Education Wellness in Healthcare Assignment

PUBLIC HEALTH ETHICS

Tobacco Control

Smoking Norms and the Regulation of E-Cigarettes Kristin Voigt, DPhil

Electronic nicotine delivery systems (ENDS)—commonly called e-cigarettes—are at the center of a polarized debate. How should they be regula- ted? Central to this debate is the concern that e-cigarettes could lead to the renormaliza- tion of smoking and that the regulation of ENDS should therefore be modeled on the regulation of conventional cigarettes. I argue that arguments

based on the renormalization of smoking can lend support to restrictions on marketing of ENDS, but that such argu- ments are problematic when used to justify restrictions on where ENDS can be used. The debate has been insuf-

ficiently sensitive to the ethi- cal complexities of attempts to manipulate social norms to change health behav- iors; these complexities must also inform the debate about ENDS and their regulation. (Am J Public Health. 2015;105: 1967–1972. doi:10.2105/AJPH. 2015.302764)

ELECTRONIC NICOTINE DELIVERY

systems (ENDS), or e-cigarettes, which mimic the sensation of smoking and deliver nicotine to users in the form of a vapor (an activity known as vaping), are in- creasingly popular. A central

aspect of the debate about how ENDS should be regulated has been the concern that these de- vices could lead to the renormali- zation of smoking and that, for that reason, the regulation of ENDS should be modeled on the regulation of conventional ciga- rettes. In particular, renormaliza- tion arguments feature in calls for regulation with respect to 2 key regulatory issues: the use of ENDS in spaces where conventional cig- arettes are currently prohibited and the advertising and marketing of these products.

I argue that concerns about the renormalization of smoking can lend support to restrictions on the marketing of ENDS, but that these arguments are problematic when used to support restrictions on where these devices can be used. The debate has been insensitive to the ethical complexities of at- tempts to manipulate social norms to change health behaviors; these complexities must also inform the debate about ENDS and their regulation.

BACKGROUND

Electronic nicotine delivery systems typically deliver nicotine in the form of a vapor, created by heating a solution of glycerol or propylene glycol, nicotine, and

flavorings.1 Although ENDS have been available since the early years of the 21st century, they have become the center of a heated debate only in recent years. For some in the public health community, the fact that e-cigarettes mimic the sensation of smoking very closely—in the physical movement, the inhalation of a vapor, and so on—means that they could provide an alternative to conventional cigarettes and be of tremendous benefit for smokers in quitting or reducing their to- bacco consumption. For others, ENDS threaten to “become one of the biggest blunders of modern public health”2 and to undo the significant progress made by to- bacco control over the past few decades.

Regulatory choices must, of course, be informed by the rele- vant facts. A particular problem for the debate about ENDS is that many of the relevant facts are, as yet, uncertain. Perhaps most im- portantly, although ENDS are generally seen as exposing users to fewer toxicants than do conven- tional cigarettes,3 significant un- certainty remains about what ENDS actually contain, whether their use creates health risks for users and bystanders, and how serious that potential risk might be.1 The wide range of different

types of ENDS and manufacturers makes it difficult to assess their potential toxicity.4

Although ENDS may seem like a promising cessation or harm re- duction tool for smokers, insuffi- cient evidence has been produced about the impact of ENDS on smoking behavior.3 A few studies suggest that ENDS are about as effective as nicotine patches in helping smokers quit, but the existing body of research does not allow firm conclusions.5,6 For smokers who continue to smoke while also using ENDS (dual use), the size of the harm reduction achieved is also uncertain: al- though reduced tobacco con- sumption has some health bene- fits, these benefits are generally much smaller than those expected from cessation.1 Despite concerns about growing numbers of youths using e-cigarettes7 and about as- sociations between e-cigarette use and openness to smoking or in- tention to smoke among youths,8,9

the worry that ENDS could act as a gateway to tobacco for young people10 has not been confirmed by currently available evidence.11,12

Finally, the increasing involve- ment of the tobacco industry in the ENDS market1 is a major source of unease for many public health experts, who are concerned that the industry could try to use

October 2015, Vol 105, No. 10 | American Journal of Public Health Voigt | Peer Reviewed | Tobacco Control | 1967

ENDS to maintain or even increase tobacco consumption.13,14 Many experts and organizations—perhaps most notably the World Health Organization (WHO)—have called for tight regulation of these devices. In the United States, the Food and Drug Administration is seeking to include ENDS within its regulatory remit.15

The facts do not, by themselves, answer the question of how ENDS should be regulated. Questions about the regulation of potentially harmful substances also have a normative dimension: they are ultimately about what governments can or should do to protect indi- viduals from harming themselves or others. Although forthcoming evidence will give us a better sense of precisely what harms might be associated with ENDS, the evi- dence must be complemented by a normative argument about the kind and degree of regulation that constitutes an appropriate response to these harms. My focus here is on 1 specific harm that, critics of ENDS have argued, is associated with ENDS—the renormalization of smoking—and the question of what kinds of regulation this concern can justify. Although I argue that the extent of regulation that renormal- ization concerns can justify has been overstated, the argument I present leaves open that other harms that may be associated with ENDS could constitute appropriate grounds for such regulation.

RENORMALIZATION OF SMOKING AND THE E-CIGARETTE DEBATE

Several health organizations, including the WHO, have called

for tight regulation of ENDS, modeled on the regulation of conventional cigarettes, incorpo- rating age restrictions on the pur- chase of these devices along with restrictions on marketing and the use of ENDS in places where conventional cigarettes are cur- rently prohibited.13 A central aspect of arguments to support tight regu- lation is the concern that ENDS will lead to the renormalization of smoking.4,13,16---18 According to the WHO, this concern focuses on the possibility that ENDS “may en- hance the attractiveness of smoking itself and perpetuate the smoking epidemic.”13 Although the effects of ENDS on the norms surrounding the smoking of conventional ciga- rettes are as yet uncertain, this argument has featured prominently in the debate.

The concern about renormali- zation is best understood by first considering denormalization, which in recent years has become an important aspect of tobacco control strategies.19 Denormaliza- tion strategies seek to make smoking less visible and seem less acceptable than it currently is.20 The underlying idea is that because social norms influence behavior, changing the norms surrounding smoking will help, over time, to change smoking be- haviors. Many tobacco control initiatives—such as marketing re- strictions, smoking bans, and pub- lic service announcements depict- ing smoking as smelly, disgusting, or irresponsible—contribute, to greater or lesser degree, to the denormalization of smoking. The dramatic change in social attitudes toward smoking over the course of just a few decades is seen by

many as an important success for tobacco control and has been adopted as an explicit goal in many tobacco control strategies. Conversely, the renormalization of smoking would involve a change of social norms to the effect that smoking would become more visible and would be seen as more desirable than it is now.

RESTRICTIONS ON THE USE OF E-CIGARETTES

How have renormalization ar- guments been used to support arguments for bans on the use of ENDS in places where smoking is currently banned, particularly public and indoor spaces? It is important to distinguish renorm- alization arguments from other, related arguments for such bans, such as that ENDS make it harder to enforce existing smoking bans13

and that ENDS will reduce quit incentives by enabling smokers to consume nicotine in places where smoking is banned.13,21 Renorm- alization arguments are also dif- ferent from concerns about “sec- ondhand vaping,” which have also been raised to support bans on the use of ENDS in public places.1

Although these are of course im- portant considerations that merit further discussion, I focus here on the role that renormalization ar- guments should play in the debate.

The concern that ENDS renormalize smoking is driven by the similarities of ENDS to conven- tional cigarettes, in both their phys- ical appearance and what it looks like when they are used. Perhaps most prominently, the WHO has stated that smoking bans are meant to help denormalize smoking and

that the use of ENDS in public places “may conflict with the smoking denormalizing effect.”13

Similarly, in an open letter to the Department of Transportation written by several organizations (including the American Lung Foundation and the Campaign for Tobacco-Free Kids), one of the reasons cited for a ban on the use of ENDS on airplanes was the renormalization of smoking:

The public health community and local and state authorities have made great strides over the last decade in shifting public atti- tudes away from smoking, espe- cially among youth. Thirty-five states and the District of Colum- bia now have some sort of law prohibiting smoking in at least one type of public place such as bars, restaurants, and/or work- places. Allowing the use of e-cigarettes in closed environ- ments serves to break down this hard-fought social norm and contradict smoking prevention and cessation public health messages.22

The fact that smoking bans have been enormously successful in establishing nonsmoking envi- ronments as the norm23—it has, in fact, been argued that they are the most effective way of denormaliz- ing smoking23,24—lends particular importance to concerns about the use of ENDS in enclosed environments.

However, relying on renormal- ization arguments to make the case for bans on the use of ENDS in spaces where conventional cig- arettes are prohibited raises prob- lems. This argument essentially proposes that an activity be pro- hibited, not because it is in itself problematic, but because it looks like an activity whose use is re- stricted and because of its possible

PUBLIC HEALTH ETHICS

1968 | Tobacco Control | Peer Reviewed | Voigt American Journal of Public Health | October 2015, Vol 105, No. 10

effects on the norms surrounding that activity. Advocates have failed to acknowledge the difficulties with this move. Although the strength of arguments for smoking bans rests to a large extent on the harms of secondhand smoke on third parties, it is not obvious that the goal of shaping smoking norms would by itself be sufficient basis for smoking bans in certain loca- tions. (This issue is also implicit in the debate about smoking bans in outdoor spaces.25---28) Further argument would have to be pro- vided to establish that the goal of shaping smoking norms justifies restrictions of activities that merely look like smoking.

Moreover, it is interesting that alternative policy options to ad- dress the renormalization concern directly have not been considered. Renormalization arguments are driven by the similarities between ENDS use and smoking. However, this similarity varies depending on the characteristics of particular e-cigarettes. Although some ENDS mimic cigarettes quite closely— beige coloring, a red glowing tip, and the vapor produced—many ENDS look decidedly less like conventional cigarettes. Many are black or translucent and notice- ably bigger than cigarettes. Some e-cigarette tips glow in blue rather than red. Perhaps most impor- tantly, some brands produce a va- por that is barely visible. This means that ENDS users often look more like they are sucking on a pen than smoking a conventional cigarette. If we accept the argu- ment that the use of ENDS in public spaces is problematic be- cause it looks like smoking and thus threatens to undermine

antismoking norms, an alternative regulatory approach would be to ban only those ENDS that actually look very similar to cigarettes when used. Many ENDS—in par- ticular those that do not mimic the appearance of a conventional cig- arette and produce little visible vapor—would not fall into this category.

Perhaps the most important concern about renormalization arguments is that the denormali- zation of smoking has not been a straightforward success story. It is worrying that renormalization arguments are used in the ENDS debate without acknowledgment of the concerns that have been raised about denormalization.

First, it is not clear what impact denormalization strategies have had on smoking rates. Some stud- ies suggest that denormalization strategies can help reduce smok- ing rates,29---31but denormalization may also have problematic effects, for example, when it makes smokers less likely to seek help with cessation because they worry about social disapproval.32,33 It is not obvious, therefore, what effect any renormalization result- ing from ENDS would have on smoking rates.

Second, beyond immediate public health concerns, commen- tators have worried that denorm- alization strategies may end up stigmatizing smokers.24,34 Stigma- tization implies that someone who engages in a particular behavior should be seen as “not normal,” deviant and failing to conform to norms of propriety or moral stan- dards.35 Conceptually, the simi- larities between this understand- ing of stigma and the goals of

denormalization—making smoking less visible and seem less desirable—are striking.19 The debate has begun to address the possible links between denormali- zation and stigmatization, including the question of whether it is possi- ble to denormalize smoking with- out also stigmatizing smokers.36---40

The denormalization of smok- ing and our increasingly negative image of smokers may also have contributed to an environment in which it is possible to penalize or discriminate against smokers in different ways; employment poli- cies that exclude job applicants who use tobacco or other nicotine products are a particularly worry- ing case in point.41,42 These de- velopments are particularly prob- lematic because smoking has increasingly become associated with poverty and other forms of disadvantage, such as poor mental health and ethnic mi- nority status.43---45 Denormali- zation strategies therefore risk further burdening individuals who are already facing distinct disadvantages.

In practice, not all tobacco con- trol strategies are likely to have stigmatizing effects, and policies may differ in the significance of any such effects. However, smok- ing bans seem particularly likely to be perceived as stigmatizing by smokers because they send a clear message to smokers that what they are doing is socially unaccept- able.34 In the face of such bans, smokers themselves report that they feel like lepers, marginalized from the rest of society31,46; that they feel ashamed of being smokers and are perceived as lacking strength of character34;

that they feel stigmatized when they smoke in public47; and that others think less of them.32 The language used to discuss smoking bans suggests that such effects are not always an unintended side effect but are in fact part of the rationale for such bans. As Glantz noted in the 1980s, “clear indoor legislation reduces smok- ing because it undercuts the social support network for smoking by implicitly defining smoking as an antisocial act.”48(p747) In this con- text, one of the attractions of ENDS is precisely that they can help smokers evade some of the stigmatization they experience.

Finally, because of its close links to stigmatization, denormalization may also be problematic because it fails to treat individuals with equal concern and respect—a re- quirement that applies to both how governments act toward individuals and how individuals treat one another. Equality re- quires that policies reflect and promote equal concern for the individuals they govern. Nuss- baum has argued that for states to enact policies that seek to shame those who deviate from certain norms is problematic because it conflicts with an appropriate un- derstanding of equality: “[i]n shaming people as deviant, the shamers set themselves up as a ‘normal’ class above the shamed, and thus divide society into ranks and hierarchies.”35(pp231---232) For the state to participate in this “is profoundly subversive of the ideas of equality and dignity on which liberal society is based.”35(p232)

Instead, she argues, states have a duty to protect their citizens from shame and stigma. Policies

October 2015, Vol 105, No. 10 | American Journal of Public Health Voigt | Peer Reviewed | Tobacco Control | 1969

PUBLIC HEALTH ETHICS

that suggest stigmatizing attitudes or encourage people to treat each other in ways that undermine their status as equals are problematic according to this argument. Al- though Nussbaum does not address health-related strategies, including denormalization strate- gies, the concerns she raises apply here.49 The fact that smoking is more prevalent in groups whose social status as equals is already threatened further strengthens this concern.

What does this mean for the e-cigarette debate and for how policymakers should respond to the concern that ENDS might renormalize smoking? What is striking about the renormalization debate is that the possible negative effects of denormalization strate- gies are seldom considered. In- deed, when these arguments are put forward, it is often taken for granted that anything—including ENDS—that might lead us to view not just smoking but also smokers in slightly less negative terms than we currently do will undermine tobacco control efforts. For exam- ple, Maziak notes,

The renormalization of the smoking act through e-cigarettes . . . will likely improve the accept- ability of the smoker’s image in the society in general—a major setback on one of the main factors that helped to reduce smoking worldwide.50(p506)

A more balanced approach would use arguments about smoking norms with greater cau- tion and acknowledge the com- plexities surrounding denormali- zation strategies. It is not clear that denormalization has been straightforwardly positive in its

impact, and, independently of any such effects, strategies that risk stigmatizing individuals run counter to basic commitments of equality. Conversely, if ENDS were to undo some of the stigma that affects smokers, this should not be regarded as an unambigu- ously unwelcome consequence.

MARKETING

A second area of policy regula- tion in which concerns about renormalization have been raised is marketing. Although general regulations regarding advertising that exist in many countries (such as prohibition of unsubstantiated health claims) would interfere with many marketing strategies currently pursued by ENDS pro- ducers, it has been suggested that marketing and advertising of ENDS should be subject to more stringent regulation,13 possibly as stringent as the regulation of con- ventional cigarettes, including bans on TV and radio advertising.1

Renormalization concerns also appear in arguments for this strategy. Two different arguments based on concerns about renorm- alization should be distinguished.

One concern is that ENDS marketing is problematic because of what it does to our perception of ENDS. For example, the WHO expresses the concern that ENDS are “marketed not only as socially acceptable but as socially supe- rior,” which could promote ENDS as a “permanent alternative to tobacco” and could attract chil- dren and nonsmokers to ENDS.13

This concern is driven, in part, by concerns about nicotine addiction. As Grana and Ling note, “Action

must be taken to stop marketing that . . . entices a new generation of nicotine addicts.”51(p402)

Are there good reasons for be- ing concerned about the normali- zation of ENDS themselves? With respect to minors, important con- cerns exist about the effects of nicotine on brain development1

and the undesirability of children accessing an addictive product. Such concerns can justify restric- tions on ENDS marketing that is targeted at minors. Moreover, con- sidering how good companies tend to be at circumventing this kind of legislation (e.g., consider the food industry’s response to bans on marketing targeted at children52), this concern could plausibly justify much broader bans on marketing, similar to those many countries have in place for tobacco.

With respect to adults, how- ever, it is not clear that marketing a nicotine product such as ENDS is problematic at the level of princi- ple (once appropriate legislation on false advertising and unsub- stantiated health claims has been applied). If ENDS turn out to carry only very limited health risks (or if they can be regulated to ensure a low level of health risk) and if consumers are informed about the addictive nature of the product (which might require, e.g., warning labels on product packaging), it is not obvious that the addictiveness of the nicotine is by itself sufficient to justify marketing restrictions. From a philosophical perspective, it is far from clear what, if any- thing, makes addiction in itself problematic.53 The addictiveness of nicotine, then, does not by itself establish the case for restrictions on how ENDS can be marketed.

A second argument for restric- tions on the marketing of ENDS focuses on the potential of such marketing activities to reglamorize smoking.1 Indeed, much ENDS marketing could easily be mis- taken for cigarette advertising.54

Particularly for companies that sell both tobacco and ENDS, the op- portunity to use ENDS advertising to market tobacco products that are subject to much heavier regu- lation will be attractive.

Although this is a renormali- zation argument, it is much less likely to run into the concerns about stigmatization that crop up in the context of bans on where ENDS can be used. The targets of marketing restrictions are com- panies, not individuals, and the goal is to prevent companies from making smoking appear sexy, glamorous, or cool, rather than to actively promote a negative image of smokers.

Although this kind of renorm- alization argument supports bans on the marketing of ENDS, it is important to acknowledge the po- tential costs of such restrictions. If ongoing research establishes that ENDS are effective as a tool for cessation or reduction of tobacco consumption, it will be important that smokers know about these products.4 It will also be impor- tant, therefore, to assess whether restrictions on the marketing of ENDS will interfere with making smokers aware of these products. The interest of smokers in access- ing this information must be taken into account in decisions about marketing restrictions on ENDS if future evidence confirms the effi- cacy of ENDS as a cessation or harm reduction device.

1970 | Tobacco Control | Peer Reviewed | Voigt American Journal of Public Health | October 2015, Vol 105, No. 10

PUBLIC HEALTH ETHICS

CONCLUSIONS

Empirical uncertainties will continue to complicate the debate about ENDS and how they should be regulated. Concerns that these devices could lead to the renormalization of smoking have played a prominent role in the regulation debate. In particular, these concerns have led some to suggest that regulation of where these products can be used and how they can be mar- keted should be modeled on the rules in place for conventional cigarettes.

I argued here that renormaliza- tion concerns do not have the force proponents tend to assume. It is not clear that the denormali- zation of smoking that has oc- curred over the past few decades has been an unequivocally posi- tive development. In particular, critics have been concerned that the shifting norms about smoking have also led to the stigmatization of smokers. This stigmatization not only conflicts with concerns of equality, but also may not have the desired effect on smoking rates.

How ENDS might shape social norms about smoking is, of course, only 1 of several considerations that must play a role in the debate about how these devices should be regulated. Forthcoming empirical research is likely to shed light on some of the many important questions surrounding ENDS for which we currently lack answers. However, it is crucial to remember that the question of how ENDS ought to be regulated cannot be settled by those facts, whatever

they turn out to be. Questions about regulation also have a nor- mative dimension: they are ulti- mately about what governments can or should do with respect to individuals, taking into account population health as well as a range of other social goals. We need more explicit debate about how, if at all, the prevention of a renormalization of smoking might contribute to, or detract from, these goals.

Although the question of how interventions might seek to shape social norms in the pursuit of im- proved health behaviors has been particularly explicit in the tobacco context,27,36,38---40 it is certainly not limited to this area of public health. Suggestions that stigmatization might be helpful in reducing obe- sity55 (though subsequently retracted56) and the use of moral- istic slogans to encourage mothers to breastfeed57 point to other areas where concerns about social norms, attitudes, and stigmatization have been highly relevant. Further re- search should investigate not only the central empirical questions (concerning in particular the vari- ous effects of norm-based interven- tions) but also important normative issues about the acceptability of interventions that seek to leverage negative attitudes in the pursuit of improved health behaviors, partic- ularly in light of the material and social inequalities that make healthy behaviors exceedingly costly and burdensome for many.j

About the Author Kristin Voigt is with the Institute for Health and Social Policy and the Department of Philosophy, McGill University, Montreal, Quebec, Canada. Correspondence should be sent to Kristin

Voigt, 1130 Pine Ave West, Montreal,

Quebec, H3A 1A3, Canada (e-mail: kristin. [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted on May 9,

2015.

Acknowledgments Earlier versions of this article were pre- sented at the Centre for Interdisciplinary Studies at the University of Bielefeld and at the Centre interuniversitaire de recherche sur science et technologie at the Université du Québec à Montréal.

For helpful comments and suggestions, I thank Katherine Frohlich, Kalle Grill, Raphael Lencucha, Adina Preda, and Gry Wester, as well as the reviewers of this journal.

Human Participant Protection No protocol approval was required be- cause no human participants were in- volved.

References 1. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circula- tion. 2014;129(19):1972---1986.

2. Chapman S. Should electronic ciga- rettes be as freely available as tobacco cigarettes? No. BMJ. 2013;346:f3840.

3. McRobbie H, Bullen C, Hartmann- Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev. 2014;12: CD010216.

4. Benowitz NL, Goniewicz ML. The regulatory challenge of electronic ciga- rettes. JAMA. 2013;310(7):685---686.

5. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessa- tion: a randomised controlled trial. Lancet. 2013;382(9905):1629---1637.

6. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. 2014;109(9):1531--- 1540.

7. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study [published correction appears in JAMA Pediatr. 2014;168(7):684]. JAMA Pediatr. 2014;168(7):610---617.

8. Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school

electronic cigarette users: National Youth Tobacco Survey, 2011-2013.Nicotine Tob Res. 2015;17(2):228---235.

9. Coleman BN, Apelberg BJ, Ambrose BK, et al. Association between electronic cigarette use and openness to cigarette smoking among US young adults. Nicotine Tob Res. 2015;17(2):212---218.

10. Kmietowicz Z. E-cigarettes are “gateway devices” for smoking among young people, say researchers. BMJ. 2014;348:g2034.

11. Bell K, Keane H. All gates lead to smoking: the “gateway theory,” e-cigarettes and the remaking of nicotine. Soc Sci Med. 2014;119:45---52.

12. Britton J, Bogdanovica I. Electronic Cigarettes: A Report Commissioned by Public Health England. London, UK: Public Health England; 2014.

13. World Health Organization. Electronic nicotine delivery systems—e-cigarettes. 2014. Available at: http://apps.who.int/ gb/fctc/PDF/cop6/FCTC_COP6_10-en. pdf?ua=1. Accessed September 8, 2014.

14. Abrams DB. Promise and peril of e-cigarettes: can disruptive technology make cigarettes obsolete? JAMA. 2014;311(2):135---136.

15. Cobb NK, Abrams DB. The FDA, e-cigarettes, and the demise of combusted tobacco. N Engl J Med. 2014;371(16): 1469---1471.

16. E-cigarettes: a moral quandary. Lancet. 2013;382(9896):914.

17. E-cigarettes: closing regulatory gaps. Lancet. 2014;383(9927):1438.

18. McKee M. Electronic cigarettes: pro- ceed with great caution. Int J Public Health. 2014;59(5):683---685.

19. Voigt K. “If you smoke, you stink.” Denormalisation strategies for the im- provement of health-related behaviours: the case of tobacco. In: Strech D, Hirschberg I, Marckmann G, eds. Ethics in Public Health and Health Policy: Concepts, Methods, Case Studies. Vol 1. Amsterdam, The Netherrlands: Springer Netherlands; 2013:47---61.

20. Lavack A. Tobacco industry denormalization campaigns: a review and evaluation. 2001. Available at: http:// www.nsra-adnf.ca/cms/file/files/pdf/ lavackpaper.pdf. Accessed January 25, 2011.

21. de Andrade M, Hastings G, Angus K. Promotion of electronic cigarettes:

October 2015, Vol 105, No. 10 | American Journal of Public Health Voigt | Peer Reviewed | Tobacco Control | 1971

PUBLIC HEALTH ETHICS

tobacco marketing reinvented? BMJ. 2013;347:f7473.

22. American Cancer Society Cancer Action Network. Letter to US Department of Transportation. Available at: http:// www.acscan.org/content/wp-content/ uploads/2013/06/DOT-e-cigarette- comments.pdf. Accessed December 3, 2014.

23. Brown A, Moodie C, Hastings G. A longitudinal study of policy effect (smoke- free legislation) on smoking norms: ITC Scotland/United Kingdom. Nicotine Tob Res. 2009;11(8):924---932.

24. Bell K, McCullough L, Salmon A, Bell J. “Every space is claimed”: smokers’ experiences of tobacco denormalisation. Sociol Health Illn. 2010;32(6):914---929.

25. Chapman S. Banning smoking out- doors is seldom ethically justifiable. Tob Control. 2000;9(1):95---97.

26. Bell K. Where there’s smoke there’s fire: outdoor smoking bans and claims to public space. Contemp Drug Probl. 2013;40(1):99---128.

27. Bayer R, Bachynski KE. Banning smoking in parks and on beaches: science, policy, and the politics of denormaliza- tion. Health Aff (Millwood). 2013;32 (7):1291---1298.

28. Colgrove J, Bayer R, Bachynski K. Nowhere left to hide? The banishment of smoking from public spaces. N Engl J Med. 2011;364(25):2375---2377.

29. Hammond D, Fong G, Zanna M, Thrasher J, Borland R. Tobacco denorm- alization and industry beliefs among smokers from four countries. Am J Prev Med. 2006;31(3):225---232.

30. Alamar B, Glantz S. Effect of in- creased social unacceptability of cigarette smoking on reduction in cigarette con- sumption. Am J Public Health. 2006;96 (8):1359---1363.

31. Amonini C, Pettigrew S, Clayforth C. The potential of shame as amessage appeal in antismoking television advertisements. Tob Control. 2015;Epub ahead of print.

32. Stuber J, Galea S, Link BG. Stigma and smoking: the consequences of our good intentions. Soc Serv Rev. 2009;83 (4):585---609.

33. Stuber J, Galea S. Who conceals their smoking status from their health care provider? Nicotine Tob Res. 2009;11 (3):303---307.

34. Kim SH, Shanahan J. Stigmatizing smokers: public sentiment toward ciga- rette smoking and its relationship to

smoking behaviors. J Health Commun. 2003;8(4):343---367.

35. Nussbaum MC. Hiding From Hu- manity: Disgust, Shame, and the Law. Princeton, NJ: Princeton University Press; 2004.

36. Bell K, Salmon A, Bowers M, Bell J, McCullough L. Smoking, stigma and to- bacco denormalization: further reflections on the use of stigma as a public health tool. Soc Sci Med. 2010;70(6):795---799.

37. Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367(9509):528---529.

38. Bayer R. Stigma and the ethics of public health redux: a response to Bell et al. Soc Sci Med. 2010;70(6):800---801.

39. Bayer R. Stigma and the ethics of public health: not can but should we. Soc Sci Med. 2008;67(3):463---472.

40. Bayer R, Stuber J. Tobacco control, stigma, and public health: rethinking the relations. Am J Public Health. 2006;96 (1):47---50.

41. Voigt K. Nonsmoker and “nonnico- tine” hiring policies: the implications of employment restrictions for tobacco con- trol. Am J Public Health. 2012;102(11): 2013---2018.

42. Schmidt H, Voigt K, Emanuel E. The ethics of not hiring smokers. N Engl J Med. 2013;368(15):1369---1371.

43. Voigt K. Smoking and social justice. Public Health Ethics. 2010;3(2):91---106.

44. Barbeau EM, Krieger N, Soobader M- J. Working class matters: socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. Am J Public Health. 2004;94(2):269---278.

45. Action on Smoking and Health. Smoking and health inequalities. 2007. Available at: http://ash.org.uk/files/ documents/ASH_82.pdf. Accessed October 11, 2008.

46. Ritchie D, Amos A, Martin C. “But it just has that sort of feel about it, a leper”— stigma, smoke-free legislation and public health. Nicotine Tob Res. 2010;12(6): 622---629.

47. Phillips R, Amos A, Ritchie D, Cun- ningham-Burley S, Martin C. Smoking in the home after the smoke-free legislation in Scotland: qualitative study. BMJ. 2007;335(7619):553.

48. Glantz SA. Achieving a smokefree society. Circulation. 1987;76(4):746--- 752.

49. Voigt K, Wester G. Relational equality and health. Soc Philos Policy. 2015;31(2):204---229.

50. Maziak W. Harm reduction at the crossroads: the case of e-cigarettes. Am J Prev Med. 2014;47(4):505---507.

51. Grana R, Ling P. “Smoking revolu- tion”: a content analysis of electronic cigarette retail websites. Am J Prev Med. 2014;46(4):395---403.

52. Voigt K, Nicholls SG, Williams G. Childhood Obesity: Ethical and Policy Is- sues. New York, NY: Oxford University Press; 2014.

53. Oddie G. Addiction and the value of freedom. Bioethics. 1993;7(5):373---401.

54. Hunt K, Sweeting H. You have been QUALIFIED for a smokeless e-cig starter kit. J Epidemiol Community Health. 2014;68(8):786.

55. Callahan D. Obesity: chasing an elusive epidemic. Hastings Cent Rep. 2013;43(1):34---40.

56. Callahan D. The author replies. Hastings Cent Rep. 2013;43(3):9---10.

57. Kukla R. Ethics and ideology in breastfeeding advocacy campaigns. Hypatia. 2006;21(1):157---180.

1972 | Tobacco Control | Peer Reviewed | Voigt American Journal of Public Health | October 2015, Vol 105, No. 10

PUBLIC HEALTH ETHICS

Copyright of American Journal of Public Health is the property of American Public Health Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.