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HomeMy WebLinkAbout03-03-2015 PH2 BeardenCOUNCIL MEETING:, �- I ITEM NO.: ? H If _ March 2, 2015 MAR 0 2 7.015 Dear San Luis Obispo City Council, My name is Don Bearden and I'm a resident of Los Osos. I was a cigarette smoker for over 25 years and in 1984 tried for the umpteenth time to quit. At that time I got a prescription (required at that time) for Nicorette chewing gum from my doctor to use as a nicotine substitute while I tried to quit smoking. It worked, I was able to quit smoking cold turkey and chew the nicotine substitute when the craving occurred. Over a period of time I mixed Juicy Fruit gum with the Nicorette gum in order to reduce the amount of nicotine my body was getting. After a time I wasn't using nicotine gum anymore and wasn't even chewing gum. The nicotine substitute saved the day for me. I no longer use any form of nicotine. I am enclosing a Research report called "Estimating the Harms of Nicotine - Containing Products using the MCDA Approach" published in European Addiction Research, vol. 20 p218. It can be found at'lWp: / /www.karger.carn /Article /Pdt/3.6022[ . It says: "Cigarettes are the nicotine product causing 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." It goes on to say: "Harm to others makes a substantial contribution only to cigarettes, and virtually none to the other 11 products." See Fig. 3. And it concludes: "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." I encourage you to keep San Luis Obispo "cigarette free" by encouraging the use of electronic nicotine delivery products (ENDS) and pharmacological nicotine replacement products (NRT) in all areas of the city. Sincerely, Don Bearden 14117 th Street Los Osos, CA 93402 dabearden @charter.net Research Report la Wca 03 Eur Addict Res 2014;20:218 -225 Received: December 23, 2013 D01:10.1159/000360220 Accepted:lanuary 30, 2014 Published online: April 3, 2014 Estimating the Harms of Nicotine - Containing Products Using the MCDA Approach David J. Nutta Lawrence D. Phillipsb David Balfourf H. Valerie Curran` Martin Dockrelid Jonathan Fouldsh Karl Fagerstromi Kgosi Letlapek Anders Milton] Riccardo Polosal John Ramsey' David Sweanorg almperial College London, UK; bDepartment of Management, London School of Economics and Political Science, and Facilitations Ltd., UK; `University College London, UK; clAction on Smoking and Health London, UK; eTICTAC Communications Ltd. at St. George's, University of London, London, UK; fUniversity of Dundee, Dundee, UK; 9Facuity of Law, University of Ottawa, Ottawa, Canada; hPennsylvania State University, College of Medicine, Hershey Pa„ USA,'Fagerstrdm Consulting, Vaxholm, Sweden; Vorld Medical Association, Milton Consulting, Stockholm, Sweden; kWorld Medical Association, Johannesburg, South Africa; 'Centre for the Prevention and Cure of Tobacco Use, University of Catania, Catania, Italy 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- KKAPLG E R 0 20145_ Karger AG, Basel Kar er 1622- 6877 /14 /0205 - 0218$39.50/0 ()F en cictess E- Mail karger @karger.com This is an Open Access article licensedunder the terms ofthe www.karger.com /ear Creative Commons Attribution- NonCommercial 3.0 Un- potted license (CC BY -NC) (www.kargeucom /OA- license), applicable to the online version of the article only. Distribu- tion permitted for non - commercial purposes only. 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 harmsfrom these products are much lower. V2014S_ KargerAG, Basel Introduction The recreational use of tobacco remains one of the principal causes of chronic ill health and early death world- 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- David Nutt Imperial College London Burlington Danes Building London W12 ONN (UK) E -Mail d.nutt @imperial.ac.uk N n �. 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 13, 41. However, in experi- mental animals, nicotine does not have the potent addic- tive properties that are required to explain the powerful addiction to tobacco experiencedbymanyhabitual 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 maybe metabolized to compounds that are poten- tially carcinogenic [12, 13]. Furthermore, studies with experimental animals suggest that the ingestion of nico- tine during 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, 191. 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 evidence that they cause chronic illness and early death is compelling. Estimating the Harms of Nicotine - Containing Products 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 ofthe 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. Methods 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 authorlist. 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; Eur Addict Res 2014;20:218 -225 DOI: 10.1159/000360220 219 (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 ofthe 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. Table 1 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 criteriaagainst which the products were evaluatedare 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 arc shomai in table 2. 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 scalingthe 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 ofharm than oth- ers, so weighting of the criteria is required. `Swing weighting' pro- vides weights that are meaningful in MCDA. As an analogy, both Fahren heit and Celsius scales con Lain 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 220 Eur Addict Res 2014;20;218 -225 DOI: 10.1159/000360220 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 harmon 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 used like a cigarette wrapped in tobacco leaf, small cigars 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 non -snus (and other) smokeless refined tobacco refined products used orally, including moist chewing tobacco and snuff (common in USA) Smokeless non -snus (and other) smokeless unrefined 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. a -cigs (electronic cigarettes either cigarette - like or personal vaporizers) Oral oral nicotine delivery products (including NRT products products) Patch dermal nicotine delivery products Nasal sprays nasal nicotine delivery products Nutt et al. u 3 � O � Product - specific mortality Product- related mortality Product - specific morbidity To users Product- related morbidity Dependence Loss of tangibles Loss of relationship 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 Injury Crime Environmental damage To others Family adversities International damage Economic cost Community Name Product - specific mortality Description deaths directly attributed to product misuse or abuse as in the case of accidental and deliberate poisoning Product - related deaths indirectly attributed to the product, e.g. death due to cancer, respiratory illness, cardiovascular disease and fire mortality Product- specific damage (morbidity, chronic ill health) to physical health directly attributed to product misuse or abuse, e.g. ulcers, morbidity lung disease, heart disease Product- related damage to physical health indirectly attributed to product misuse or abuse, e.g. burns, allergies morbidity 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 Crime Environmental damage 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 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) 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 the extent to which the use of the product contributes to damage at an international level, e.g. deforestation, damage 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 Estimating the Harms of Eur Addict Res 2014;20:218 -225 221 Nicotine- Containing Products DOI: 10.1159/000360220 �a ,a qM1 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- 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, theywere input to the H iview computer program', which normalizedthe weights so theysurnmed to 100, calculated the weighted scores and displayed the results. Results 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- 'An MCDA computer program first developed at the London School of Eco- nomics and Political Science and now available from Catalyze Ltd., www. catalyzc.co.uk. 222 Eur Addict Res 2014;20:218 -225 DOE 10.1159/000360220 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. 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 llann to others as red, Harm to others snakes 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 displaygives 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. Note that 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- Nutt et al. iJ 'o On 100 Relative nicotine harms z ■ product- specific mortality 0.3 Product- related mortality 27 S 90 - C Product- specific morbidity 32 .9 go ■ Product-related morbidity 2 F 70 ■ Dependence 5 13 60- — ■ Loss of tangibles 2 ■ Loss of relationships 1 50- Injury 8 40 Crime 1 30 ■ Environmental damage 1 20 ■ Family adversities 1 International damage 0.3 10 — - Economic cost 22 0 Community 0 fl y4��r 0 y 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- 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, theywere input to the H iview computer program', which normalizedthe weights so theysurnmed to 100, calculated the weighted scores and displayed the results. Results 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- 'An MCDA computer program first developed at the London School of Eco- nomics and Political Science and now available from Catalyze Ltd., www. catalyzc.co.uk. 222 Eur Addict Res 2014;20:218 -225 DOE 10.1159/000360220 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. 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 llann to others as red, Harm to others snakes 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 displaygives 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. Note that 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- Nutt et al. iJ 'o On 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. 100 4 ■ To users 67 9 90 ■ To others 33 1 80 - o 70 - 0 60 - 50 40 30 — - - - — 20 - 10 — - - 0' G" �l h y1D` 'o $� �h\ a \�4 o�0�e''y4ye st C 5 Compare Cigarettes minus [AII at 0 Model Order I Cum Wt I DIfl Wld Diff I Sum TO USERS Product spec mor6 315 100 315 31 5 TO USERS USERS Product rel mort 26 8 100 26 8 584 TO OTHERS OTHERS Economic cost 22 1 100 22 1 804 TO OTHERS Injury T6 100 76 86 0 TO USERS Dependence 4 7 100 4 7 92 7 TO USERS Loss of tang lutes 16 100 16 943 TO USERS Product rel morh 16 95 15 95 8 TO OTHERS Family art-aersitres 1 3 100 13 9T 1 TO OTHERS Crime 09 100 09 98 0 TO USERS loss of felationshrp 06 100 0 6 987 TO OTHERS Em,ronmental damage 0.6 100 0 6 99 3 TO OTHERS International damage 0 3 100 0 3 996 TO USERS Product spec mort 03 0 0 0 996 TO OTHERS Community 0 0 100 0 0 996 1000 99 6 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 Estimating the Harms of Eur Addict Res 2014;20:218 -225 223 Nicotine - Containing Products DOI: 10.1159/000360220 0 v m 0 a a U N �N 3 Cn harm calve 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- farming [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 hands 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 - reviewsetting 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 229 Eur Addict Res 2014;20:218 -225 D01- 10.1159/000360220 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 wouldlike 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. 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Ther Adv Drug Safety 2014;2:67 -86. 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. Estimating the Harms of Eur Addict Res 2014;20:218 -225 225 Nicotine- Containing Products DOI: 10.1159/000360220