Category Archives: Background

by Carl V Phillips

This new short electronic book (available for a nominal purchase price at Amazon USA and UK, with free reader software available for all typical platforms) collects interviews that the editors conducted from 2009 to 2012.  Most, though not all, are indeed experts on the topic.  Four (myself included) are researchers who had published research on e-cigarettes at the time of their interviews, and the remaining 13 are researchers in related fields, political operatives, commentators, and community leaders including CASAA’s own Elaine Keller and ECCA’s Chris Price.

(A few disclosures about relationships: I brought Paul into THR work and he worked in my THR research group at University of Alberta School of Public Health for about five years, longer than anyone else, and we did numerous projects together.  I have also coauthored with James (he collected the first survey data about e-cigarette users and I volunteered my group at UASPH to analyze it).  The proceeds from sales will be split between CASAA and ECCA, though given the low sale price, this is probably less a source of bias for me than the choice to feature me as the first interview in the book.  James is an e-cigarette merchant.  Paul has done paid work for James, presumably including this book, and now works for an e-cigarette trade association.)

The interviews – mostly written exchanges apparently, though mine and a few others are transcripts of oral interviews – are a mixed collection of snapshots.  Some provide in-depth views of the subjects, while others are broad overviews.

Some of the older interviews provide interesting historical perspective.  In 2009, I expressed worry about a contaminated batch of e-cigarettes (or, more precisely of e-cigarette liquid) causing acute poisonings.  I am genuinely surprised that over three years have passed with no such incident, and I think it is still a possibility.  As noted by the editors in a comment, there are self-regulation systems in place to reduce this risk, but there are still far too many wild cards in the market.  It is a good reminder that the authorities whose duty it is to try to ensure quality of what people buy, and thus prevent such an incident, have already wasted years pursuing bans rather than doing their jobs – something else I noted in 2009.  If such an incident does occur now, there will be no denying their guilt in letting years pass without attempting to provide any regulatory guidance.

The time capsule provided by the 2009 interviews is also a good reminder about how little historical memory the e-cigarette community has, a good reason for producing a book like this.  The best response to the FDA anti-e-cigarette propaganda has not changed from what I and others observed in the interviews, and yet we need to keep re-writing this same information.  Of course any frustration from that pales in comparison to what comes from trying to get the information beyond our community.  The interviews are a reminder that if the current incarnation of CASAA (and ECCA) had been active in 2009, we might have had a better shot at capping the damage done by the US government’s lies.

The 2009 interview with Adrian Payne, formerly of British American Tobacco, has a similar feel to my interview from the same year.  At that time, for example, it was generally recognized that most of what we know about the risk from e-cigarettes is extrapolated from our knowledge of smokeless tobacco.  That is barely less true now, and so it is an interesting reminder of how quickly this was forgotten as the e-cigarette community emerged over the last four years.  Nowadays, the belief that e-cigarettes are low risk mainly traces to the fact that this was believed in 2012, and that belief in turn is an echo of what was believed in 2011.  There is remarkably little awareness that this recursion traces back to 20 year of research on Swedish and American smokeless tobacco, and my calculation that it is roughly 1/100th that of smoking, coupled with our best guess – which has stood the test of a few years – that there was nothing about e-cigarettes that would make them substantially more harmful than smokeless tobacco.  Overly precise claims that suggest we know more than this about the risk from e-cigarettes, claims which are basically just made up based on nothing and repeated, can be found in several of the more recent interviews.

The 2011 interview with Scott Ballin focused on his optimism about finding common ground between real public health advocates, the ANTZ (a term that he would presumably not use, and indeed that had not been coined yet), and other factions.  He specifically was optimistic about the FDA Center for Tobacco Products serving as an honest broker.  Two years is not a long time, and things could change, but the trend definitely does not support his optimism.

The elegant gem in the book, in my view, is the interview with David Sweanor, which ranged across general observations about the past and future, making it a somewhat better fit for a collection like this than some of the other chapters.  I disagree with several of the specific points Dave made, but the broad sweep was insightful and well crafted as a whole.  Sadly, if that interview were simply reposted today without a date, the reader would be hard pressed to notice any clues that it is almost four years old.  A lot of details have changed in that time, but the overview narrative has seen limited progress.

The recent Clive Bates interview provides another nice overview of the arguments for THR.  Once again, the historical observation from this is that the same observations could have been made at the time of the earliest interview in the book (though Bates was not working in this area at the time), and are basically what I and others (including Bates, during his previous incarnation in the field) have been writing for more than a decade.

Other interviews focus on the details and are basically current.  These were conducted in greater depth, and so offer somewhat different value compared to the historical snapshots.  Konstantinos Farsalinos offers interesting observations about the situation in Greece and his view about optimal research strategies.  The Riccardo Polosa interview is more of a typical journalist exploration of a single study and its results, as well as some details about the situation in Italy.  Elaine Keller provides a great discussion of the recent US politics of THR, as well as her compelling personal story.

The story of Chris Price and ECCA and ECF is interesting, and much of it was news to me.  His biting insight (in what is really more of an authored essay than an interview) makes it valuable reading even for an expert on the topic, though the reader should be cautioned that even I think he is perhaps he is a bit too cynical in some of his observations (yes, it is possible to be too cynical, even when observing opposition to THR, though I think it does lead to exactly the right conclusions about what we should be doing).

More generally, the reader should realize that this is definitely not a reference book, and is not designed to be a primer on the topic for someone just learning about THR or e-cigarettes.  There are some statements by interviewees that are out-and-out wrong and at least one of the interviews would make many readers decidedly less knowledgeable if all the content were believed.  Many other statements are defensible but debatable, and the reader will not be aware of that debate without extensive outside knowledge.  Thus, the book functions best as a “reader” – a collection of thoughts for someone who already has a general understanding of the topic and is able to bring some critical thinking.

The fact that the book consists of interviews that were intended to be free-standing short overviews that emphasized the hot topics of the month creates several limitations.  The questions asked in the interviews were somewhat random, with most interviews tending toward a general overview rather than a focus on the particular individual’s expertise.  Non-scientists were asked about as many scientific questions as the scientists, for example.

The interviewers do not seek to illustrate differing views and do not probe points of controversy.  Some contrasts are immediately apparent, such as Price vs. Ballin (and points in between) on whether there is any value in we genuine advocates for consumers and health trying to work with the “public health” power brokers.  But there are few questions, other than general overviews, that were put to more than one interviewee, and thus extensive background knowledge is required to observe the evolution of thinking and points of disagreement (and to sort out one from the other).  It is there, and it is interesting reading when put side-by-side, but it does require some thinking beyond the content of the text.  Most interviews include some general statement about harm reduction being a good idea and the politics arrayed against it being deplorable, but only one or two include any further details, offering the reader limited opportunity to explore nuances of those views.

A knowledgeable or very careful reader will notice a few other contrasts.  Some interviewees have worked in tobacco harm reduction for a long time, while others became interested in e-cigarettes specifically, usually as a result of personal or family experience.  Some have done key research while others are pundits and activists who have made use of that research.  But those divisions do not correspond to the outline of the book and are not highlighted, and so even careful readers may remain unaware.  Similarly, ethical or ideological differences – those who support consumer freedom versus those who grudgingly accept THR as merely a poor substitute for abstinence, for example – are somewhat apparent, but are not probed in the interviews.

The evolution of the thinking of the interviewers themselves is apparent.  The questions posed in the later interviews definitely make the content more useful for a collected volume.  Presumably at some point during their process, the editors started to envision creating this collection, and there are rumors that they will continue this process in another volume.

A few paragraphs of context about each interviewee and some background on the subject matter covered in the chapter would have aided most readers.  This would have dramatically changed the feel of the book, though, and so presumably it was intentional on the part of the editors to let the interviews stand on their own with only a few sentences of biosketch as an introduction.  I probably would have made a different choice if I were the editor, but no one ever accused me of having a light touch.  (Indeed, I suppose this review provides some of the additional observations that I might have added, had I been writing introductions to the chapters.)

With the cautions in mind, I would suggest that anyone who regularly reads my work or otherwise has an interest and some background in the topic will want to throw a few pennies to CASAA and ECCA and get this book.

by Carl V Phillips

As a tribute to Aaron Swartz, Lifehacker republished this essay by him from a few months ago.  In it, Swartz gives some nice tips about how to avoid falling into certain self-defeating traps about self-knowledge and external honesty, leading off with a nice recounting of the story of Ignaz Semmelweis.  (His youthfully naive optimism — failure to recognize why some people cannot just take that advice — as well as the bit about Semmelweis’s ultimate demise make for quite the sad irony also.)

Swartz observes about the reaction to Semmelweis’s discovery that physicians were frequently killing birthing mothers and their babies (and many others) by not washing their hands:

You’d think doctors would be thrilled by this incredible discovery. Instead, Semmelweis was ridiculed and attacked. He was fired from the hospital and forced out of Vienna. “In published medical works my teachings are either ignored or attacked,” he complained. “The medical faculty at Würzburg awarded a prize to a monograph written in 1859 in which my teachings were rejected.” Even in his native Vienna, hundreds of mothers continued to die every year.

…

Cognitive dissonance psychologists have proven in dozens of experiments that people don’t like bad news about themselves: Force students through an embarrassing initiation to take a class, and they’ll insist the class is much more interesting. Make them do a favor for someone they hate, and they start insisting they actually like them. Have them make a small ethical compromises [sic] and they’ll feel comfortable making bigger and bigger ones. Instead of just accepting we made a mistake, and shouldn’t have compromised or done the favor or join the class, we start telling ourselves that compromising isn’t so bad—and when the next compromise comes along, we believe the lies we tell ourselves, and leap at making another mistake. We hate hearing bad news about ourselves so much that we’d rather change our behavior than just admit we screwed up.

It doesn’t help much when our friends point out what we did wrong. If we’re so scared of hearing from ourselves that we made a mistake, just imagine how much we hate hearing it from someone else.

It is quite remarkable how little the medical industry (and medical publication) have changed.  Technology and knowledge and improved enormously, of course, so the worst mistakes from back then are avoided.  But the unwillingness to admit mistakes is as ingrained as ever.  This is one of the several reasons why anti-THR lies are perpetuated:  those who vociferously opposed THR out of ignorance mostly would rather keep killing smokers than admit their error.  They try desperately to find some way to vindicate their position, clinging to absurd claims such as how all tobacco use will be eliminated by 2000 2010 2020 2075, and the myth that this will actually be better for public health than THR.

Swartz’s essay goes on to point out how those who admit mistakes are often (but not always, of course — he naturally cherrypicks) praised for having done so.  I have to admit it is rather annoying to observe how some commentators treat reformed former members of the tobacco control industry — people who opposed THR and then admitted they had screwed up — as the most credible supporters of THR, rather than given that credit to those of us who got the analysis correct from the start.  But I understand the urge to praise the rare honest admissions.  I have no such sympathy in those cases where someone never admitted he had been wrong, and now tried to quietly ignore his past errors, however; this also fits nicely into Swartz’s analysis.

But one thing about inherent tendencies that we frail individuals fall into, is that institutions — both private and public — should be intentionally designed to overcome them.  Ideally there is an evolution that favors institutions that do just that.  (A related aside that also relates to the themes of the essay:  Those who strongly support government interventions tend to reinforce their biases by finding private-sector institutions that fail to do this, while those who habitually oppose government reenforce their biases by finding public-sector examples of such failures.  In both cases, there is a tendency to pointedly ignore the examples where the institutions work.)

The medical industry, and even worse, the “public health” industry, and the related publishing industries fail badly as institutions in this respect.  They tend to reward the natural human failings, or at least insulate them from any pressure to improve.  In fairness, there are important and often influential corners of the medical profession that are acutely aware of this problem and try to do something about it (that was basically my job description once, and I think what we were doing did help).  That does not seem to be the case in “public health”, especially when it comes to topics like tobacco.

I could write a very long post as a point-by-point of how the “public health” institutions discourage every potentially productive suggestion in Swartz’s essay, but if you want to just read the essay, I suspect you can just do that in your head as you go.  I realize that doing so is a rather odd tribute to a champion of information freedom, but it is a nice tribute to the general insightfulness of a mind like his.