , Canada
3 Division of Cardiology, Jewish General Hospital, McGill University , Montreal, QC , Canada
4 Department of Family Medicine, McGill University , Montreal, QC , Canada
5 Department of Social Studies and Medicine, McGill University , Montreal, QC , Canada
6 Biomedical Ethics Unit, McGill University Montreal , Montreal, QC , Canada
7 Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University , 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, Quebec H3T 1E2 , Canada
Due to their similarity to tobacco cigarettes, electronic cigarettes (e-cigarettes) could play an important role in tobacco harm reduction. However, the public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear. We identified the major ethical considerations surrounding the use of e-cigarettes for tobacco harm reduction, including product safety, efficacy for smoking cessation and reduction, use among non-smokers, use among youth, marketing and advertisement, use in public places, renormalization of a smoking culture, and market ownership. Overall, the safety profile of e-cigarettes is unlikely to warrant serious public health concerns, particularly given the known adverse health effects associated with tobacco cigarettes. As a result, it is unlikely that the population-level harms resulting from e-cigarette uptake among non-smokers would overshadow the public health gains obtained from tobacco harm reduction among current smokers. While the existence of a gateway effect for youth remains uncertain, e-cigarette use in this population should be discouraged. Similarly, marketing and advertisement should remain aligned with the degree of known product risk and should be targeted to current smokers. Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.
E-cigarettes; Harm reduction; Ethics
Background
Electronic cigarettes (e-cigarettes) have polarized the
public health community unlike any previous alternative
to smoking. Although their efficacy as smoking cessation
aids remains unclear [
1
], anecdotal evidence suggests
that many people have successfully quit smoking with
the use of e-cigarettes. Due to their similarity in form
and function to tobacco cigarettes, e-cigarettes could
play an important role in tobacco harm reduction.
However, intense divisiveness has resulted from the absence
of conclusive evidence demonstrating product safety for
individual and public health. Several ethical issues have
been identified pertaining to their use both as
recreational products and harm reduction devices, including
their potential appeal to non-smokers, their potential to
act as a gateway to cigarette smoking, and their potential
to renormalize a public smoking culture. To this end, we
examined the ethical issues surrounding the availability
and use of e-cigarettes for tobacco harm reduction, with
the objective of understanding their potential
contributions to public health. Specifically, our framework draws
upon tensions between utilitarianism and liberalism in
public health ethics [
2
], the former aiming to produce
the largest public health gains through the greatest
reduction in the burden of disease, and the latter holding
paramount individuals' right to self-determination in
health.
The burden of smoking-attributable disease
Cigarette smoking remains the leading cause of
preventable mortality worldwide, contributing to the death of
approximately 480,000 Americans annually [
3
]. Smoking
also produces substantial morbidity costs: estimates
show that 6.9 million Americans reported major
smoking-related morbidity in 2009, constituting 10.9
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