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Commentaries
References 1. Hall W. G., Gartner C., Forlini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction 2015; 110: 1061–7. 2. Kozlowski L. T. Harm reduction, public health, and human rights: smokers have a right to be informed of significant harm reduction options. Nicotine Tob Res 2002; 4: S55–60. 3. Kozlowski L. T., O’Connor R., Edwards B. Q. Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus. Tob Control 2003; 12: 372–3. 4. Kozlowski L. T. Effect of smokeless tobacco product marketing and use on population harm from tobacco use: policy perspective for tobacco-risk reduction. Am J Prev Med 2007; 33: S379–86. 5. Kozlowski L. T. Prospects for a nicotine-reduction strategy in the cigarette endgame: alternative tobacco harm reduction scenarios. Int J Drug Policy 2015; available online 23 February. doi:10.1016/j.drugpo.2015.02.001 6. Kozlowski L. T. Less-hazardous tobacco use as a treatment for the ‘smoking and health’ problem. Res Adv Alcohol Drug Prob 1984; 8: 309–28. 7. Meier B. M., Shelley D. The Fourth Pillar of the Framework Convention on Tobacco Control: harm reduction and the international human right to health. Public Health Rep 2006; 121: 494–500. 8. Berridge V. Histories of harm reduction: illicit drugs, tobacco, and nicotine. Subst Use Misuse 1999; 34: 35–47. 9. Haidt J. The Righteous Mind: Why Good People are Divided by Politics and Religion. New York: Pantheon Books; 2012. 10. Haidt J. The new synthesis in moral psychology. Science 2007; 316: 998–1002. 11. Alderman J., Dollar K. M., Kozlowski L. T. Understanding the origins of anger, contempt, and disgust in public health policy disputes: applying moral psychology to harm reduction debates. J Public Health Pol 2010; 31: 1–16. 12. Kozlowski L. T. Ending versus controlling versus employing addiction in the tobacco-caused disease endgame: moral psychological perspectives. Tob Control 2013; 22: i31–2. 13. Kozlowski L. First, tell the truth: a dialogue on human rights, deception, and the use of smokeless tobacco as a substitute for cigarettes. Tob Control 2003; 12: 34–36. 14. Applbaum A. I. Ethics for Adversaries: The Morality of Roles in Public and Professional Life. Princeton, NJ: Princeton University Press; 1999. 15. Cope M. B., Allison D. B. White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting. Int J Obesity 2010; 34: 84–88.
ACCOUNTING FOR THE MASTERS OF DECEPTION Hall and colleagues’ paper [1] is a well-constructed, characteristically thoughtful examination of ethical issues associated with banning electronic cigarettes. I suggest that a © 2015 Society for the Study of Addiction
more explicit analysis of the tobacco industry would add to this assessment. Addiction industries [2] are versatile. More than 50 years ago the Board of the Distillers spirits company (now part of Diageo) became alarmed that Aldous Huxley’s vision of a pill-popping brave new world would see them put out of business. Their subsequent search for a relaxing pill led to the thalidomide tragedy [3]. Growing public awareness of carcinogenicity led the tobacco companies to develop low-tar cigarettes for ‘health-conscious’ smokers. This was a cynical exercise, with the companies knowing there was no health benefit for switchers [4]. Electronic cigarettes are different. This technology has been appropriated by the tobacco companies rather than originally developed by them, and has the obvious potential to be of major health benefit if fewer smokers use cigarettes, or use fewer of them [1]. What will this addiction industry do with this technology? It is difficult to know. Ethical analyses are richer the more they are strongly informed by empirical data [5]. Addiction generates profits. We know that decades have been spent skilfully making cigarettes more addictive [6]. ‘Addiction by design’ [7] is also fundamental to the business models of other addiction industries, so it would be somewhat surprising if e-cigarettes prove to be an exception. The tobacco companies have been consistently deceptive over the long term about their motivations and activities [8], complicating ethical analyses. They are governed by the profit imperative and legally mandated to maximize shareholder value [9], and not to act in the public interest. Tobacco companies have been highly stigmatized as their internal workings have been exposed and their political power has been reduced, and they are desperate to reclaim it. Writing from outside the tobacco control community, it is striking how divisive e-cigarettes have been. Individuals within the scientific community who have financial relationships with the tobacco companies are prominent among the advocates of e-cigarettes, although most have no such conflicts. Tobacco control advocates and scientists (in the United Kingdom in particular) are moving towards engaging with the tobacco companies on e-cigarettes, some believing the public relations message that they have changed [10]. Critics see no evidence of this [11]. They are concerned about the use of the concept of tobacco harm reduction [12], just as the concept of alcohol harm reduction was captured by industry interests [13–15]. This appears largely a disagreement about the nature of the tobacco companies and what they will do with e-cigarettes. We do not know whether there have been deliberate efforts aimed at nurturing this division and subverting science, although this must seem very likely Addiction, 110, 1068–1075
Commentaries
to some, including myself, given the history [16,17]. A schism can be expected to serve the interests of the tobacco industry, and not the public interest. Hall and colleagues rightly emphasize the need for consistency in approaches to electronic and conventional cigarettes. The great gains of tobacco control, via demand reduction, contrast with the lack of progress made in regulation of supply. Alongside the licence to operate which we give corporations, we have the right to require that they behave in socially responsible ways. Addiction by design is inherently antisocial. Society should define corporations’ social responsibilities and not simply leave this to the corporations, who do so in their own interests, rather than in the public interest [18]. This lack of regulation of production and supply allows addiction industries to design products to cause addictions to generate greater profits. Indeed, if one wishes to predict the course of future epidemics, one can simply follow the business trends. We should, of course, do more than observe these trends, however, and one possible way forward is to argue that addiction industries merit specific provisions in company law to manage production and supply, as well as marketing, in the public interest. This suggestion significantly extends the levelling-down approach described by Hall and colleagues. Disputes about e-cigarettes would be easier to settle if we had greater control over the content of all cigarettes, and this may be necessary if the public health potential is not to be squandered. Keywords Corporations, electronic cigarettes, ethics, public health, tobacco, tobacco industry. JIM MCCAMBRIDGE Chair in Addictive Behaviours and Public Health, Department of Health Sciences, Faculty of Science, University of York, Heslington YO10 5DD, UK. E-mail: [email protected]
References 1. Hall W., Gartner C., Fortini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction 2015; 110: 1061–7. 2. Adams P. J. Addiction industry studies: understanding how proconsumption influences block effective interventions. Am J Public Health 2013; 103: e35–8. 3. BBC. Thalidomide—The Fifty Year Fight. 2014. http://www. bbc.co.uk/programmes/b0441xct: BBC; 2014. https://www. youtube.com/watch?v=TOdKe9PzKB0 (accessed 12 May 2014). 4. Hurt R. D., Ebbert J. O., Muggli M. E., Lockhart N. J., Robertson C. R. Open doorway to truth: legacy of the Minnesota Tobacco Trial. Mayo Clin Proc 2009; 84: 446–56. 5. Miller F. G., Wendler D. The relevance of empirical research in bioethics. Schizophr Bull 2006; 32: 37–41. © 2015 Society for the Study of Addiction
1073
6. Stevenson T., Proctor R. N. The secret and soul of Marlboro: Phillip Morris and the origins, spread, and denial of nicotine freebasing. Am J Public Health 2008; 98: 1184–94. 7. Schull N. D. Addiction by Design. Princeton, NJ: Princeton University Press; 2014. 8. Bero L. Implications of the tobacco industry documents for public health and policy. Annu Rev Publ Health 2003; 24: 267–88. 9. Wilks S. The Political Power of the Business Corporation. Cheltenham: Edward Eigar; 2013. 10. British American Tobacco. Harm reduction 2015. Available at: http://www.bat.com/group/sites/UK__9D9KCY.nsf/vwPagesWeb Live/DO9DCGG2?opendocument (accessed 12 May 2014). 11. Schick S. F., Glantz S. A. Old ways, new means: tobacco industry funding of academic and private sector scientists since the Master Settlement Agreement. Tob Control 2007; 16: 157–64. 12. Peeters S., Gilmore A. B. Understanding the emergence of the tobacco industry’s use of the term tobacco harm reduction in order to inform public health policy. Tob Control 2015; 24: 182–9. 13. McCambridge J., Kypri K., Drummond C., Strang J. Alcohol harm reduction: corporate capture of a key concept. PLOS Med 2014; 11: e1001767. 14. Caetano R. The alcohol industry’s smoke and mirrors. Addiction 2008; 103: 1231–2. 15. Farrell M. The alcohol industry: taking on the public health critics. BMJ 2007; 335: 671. DOI: 10.1136/bmj. 39337.431667.4E. 16. Oreskes N., Conway E. M. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming. London: Bloomsbury Press; 2010. 17. McGarity T. O., Wagner W. E. Bending Science: How Special Interests Corrupt Public Health Research. Cambridge, MA: Harvard University Press; 2012. 18. Fooks G. J., Gilmore A. B., Smith K. E., Collin J., Holden C., Lee K. Corporate social responsibility and access to policy elites: an analysis of tobacco industry documents. PLOS Med 2012; 8: e1001076.
NUANCES IN THE ETHICAL REGULATION OF ELECTRONIC NICOTINE DELIVERY SYSTEMS We thank the commentators for their thoughtful reflections on our paper. Billie Bonevksi [1] makes a strong case for giving greater weight to equity in regulating electronic nicotine devices (ENDS). Equity is an increasingly important ethical value in this debate, because cigarette smoking is now concentrated among the most disadvantaged citizens in developed countries where cigarette smoking has been reduced substantially by increasing taxes, banning advertising and implementing smoke-free policies. She argues that it is still too early to say if ENDS will Addiction, 110, 1068–1075
Commentaries
References 1. Hall W. G., Gartner C., Forlini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction 2015; 110: 1061–7. 2. Kozlowski L. T. Harm reduction, public health, and human rights: smokers have a right to be informed of significant harm reduction options. Nicotine Tob Res 2002; 4: S55–60. 3. Kozlowski L. T., O’Connor R., Edwards B. Q. Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus. Tob Control 2003; 12: 372–3. 4. Kozlowski L. T. Effect of smokeless tobacco product marketing and use on population harm from tobacco use: policy perspective for tobacco-risk reduction. Am J Prev Med 2007; 33: S379–86. 5. Kozlowski L. T. Prospects for a nicotine-reduction strategy in the cigarette endgame: alternative tobacco harm reduction scenarios. Int J Drug Policy 2015; available online 23 February. doi:10.1016/j.drugpo.2015.02.001 6. Kozlowski L. T. Less-hazardous tobacco use as a treatment for the ‘smoking and health’ problem. Res Adv Alcohol Drug Prob 1984; 8: 309–28. 7. Meier B. M., Shelley D. The Fourth Pillar of the Framework Convention on Tobacco Control: harm reduction and the international human right to health. Public Health Rep 2006; 121: 494–500. 8. Berridge V. Histories of harm reduction: illicit drugs, tobacco, and nicotine. Subst Use Misuse 1999; 34: 35–47. 9. Haidt J. The Righteous Mind: Why Good People are Divided by Politics and Religion. New York: Pantheon Books; 2012. 10. Haidt J. The new synthesis in moral psychology. Science 2007; 316: 998–1002. 11. Alderman J., Dollar K. M., Kozlowski L. T. Understanding the origins of anger, contempt, and disgust in public health policy disputes: applying moral psychology to harm reduction debates. J Public Health Pol 2010; 31: 1–16. 12. Kozlowski L. T. Ending versus controlling versus employing addiction in the tobacco-caused disease endgame: moral psychological perspectives. Tob Control 2013; 22: i31–2. 13. Kozlowski L. First, tell the truth: a dialogue on human rights, deception, and the use of smokeless tobacco as a substitute for cigarettes. Tob Control 2003; 12: 34–36. 14. Applbaum A. I. Ethics for Adversaries: The Morality of Roles in Public and Professional Life. Princeton, NJ: Princeton University Press; 1999. 15. Cope M. B., Allison D. B. White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting. Int J Obesity 2010; 34: 84–88.
ACCOUNTING FOR THE MASTERS OF DECEPTION Hall and colleagues’ paper [1] is a well-constructed, characteristically thoughtful examination of ethical issues associated with banning electronic cigarettes. I suggest that a © 2015 Society for the Study of Addiction
more explicit analysis of the tobacco industry would add to this assessment. Addiction industries [2] are versatile. More than 50 years ago the Board of the Distillers spirits company (now part of Diageo) became alarmed that Aldous Huxley’s vision of a pill-popping brave new world would see them put out of business. Their subsequent search for a relaxing pill led to the thalidomide tragedy [3]. Growing public awareness of carcinogenicity led the tobacco companies to develop low-tar cigarettes for ‘health-conscious’ smokers. This was a cynical exercise, with the companies knowing there was no health benefit for switchers [4]. Electronic cigarettes are different. This technology has been appropriated by the tobacco companies rather than originally developed by them, and has the obvious potential to be of major health benefit if fewer smokers use cigarettes, or use fewer of them [1]. What will this addiction industry do with this technology? It is difficult to know. Ethical analyses are richer the more they are strongly informed by empirical data [5]. Addiction generates profits. We know that decades have been spent skilfully making cigarettes more addictive [6]. ‘Addiction by design’ [7] is also fundamental to the business models of other addiction industries, so it would be somewhat surprising if e-cigarettes prove to be an exception. The tobacco companies have been consistently deceptive over the long term about their motivations and activities [8], complicating ethical analyses. They are governed by the profit imperative and legally mandated to maximize shareholder value [9], and not to act in the public interest. Tobacco companies have been highly stigmatized as their internal workings have been exposed and their political power has been reduced, and they are desperate to reclaim it. Writing from outside the tobacco control community, it is striking how divisive e-cigarettes have been. Individuals within the scientific community who have financial relationships with the tobacco companies are prominent among the advocates of e-cigarettes, although most have no such conflicts. Tobacco control advocates and scientists (in the United Kingdom in particular) are moving towards engaging with the tobacco companies on e-cigarettes, some believing the public relations message that they have changed [10]. Critics see no evidence of this [11]. They are concerned about the use of the concept of tobacco harm reduction [12], just as the concept of alcohol harm reduction was captured by industry interests [13–15]. This appears largely a disagreement about the nature of the tobacco companies and what they will do with e-cigarettes. We do not know whether there have been deliberate efforts aimed at nurturing this division and subverting science, although this must seem very likely Addiction, 110, 1068–1075
Commentaries
to some, including myself, given the history [16,17]. A schism can be expected to serve the interests of the tobacco industry, and not the public interest. Hall and colleagues rightly emphasize the need for consistency in approaches to electronic and conventional cigarettes. The great gains of tobacco control, via demand reduction, contrast with the lack of progress made in regulation of supply. Alongside the licence to operate which we give corporations, we have the right to require that they behave in socially responsible ways. Addiction by design is inherently antisocial. Society should define corporations’ social responsibilities and not simply leave this to the corporations, who do so in their own interests, rather than in the public interest [18]. This lack of regulation of production and supply allows addiction industries to design products to cause addictions to generate greater profits. Indeed, if one wishes to predict the course of future epidemics, one can simply follow the business trends. We should, of course, do more than observe these trends, however, and one possible way forward is to argue that addiction industries merit specific provisions in company law to manage production and supply, as well as marketing, in the public interest. This suggestion significantly extends the levelling-down approach described by Hall and colleagues. Disputes about e-cigarettes would be easier to settle if we had greater control over the content of all cigarettes, and this may be necessary if the public health potential is not to be squandered. Keywords Corporations, electronic cigarettes, ethics, public health, tobacco, tobacco industry. JIM MCCAMBRIDGE Chair in Addictive Behaviours and Public Health, Department of Health Sciences, Faculty of Science, University of York, Heslington YO10 5DD, UK. E-mail: [email protected]
References 1. Hall W., Gartner C., Fortini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction 2015; 110: 1061–7. 2. Adams P. J. Addiction industry studies: understanding how proconsumption influences block effective interventions. Am J Public Health 2013; 103: e35–8. 3. BBC. Thalidomide—The Fifty Year Fight. 2014. http://www. bbc.co.uk/programmes/b0441xct: BBC; 2014. https://www. youtube.com/watch?v=TOdKe9PzKB0 (accessed 12 May 2014). 4. Hurt R. D., Ebbert J. O., Muggli M. E., Lockhart N. J., Robertson C. R. Open doorway to truth: legacy of the Minnesota Tobacco Trial. Mayo Clin Proc 2009; 84: 446–56. 5. Miller F. G., Wendler D. The relevance of empirical research in bioethics. Schizophr Bull 2006; 32: 37–41. © 2015 Society for the Study of Addiction
1073
6. Stevenson T., Proctor R. N. The secret and soul of Marlboro: Phillip Morris and the origins, spread, and denial of nicotine freebasing. Am J Public Health 2008; 98: 1184–94. 7. Schull N. D. Addiction by Design. Princeton, NJ: Princeton University Press; 2014. 8. Bero L. Implications of the tobacco industry documents for public health and policy. Annu Rev Publ Health 2003; 24: 267–88. 9. Wilks S. The Political Power of the Business Corporation. Cheltenham: Edward Eigar; 2013. 10. British American Tobacco. Harm reduction 2015. Available at: http://www.bat.com/group/sites/UK__9D9KCY.nsf/vwPagesWeb Live/DO9DCGG2?opendocument (accessed 12 May 2014). 11. Schick S. F., Glantz S. A. Old ways, new means: tobacco industry funding of academic and private sector scientists since the Master Settlement Agreement. Tob Control 2007; 16: 157–64. 12. Peeters S., Gilmore A. B. Understanding the emergence of the tobacco industry’s use of the term tobacco harm reduction in order to inform public health policy. Tob Control 2015; 24: 182–9. 13. McCambridge J., Kypri K., Drummond C., Strang J. Alcohol harm reduction: corporate capture of a key concept. PLOS Med 2014; 11: e1001767. 14. Caetano R. The alcohol industry’s smoke and mirrors. Addiction 2008; 103: 1231–2. 15. Farrell M. The alcohol industry: taking on the public health critics. BMJ 2007; 335: 671. DOI: 10.1136/bmj. 39337.431667.4E. 16. Oreskes N., Conway E. M. Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Global Warming. London: Bloomsbury Press; 2010. 17. McGarity T. O., Wagner W. E. Bending Science: How Special Interests Corrupt Public Health Research. Cambridge, MA: Harvard University Press; 2012. 18. Fooks G. J., Gilmore A. B., Smith K. E., Collin J., Holden C., Lee K. Corporate social responsibility and access to policy elites: an analysis of tobacco industry documents. PLOS Med 2012; 8: e1001076.
NUANCES IN THE ETHICAL REGULATION OF ELECTRONIC NICOTINE DELIVERY SYSTEMS We thank the commentators for their thoughtful reflections on our paper. Billie Bonevksi [1] makes a strong case for giving greater weight to equity in regulating electronic nicotine devices (ENDS). Equity is an increasingly important ethical value in this debate, because cigarette smoking is now concentrated among the most disadvantaged citizens in developed countries where cigarette smoking has been reduced substantially by increasing taxes, banning advertising and implementing smoke-free policies. She argues that it is still too early to say if ENDS will Addiction, 110, 1068–1075
