Ethical considerations of e-cigarette use for tobacco harm reduction

Abstract

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.

Keywords: E-cigarettes; Ethics; Harm reduction.

Fig. 1

The risk/use equilibrium. Each point on this curve indicates the multiplier needed to achieve a constant level of population risk, given specific levels of decreased danger per user. For example, if 100 individuals used a product with full danger (for example, killing 100 % of users), 10 times that number (1000 individuals) would need to use a product that had 90 % decreased danger, to achieve an equal health problem (100 dead in each instance). The formula is Y = 100/100-X, where Y = multiplier and X = decrease in danger, expressed in percentages. If danger is 0.1 %, use would have to increase by 1000 times to produce a problem of the same magnitude as the full risk product (not plotted on figure). For a given risk on the curve, use that is increased by a smaller multiplier represents a public health benefit, and use that is increased by a larger multiplier represents a public health (population level) cost. Figure and legend reproduced from [47] with permission from BMJ Publishing Group Ltd.