Ethical considerations of e-cigarette use for tobacco harm reduction

Respiratory Research, May 2016

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.

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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 © 2016 Franck et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data m (...truncated)


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Caroline Franck, Kristian Filion, Jonathan Kimmelman, Roland Grad, Mark Eisenberg. Ethical considerations of e-cigarette use for tobacco harm reduction, Respiratory Research, 2016, pp. 53, 17, DOI: 10.1186/s12931-016-0370-3