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Research Report
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
Estimating the Harms of
Nicotine-Containing Products
Using the MCDA Approach
David J. Nutt a Lawrence D. Phillips b David Balfour f H. Valerie Curran c
Martin Dockrell d Jonathan Foulds h Karl Fagerstrom i Kgosi Letlape k
Anders Milton j Riccardo Polosa l John Ramsey e David Sweanor g
a Imperial College London, UK;
b Department of Management, London School of Economics and Political
Science, and Facilitations Ltd., UK;
c University College London, UK;
d Action on Smoking and Health London,
UK;
e TICTAC Communications Ltd. at St. George’s, University of London, London , UK;
f University of Dundee,
Dundee , UK; g Faculty of Law, University of Ottawa, Ottawa, Canada;
h Pennsylvania State University, College
of Medicine, Hershey Pa., USA;
i Fagerström Consulting, Vaxholm, Sweden; j World Medical Association, Milton
Consulting, Stockholm, Sweden;
k World Medical Association, Johannesburg , South Africa; l Centre for the
Prevention and Cure of Tobacco Use, University of Catania, Catania , Italy
vided a single, overall score for each product. Cigarettes
(overall weighted score of 100) emerged as the most harmful
product, with small cigars in second place (overall weighted
score of 64). After a substantial gap to the third-place prod-
uct, pipes (scoring 21), all remaining products scored 15
points or less. Interpretation: Cigarettes are the nicotine
product causing by far the most harm to users and others in
the world today. Attempts to switch to non-combusted
sources of nicotine should be encouraged as the harms from
these products are much lower. © 2014 S. Karger AG, Basel
Introduction
The recreational use of tobacco remains one of the
principal causes of chronic ill health and early deathworld-
wide. The tobacco epidemic was largely reflected in more
affluent Western countries but, increasingly, the illnesses
associated with tobacco use have spread to the developing
world
[1] . Cigarettes are considered to be the most harm-
Key Words
Smoked tobacco products · Oral tobacco products ·
Electronic cigarettes · Multi criteria decision analysis ·
Harm assessment · ENDS (electronic nicotine delivery
systems)
Abstract
Background: An international expert panel convened by the
Independent Scientific Committee on Drugs developed a
multi-criteria decision analysis model of the relative impor-
tance of different types of harm related to the use of nico-
tine-containing products. Method: The group defined 12
products and 14 harm criteria. Seven criteria represented
harms to the user, and the other seven indicated harms to
others. The group scored all the products on each criterion
for their average harm worldwide using a scale with 100 de-
fined as the most harmful product on a given criterion, and
a score of zero defined as no harm. The group also assessed
relative weights for all the criteria to indicate their relative
importance. Findings: Weighted averages of the scores pro-
Received: December 23, 2013
Accepted: January 30, 2014
Published online: April 3, 2014
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David Nutt
Imperial College London
Burlington Danes Building
London W12 ONN (UK)
E-Mail d.nutt @ imperial.ac.uk
© 2014 S. Karger AG, Basel
1022–6877/14/0205–0218$39.50/0
www.karger.com/ear
is is an Open Access article licensed under the terms of the
Creative Commons Attribution-NonCommercial 3.0 Un-
ported license (CC BY-NC) (www.karger.com/OA-license),
applicable to the online version of the article only. Distribu-
tion permitted for non-commercial purposes only.
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
219
ful tobacco product although other forms of tobacco used
recreationally may also result in harm to the user
[2] .
It is now widely accepted that the compulsive use of
tobacco reflects the development of dependence upon the
nicotine present in tobacco and many of the pharmaco-
logical interventions that are employed to aid smoking ces-
sation target this dependence
[3, 4] . However, in experi-
mental animals, nicotine does not have the potent addic-
tive properties that are required to explain the powerful
addiction to tobacco experienced by many habitual smok-
ers
[5, 6] . Thus, it has been proposed that other pharmaco-
logically active substances present in tobacco smoke and
the conditioned sensory stimulation associated with inhal-
ing tobacco smoke have a significant role in the develop-
ment of dependence upon tobacco
[7–10] . Pharmacologi-
cal nicotine replacement products (NRT) were introduced
as aids to smoking cessation in the late 1970s and continue
to be used extensively in the treatment of tobacco depen-
dence. Experience with these preparations suggests that
their use is not associated with an increased risk of chron-
ic obstructive pulmonary disease, lung cancer or cardio-
vascular disease
[3, 11] although there are reports that nic-
otine may be metabolized to compounds that are poten-
tially carcinogenic
[12, 13] . Furthermore, studies with
experimental animals suggest that the ingestion of nico-
tineduring pregnancy can have adverse effects on the brain
development of the fetus and the vulnerability of the prog-
eny to nicotine dependence
[14, 15] . Relatively little direct
information is available for the effects of maternal nicotine
on human development and behaviour. However, smoke-
less tobacco has been found to have a negative effect
[16]
and Bruin et al.
[17] have argued that the possibility of
adverse effects for both the mother and fetus of NRT use
during pregnancy should not be disregarded. Thus, indi-
vidual researchers have expressed differing opinions on
the safety of pharmacological nicotine. Nevertheless, some
40 years’ experience with NRT preparations suggest that
they are safe and are not associated with significant adverse
medical consequences
[4] . This conclusion is consistent
with the compelling evidence that many of the adverse
health effects of inhaling tobacco smoke are caused by oth-
er components of the smoke such as nitrosamines, carbon
monoxide and nitric oxide
[18, 19] . Thus, despite some
differences in opinion, it seems that tobacco use lends itself
rather better than many other forms of addiction to a harm
reduction approach using pharmacological interventions
including therapeutic nicotine preparations.
Most attention with regard to the harmful effects of
tobacco use has focused on cigarettes and the evidencethat
they cause chronic illness and early death is compelling.
However, other forms of tobacco use also need to be con-
sidered. There is good evidence, for example, that Swedish
snus, a form of refined oral tobacco which is low in nitro-
samines, is at worst only weakly associated with an in-
creased risk of cancer or cardiovascular disease
[20] . By
contrast, other smokeless unrefined oral tobacco prod-
ucts seem to be associated with significantly more harm
to the user
[21] . For example, the chronic use of gutkha,
a form of smokeless tobacco popular with members of the
Asian community, is associated with the development of
disorders of the oral mucosa and oral cancer
[22] . Water
pipes, widely used in the Middle East, are finding increas-
ing favour in Western society. The potential toxic effects
of water pipe smoke have not yet been fully evaluated al-
though some concerns have been expressed about the po-
tential adverse consequences for health of using this form
of tobacco
[23, 24] . Our understanding of the potential
hazards associated with using electronic nicotine delivery
systems (ENDS, e.g. E-cigarettes) is at a very early stage.
These delivery systems are seen as an acceptable form of
recreational nicotine use with a minimal potential for sec-
ond-hand environmental contamination. Nevertheless,
there is concern that these devices should not be intro-
duced in an unregulated way until potential associated
harms are adequately evaluated
[25] .
There remains a need for policy makers to become bet-
ter informed of the relative harms of nicotine delivery sys-
tems in order to build a regulatory framework that mini-
mizes harm. The aim of the current study was to convene
a group of experts with expertise in the field of nicotine and
tobacco research from different disciplines (animal and be-
havioural pharmacology, toxicology, medicine, psychiatry,
policy and law) that could discuss and agree on the harm-
fulness of nicotine-containing products using a multi-cri-
teria decision analysis (MCDA) model and, thus, provide a
sound framework within which policy makers might work.
M e t h o d s
Study Design
The Independent Scientific Committee on Drugs selected ex-
perts from several different countries to ensure a diversity of ex-
pertise and perspective, as evident from the author list. The MCDA
process
[26] was conducted during a 2-day facilitated workshop
held in London in July 2013. The MCDA model for the harm of
psychoactive drugs developed by the Independent Scientific Com-
mittee on Drugs in 2010
[27] provided a starting point for this
nicotine harm study, as it covered all the potential parameters of
harm that might potentially be caused by any drug.
The MCDA process is a way to compare variables of harm in
widely different areas where traditional metrics are not available.
It works through a series of eight stages: (1) establishing context;
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Nutt etal.
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
220
(2) agreeing on the products to be evaluated and producing defini-
tions of these; (3) agreeing on the criteria on which the products
were to be compared; (4) scoring the products on each criterion;
(5) weighting the criteria; (6) calculating weighted scores to give
an overall index of the harm of each product; (7) examining results
and resolving any inconsistencies, and (8) exploring the sensitivity
of the indices to different assessments of scores and weights.
The Context
The group recognized that there are regional and national dif-
ferences in actual and perceived harm of nicotine products, so par-
ticipants agreed to take a worldwide perspective and consider aver-
age harm.
The Nicotine Products
After considering many nicotine products and the criteria for
comparing the products, the group discussed steps 2 and 3 above in
a reciprocal and iterative way so that the final set of products was
substantially different from one another in important ways. Table1
gives the final agreement about the products and their definitions.
The Criteria of Harms
The group reviewed the 16 criteria that had first been agreed by
the UK Advisory Council on the Misuse of Drugs
[28] and used by
the Independent Scientific Committee on Drugs in their 2010 deci-
sion conference on 20 psychoactive drugs
[27] . All but two criteria
were retained but where necessary were redefined to be relevant to
nicotine products. The two that were dropped were drug-specific
and drug-related mental impairment as it was thought that there
was little evidence for these with any of the nicotine products.
The criteria against which the products were evaluated are shown
at the extreme right of the harm tree in figure 1 . The main objective
was to determine an ordering of the products at the ‘Product harms’
node. The next level to the right provides separate harm groupings
of the criteria: ‘To users’ (harm to those who are using the product)
and ‘To others’ (harm as a consequence of the use of the product to
others both directly and indirectly). Assessments of the harms for all
products were made against the criteria given at the extreme right of
the value tree. The final definitions are shown in table2 .
Scoring the Products
The group scored all products on all criteria. The scoring sys-
tem used points out of 100, with 100 assigned to the most harmful
product on a given criterion and zero representing ‘no harm’.
In scaling the products, care is required to ensure that each suc-
cessive point on the scale represents equal increments of harm.
Thus, if a product is scored at 50, then it should be half as harmful
as the product scored 100. Because zero represents no harm, this
scale can be considered a ratio scale, which makes possible ratio
comparisons of the weighted scales.
Weighting
Some criteria are more important expressions of harm than oth-
ers, so weighting of the criteria is required. ‘Swing weighting’ pro-
vides weights that are meaningful in MCDA. As an analogy, both
Fahrenheit and Celsius scales contain 0–100 portions, but the swing
in temperature from 0 to 100 on the Fahrenheit scale is, of course,
a smaller swing in temperature than 0–100 on a Celsius scale; it
takes 5 Celsius units to equal 9 Fahrenheit units. The purpose of
weighting is to ensure that the units of harm on the different harm
scales are equivalent, thus enabling weighted scores to be compared
and combined across the criteria. Weights are scale factors.
To assess scale factors two steps in thinking must be separated.
First, it is necessary to think about the difference in harm between
the most and least harmful products on that criterion. The next step
is to think about how much that difference in harm matters in a giv-
en context. ‘How big is the difference in harm and how much do you
care about that difference?’ This is the question that was posed in
comparing the 0-to-100 swing in harm on one scale with the 0-to-100
swing on another scale, assuming the harm is a worldwide average.
Swing weights for the User criterion were assessed first; the
largest swing, on Product-specific morbidity, the difference be-
tween cigarettes and nasal sprays was assigned a weight of 100.
Next, weights were judged for the criteria at the Other node: the
largest swing, the difference between cigarettes and small cigars for
Economic cost, was set at 100. Finally, those two 100’s were com-
pared by judging their swing weights. The swing for Product-re-
Table 1. The 12 products considered during the decision confer-
ence and their definitions
Cigarettes manufactured and hand-rolled cigarettes in which
the tobacco is wrapped in paper
Cigars smoked cigars: roll of tobacco wrapped in tobacco
leaf
Little and
small cigars
used like a cigarette wrapped in tobacco leaf,
sometimes with a filter (a product that has
emerged in response to the US tobacco taxation
system and would, in most jurisdictions be
considered cigarettes)
Pipes a tube with a small bowl at one end for smoking
tobacco
Water pipe a pipe where tobacco smoke is bubbled through
water
Smokeless
refined
non-snus (and other) smokeless refined tobacco
products used orally, including moist chewing
tobacco and snuff (common in USA)
Smokeless
unrefined
non-snus (and other) smokeless unrefined
tobacco products used orally, including chewing
tobacco and dry snuff (products common in SE
Asia)
Snus a low nitrosamine and non-fermented smokeless
tobacco product (popular in Scandinavia and now
in USA)
ENDS electronic nicotine delivery system products,
e.g. e-cigs (electronic cigarettes either cigarette-
like or personal vaporizers)
Oral
products
oral nicotine delivery products (including NRT
products)
Patch dermal nicotine delivery products
Nasal sprays nasal nicotine delivery products
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
221
Community
Economic cost
International damage
Family adversities
Environmental damage
Crime
Injury
Loss of relationship
Loss of tangibles
Dependence
Product-related morbidity
Product-specific morbidity
Product-related mortality
Product-specific mortality
To users
To others
Product harms
Fig. 1. Evaluation criteria organized by
harms to users and harms to others.
Table 2. Definitions of the evaluation criteria for the nicotine products
Name Description
Product-specific
mortality
deaths directly attributed to product misuse or abuse as in the case of accidental and deliberate poisoning
Product-related
mortality
deaths indirectly attributed to the product, e.g. death due to cancer, respiratory illness, cardiovascular disease and fire
Product-specific
morbidity
damage (morbidity, chronic ill health) to physical health directly attributed to product misuse or abuse, e.g. ulcers,
lung disease, heart disease
Product-related
morbidity
damage to physical health indirectly attributed to product misuse or abuse, e.g. burns, allergies
Dependence extent to which the product creates a propensity or urge to continue use despite adverse consequences and causes
withdrawal symptoms on cessation
Loss of tangibles extent of loss of tangible things (e.g. income, housing, job)
Loss of relationships extent of loss of relationships with family and friends
Injury the extent to which the product increases chances of injuries to others both directly and indirectly, e.g. traffic accident,
fetal harm, second-hand smoke, accidental poisoning, burns
Crime the extent to which the use of the product increases criminal behaviour (e.g. smuggling) directly or indirectly (at the
population level, not the individual)
Environmental
damage
the extent to which the use and production of this product causes environmental damage locally, e.g. fires, competition
for arable land, cigarette stub pollution
Family adversities
the extent to which the use of the product causes family adversities, e.g. economic well-being, future prospects of children
International
damage
the extent to which the use of the product contributes to damage at an international level, e.g. deforestation,
contraband as criminal activity, counterfeiting
Economic cost the extent to which the use of the product results in effects that create direct costs to countries (e.g. health-care costs,
customs) and indirect costs (e.g. loss of productivity, absenteeism)
Community
the extent to which the use of the product creates decline in social cohesion and decline in the reputation of the community
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Nutt etal.
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lated morbidity was weighted as the larger harm that matters, so
its weight of 100 was retained. The swing for Economic cost was
assessed as 70% of that, so the original weights for all the Econom-
ic criteria were multiplied by 0.70.
As scores and weights were agreed, they were input to the Hiview
computer program
1
, which normalized the weights so they summed
to 100, calculated the weighted scores and displayed the results.
R e s u l t s
Figure 2 shows the overall weighted scores of the nico-
tine products as stacked bar graphs. Cigarettes and small
cigars are each several times more harmful than any of the
other products. Similarly coloured sections of the bar
graphs show a given criterion’s weighted harm value as it
contributes to the overall weighted scores of the nicotine
products. Thus, Product-related mortality and Product-
specific morbidity are the main harms for cigarettes and
small cigars, while Economic cost is also a substantial
contributor to the overall harm for cigarettes.
The stacked bar graphs can also be shown for their
separate contributions of harm ‘To users’ and harm ‘To
others’. Figure 3 gives the harm to users as the blue sec-
tion, and harm to others as red. Harm to others makes a
substantial contribution only to cigarettes, and virtually
none to the other 11 products.
Why are cigarettes considered the most harmful? Figure
4 shows the contribution that each criterion makes to ciga-
rettes’ total weighted score. Each row in the display gives the
part-score for that criterion (Wtd Diff), and it is the sum of
those part scores that gives the overall score of 99.6. These
part-scores determine the relative heights of each of the
coloured bands for the cigarettes’ bar graph in figure 4 .
Notethat cigarettes were assigned harm scores of 100 on 12
of the 14 criteria, but that just five of those 14 collectively
contribute a score of 92.7, nearly as much as the total of 99.6.
Both cigarettes and small cigars score 100 on three of
the most important criteria: Product-specific morbidi-
Fig. 2. Overall weighted scores for each of the products. Cigarettes,
with an overall harm score of 99.6, are judged to be most harmful,
and followed by small cigars at 67. The heights of the coloured por-
tions indicate the part scores on each of the criteria. Product-relat-
ed mortality, the upper dark red sections, are substantial contribu-
tors to those two products, and they also contribute moderately to
cigars, pipes, water pipes, and smokeless unrefined. The numbers
in the legend show the normalized weights on the criteria. Higher
weights mean larger differences that matter between most and
least harmful products on each criterion.
Color version available online
1 An MCDA computer program first developed at the London School of Eco-
nomics and Political Science and now available from Catalyze Ltd., www.
catalyze.co.uk.
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
223
ty, Product-related mortality and Dependence. Those
three are harms to the users, criteria which do not take
account of the extent of usage worldwide. However, cig-
arettes also score 100 on Economic cost and Injury,
which are harms to others that do take account of glob-
al usage. It is those two criteria that account for the dif-
ference in the total scores of cigarettes compared to
small cigars.
Discussion
Perhaps not surprisingly, given their massively great-
er use as compared with other products, cigarettes were
ranked the most harmful, followed by small cigars as two
thirds as harmful. It is only the relative lack of harm to
others that positioned small cigars at two thirds the harm
of cigarettes. For both these products the bulk of the
Fig. 3. The products ordered by their over-
all harm scores, with the stacked bar graphs
showing the contribution to the overall
score of harms to users and harm to others.
The numbers in the legend show the sums
of the normalized weights at each node.
Fig. 4. The relative harms of cigarettes. The
cumulative weight (Cum Wt) column
shows the normalized weight for each cri-
terion. The harm score for cigarettes,
shown in the Diff column, on each criteri-
on is multiplied by the cumulative weight
of the corresponding criterion to give a
weighted score (i.e., a part-score), shown in
the Wtd Diff column. The lengths of the
green bars are proportional to the weighted
scores, so the longer the green bars, the
more that harm matters for its effects from
cigarettes.
Color version available onlineColor version available online
0
10
20
30
40
50
60
70
80
90
100
To users 67££
To others 33£
Cigarettes
Small cigars
Pipes
Cigars
Water pipe
Smokeless unrefined
Smokeless refined
Snus
ENDS
Nasal sprays
Oral products
Patch
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harm came from morbidity and mortality areas such as
cancer, respiratory and cardiovascular disease, followed
by Economic cost, Injury and Dependence. There was a
big drop in harm from small cigars (67% of maximum
relative harm, MRH) to pipes 22%. Within the tobacco
products there was a gradual reduction in harm from
water pipe, smokeless unrefined, smokeless refined to
snus that has 5% of MRH. Among the purer non-tobacco
vehicle products ENDS were rated to have only 4% of
MRH and for the even purer NRTs the MRH was only
rated at about 2%. Thus there is wide variability in harm
among the combustible tobacco-based products, from
cigarettes (100%) to water pipe (14%) and even more
within the tobacco-based category, from cigarettes
(100%) to snus (5%). Not surprisingly the purest prod-
ucts, NRTs, with few other ingredients than nicotine
were the least harmful and pose little risk for intrinsic
harm when used for the treatment of tobacco depen-
dence. Indeed their use would bring significant benefits
not just to users but also to non-smokers and society as
a whole.
Clearly this exercise speaks to a continuum of harm
from nicotine-containing products with cigarettes at
one end and NRT products at the other end. The differ-
ences between the products are substantial and if policy
actions could help to switch use away from cigarettes
and other smoked products to purer nicotine products,
such as NRT products, massive public health gains
would occur.
There is also some evidence that the cigarettes are the
most dependence-forming product and products with
less harm also may be less dependence-forming
[9] . An
analogue can be found with alcohol where most coun-
tries have policies that steer consumption as much as
possible to alcohol-containing beverages with a low alco-
hol content.
A limitation of this study is the lack of hard evidence
for the harms of most products on most of the criteria.
That is why we adopted the decision conferencing pro-
cess: the group of experts worked face-to-face in a peer-
review setting with impartial facilitation, sharing relevant
data, knowledge and experience to ensure that all per-
spectives were heard. It is the combination of impartial
facilitation, modelling (in this case, MCDA), and infor-
mation technology (projecting the MCDA model for the
group to observe as it was constructed and explored) that
enables a group to outperform its members, thus provid-
ing the best collective expertise of the experts
[28] . An-
other weakness might be the kind of sample of experts.
There was no formal criterion for the recruitment of the
experts although care was taken to have raters from many
different disciplines.
Even if data were available for all the harms of all the
products on all the criteria, judgements would still be re-
quired to assess swing-weights. While the magnitude of
harm of the most harmful product on each criterion can
be informed by data, how much that worst-best differ-
ence matters requires an act of judgement. In this way,
MCDA separates matters of fact from value judgements.
As value judgements are at the heart of political debate, it
might be instructive to engage in a public consultation
exercise to allow different constituencies to express their
views about the weights. This could be a first step in ini-
tiating a structured deliberative discourse about nicotine-
containing products, as the politicians, the law and the
public might weight the harm criteria differently
[29] . In
addition, including the benefits of using nicotine prod-
ucts along with the harmful criteria might provide in-
sights into the nature of the benefit-harm balance.
The results of this study suggest that of all nicotine-
containing products, cigarettes (and small cigars in the
USA) are very much the most harmful. Interventions to
reduce this pre-eminence are likely to bring significant
benefits not just to users but also to non-smokers and so-
ciety as a whole. Attempts to use other forms of nicotine
such as ENDS and NRT to reduce cigarette smoking
should be encouraged as the harms of these products are
much lower.
Acknowledgement
The authors would like to thank Euroswiss Health ( Switzerland)
for funding and LIAF (Lega Italiana Anti Fumo) for supporting
this research.
Disclosure Statement
The sponsor of the study had no role in any stage of the
MCDA process or in the writing of this article, and was not pres-
ent at the workshop. All authors had full access to all the data in
the study, and had final responsibility for the decision to submit
for publication.
K.F. has served as a consultant for most companies with an
interest in tobacco dependence treatments. J.F. has served as a
consultant to manufacturers of smoking cessation products (e.g.
Pfizer, GSK, J & J, Novartis) and has received a research grant
from Pfizer. R.P. has received lecture fees from Pfizer and GSK,
a research grant from Pfizer, and he has served as a consultant
for Pfizer, Global Health Alliance for treatment of tobacco de-
pendence, and Arbi Group Srl., an e-cigarette distributor. All
other authors have no conflicts of interest to declare.
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Estimating the Harms of
Nicotine-Containing Products
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DOI: 10.1159/000360220
225
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Editors’ Note
The editors are aware that K.F. has
connections with a company that is associ-
ated with one of the largest tobacco indus-
tries in the world (BAT: Nicoventures),
but would like to notice that this stand-
alone company produces smoking cessa-
tion products, i.e. electronic cigarettes,
that are now in discussion to be regarded
as a new form of NRT. NRT is widely ac-
cepted as a treatment of patients with to-
bacco dependence. Therefore, the editors
decided that the potential conflict of inter-
est of K.F. should not preclude acceptance
and publication of this article. However,
the scientific community has to discuss
the demarcation between potential con-
flicts of interest related to companies pro-
ducing addictive drugs and companies
producing therapeutics.
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