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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

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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

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realize the health benefits for low socio-economic status (SES) smokers claimed by their proponents. We agree there needs to be more investigation of their value and some form of regulated access to ENDS is the best way of allowing this to be conducted. Lyn Kozlowski [2] illustrates the ways in which moral biases have truncated ethical analyses of tobacco harm reduction (THR) policies. He reminds us that moral reasoning often involves a motivated search for reasons to justify pre-existing beliefs, as has occurred on both sides of the polarized debate about THR. Each side is convinced of the justice and cogency of its cause, which it supports by the selective citation of equivocal evidence. Each is exasperated by what they see as their opponents’ failure to appreciate the strength of their arguments. This creates a readiness to impute the worst motives to those with whom they disagree (e.g. that advocates of ENDS are in the pay of the tobacco industry or that opponents of ENDS hate smokers). The often acrimonious debate has been a barrier to constructive dialogue and rational policy formation. Jim McCambridge argues [3] that our ethical analysis of ENDS regulations is incomplete without empirical investigations of how the tobacco industry (TI) will use these products. We agree on the desirability of such research, but our focus was on ethical differences about ENDS policies within the tobacco control community (TCC). Views differ within the TCC on what the TI will do with ENDS. Proponents argue that bans will prevent them from using ENDS to discourage quitting. Advocates of ENDS fear that a ban will enable the TI to eliminate a lower-risk nicotine product. Our paper specified the types of regulation most likely to reduce the risks feared by advocates of a ban while encouraging producers who do not have the same major conflicts of interest of ENDS producers owned by the TI. We agree with McCambridge that the tobacco control community should use the advent of ENDS as an opportunity to increase the regulation of all tobacco products. Simon Chapman & Mike Daube claim [4] that the case against a ban has been undermined by observational evidence that smokers who use ENDS are less likely to quit than those who do not. We believe this is a premature conclusion from a small number of prospective studies with conflicting results. It also ignores differences between different ENDS products, different reasons for their use and the possible effects of misleading public warnings about the dangers of ENDS. Brose et al. [5] found a suggestion that smokers who used ‘cigalikes’ daily were more likely to reduce their smoking substantially, but less likely to stop smoking altogether (although the latter was not statistically significant). Analysis of the same data set also found that daily users © 2015 Society for the Study of Addiction

of newer ‘tank’ systems, which deliver nicotine more efficiently than cigalikes, were much more likely to quit successfully than non-ENDS users (27.5 versus 13.5%) [6]. We did not condemn explicitly the type of ENDS promotion and advertising that is allowed in the United States and United Kingdom, but our levelling-down approach to regulation included the same bans on ENDS promotion and advertising as exist for tobacco products. As we argued, we do not have to choose between banning ENDS and laissez faire. A ban on ENDS sales prevents their being used to increase the regulation of tobacco cigarettes. If ENDS proved to be much safer than cigarettes, then we would have a stronger case for removing cigarette sales from convenience stores and supermarkets and for using market forces, e.g. differential taxes on tobacco cigarettes and ENDS, to encourage continuing smokers to switch to ENDS. Nor did we directly criticize misleading risk communications about ENDS products by some public health spokespeople who ignore the potential adverse unintended effects of their messages. These include authoritative unproven claims that there are no differences in health risk between using ENDS and smoking conventional tobacco cigarettes, such as the California Department of Health’s ‘still blowing smoke’ campaign, which implies that ENDS may be more dangerous than combustible cigarettes (e.g. http://stillblowingsmoke.org/ #health). This misinformation about the potential health risks of ENDS may well encourage the dual use and switching from ENDS to cigarettes that public health proponents of a ban profess to be most concerned about preventing. Declaration of interests None. Keywords E-cigarettes, ENDS, ethics. WAYNE HALL1, CORAL GARTNER2 & CYNTHIA FORLINI3 Centre for Youth Substance Abuse, University of Queensland, Brisbane, Australia1, School of Public Health, University of Queensland, Brisbane, Australia2 and University of Queensland Centre for Clinical Research, Brisbane, Australia3 E-mail: [email protected] References 1. Bonevski B. Electronic nicotine devices considered through an equity lens. Addiction 2015; 110: 1069–70. 2. Kozlowski L. T. The truncation of moral reasoning on harm reduction by individuals and organizations. Addiction 2015; 110: 1070–1. Addiction, 110, 1068–1075

Commentaries 3. McCambridge J. Accounting for the masters of deception. Addiction 2015; 110: 1072–3. 4. Chapman S., Daube M. Ethical imperatives assuming electronic nicotine devices (ENDS) effectiveness and safety are fragile. Addiction 2015; 110: 1068–9. 5. Brose L. S., Hitchman S. C., Brown J., West R., McNeill A. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette

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consumption? A survey with a 1-year follow-up. Addiction 2015; 110: 1160–8. 6. Hitchman S. C., Brose L. S., Brown J., Robson D., McNeill A. Associations between e-cigarette type, frequency of use, and quitting smoking: findings from a longitudinal online panel survey in Great Britain. Nicotine Tob Res 2015; 20 April. doi: 10.1093/ntr/ntv078.

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Nuances in the ethical regulation of electronic nicotine delivery systems.

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