Tag Archives: fundamental lies

The myth of tobacco/nicotine’s uniqueness

Posted on 5 March 2013 by | 5 Comments

by Carl V Phillips

Brad Rodu and I just finished an overview paper about THR (which we expect will appear in a journal fairly soon).  In it we mention that there are a few legitimate debates about THR that get very little coverage.  A few of us who work in THR do discuss these.  But since most of the discourse on THR is dominated by anti-THR lies, and thus most of the public “debate” is just attempts to debunk the blatant lies, it is very difficult to have a conversation about the genuine questions.

One of the legitimate debates is about whether low-risk tobacco/nicotine products should just be treated as normal consumer products, given that they are no more hazardous than many such products.  If not, where on the spectrum of product control should they should fall?  That spectrum ranges from normal consumer products that can affect health (like food or most items you can hold in your hand; there is quality-assurance regulation, but little more), to definitely dangerous but still easily obtained products (like basic medicines or ladders; to these we add warning labels and mandatory safety features), to substantially dangerous but legal products (like cigarettes or cars: to which we add substantial restrictions and other regulations), and on to restricted products (like prescription-only or banned drugs).

(Note:  There is a case to be made that those items on this list that can hurt others, like cars, are the only ones that should be subject to anything other than quality control and warnings.  The argument is that people should be free to make their own decisions about accepting their own risk, and so only those products with clear external risks should be actively controlled.  I am not trying to address this normative question here, and am simply working from the reality on the ground that some products are regulated to protect people from themselves.)

Two articles in today’s New York Times very nicely illustrate this question.  The first concerns an “energy drink” company that is being sued over the death of a teenager who died of heart failure after consuming the product.  The question at issue is apparently whether the caffeine in the drink caused her death.  As I have written about extensively at my EP-ology blog, the levels of caffeine in these drinks is no more than is available from coffee, and often is no more than the modest quantities in Coke or other popular sodas.  There are other active ingredients in the energy drinks (which are really stimulant drinks, though the sugar does provide energy too), but since the focus is always on the caffeine, I will stick with that for now.

The claim is that the caffeine triggered a fatal cardiac event.  But if smoke-free tobacco/nicotine really poses 1/100th the risk of smoking (or 1/200th or 1/50th, rather than zero risk), almost all the risk seems to come from the risk to the cardiovascular system of consuming a mild stimulant (this was the analysis of our 2006 analysis that is the source for the “99% less harmful” conventional wisdom).  The major concern is the accumulated long-term effect, though there might be the occasional triggering effect for serious conditions that were not caused by the consumption.  In the energy drink case, the teen is said to have had a structural heart defect that was a cause of her death, and this seems to be the defense in the lawsuit.  But this would not actually rule out that the stimulants in the drink also were a cause, triggering the event (in legal arguments there is often a notion that an outcome has only one cause; scientists, in epidemiology and other fields, recognize that every outcome has multiple causes).

But if it is the case that the caffeine sometimes does cause someone’s death — a dosage of caffeine that most of us frequently brew in our own kitchens and that you can buy pretty much anywhere that serves or sells food — how should we respond to that?  Ok, forget that and just answer the much easier question:  How do we respond to that?  The answer, of course, is that we allow it, without restrictions on age or anything else.  And, of course, as I and others have often pointed out, smoke-free nicotine is pretty similar to caffeine.

If the energy drink maker wins their case, I really hope the defense includes the observation that if the caffeine was really a cause, the poor kid was doomed.  That is, even if the energy drink had been unavailable, she would have eventually gone to Starbucks.  If they lose their case, it will be a legal ruling that caffeine kills via cardiovascular disease — very rarely — and it will be rather difficult to contrive a reason why nicotine should be treated any differently than this proven dangerous drug.

The second article is a commentary about the rather common use of the ADD drug Adderall as a stimulant and smart drug among college students.  The commentary is kind of silly, with its Reefer Madness story of one kid’s experience (as well as the suggestion that performance enhancement in school is somehow cheating, like doping in sports).  But it does effectively point out that this popular stimulant is not exactly the most benign drug in the world.

The story makes you wonder if those students would get most of the same benefit from the proven low-risk drug, nicotine.  The demonization of tobacco has been so effective that those kids probably think they are making the healthier choice by using a somewhat dangerous prescription drug.  In theory, it is illegal to acquire Adderall for the purpose the students are using it, whereas they could legally buy and use snus or e-cigarettes.  But the reality is that within the population discussed in the article, students of major universities in the Boston area, there are greater barriers to nicotine use than there are to Adderall use.

Perhaps the tobacco would not work as well as a smart drug and many who tried it would go back to Adderall.  But given what is happening, how can it possibly make sense to erect greater barriers to an almost harmless stimulant than there are for an amphetamine?

I am reminded of an observation by colleague from graduate school, as we hung out in our Boston-area basement office:  If using nicotine could be made harmless, no one doing intellectual work could afford to not consume it.  What neither he nor I knew at the time (though in fairness, it was still two years before Rodu’s seminal paper on the topic) was that nicotine was already available that had about the same risk profile as the coffee we were brewing at the time.  So instead, other sketchier attention aids and smart drugs were preferred in our circles.  And apparently they still are.

The popular myth that smoke-free products are as dangerous as smoking, so you might as well smoke, is obviously harmful to public health.  But there is also a good case to be made that the myth that nicotine is worse than other attention or intellect boosting drugs may be doing plenty of harm itself.

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Second-order preferences as addiction, cont. (part 4 of “what is addiction” dialog tree)

Posted on 13 February 2013 by | 3 Comments

by Carl V Phillips

This post continues immediately from the previous one, which you will need to read to make sense of this.  That, in turn, is part of the “dialog tree” of how to talk to someone about what they think addiction is (starting here), which in turn follows from this post.  Got all that?

In the previous post, I pointed out that one thing that people often mean when they say “addiction” is that someone chooses smoking over not smoking, but “wants to quit”.  I pointed out that this almost certainly means they have a second-order preference for wanting to prefer not smoking over smoking, but that is not their actual preference.

I emphasized one critical point that is often overlooked when this concept is implicitly invoked as an excuse for torturing smokers into quitting:  Most everyone has been tricked into believing that every smoker who manages to quit will find himself just as happy/alert/clear-headed/etc. when he abstinent as he was when he smoked.  While this will be true for some people who give up tobacco/nicotine, it is definitely not true for many.  In particular, it is almost certainly not true for those who “want to quit” but start again after a period of abstinence.

In a hundred different ways, this lie permeates discussions about use and cessation (“all you need is just a little help getting over that hurdle”).  The lie dooms countless smokers — literally millions of them — to a repeated cycle of temporary abstinence, expecting to find that they no longer want to smoke after being abstinent for a while, followed by starting to smoke again because they still prefer smoking to abstinence.  But it is also one of the fundamental anti-THR lies that I have written about before:  Everyone would be happy being abstinent, and so they just need to get there; thus, we do not need THR.  (Actually, this claim is wrong for other reasons too, actually, but I will stick to the one theme.)

Circling back to the dialog tree of what to say to a non-ANTZ who invokes the old “…but they are still addicted” claim as a reason for opposing THR, when someone defines “addiction” with answer #6, how should we respond?  I took so long getting to this because I think it is necessary to really understand the implications of second-order preferences in order to answer well.  With the background in mind, the script for responding should begin with:

If someone says they want to quit but never does, or they quit for a while and start again, it shows that they actually prefer smoking to abstinence when those are the only two choices.  But there is a good chance they would act on their stated desire to quit, and stick with it, if given a way to make non-smoking better — that is, to keep some of the advantages of smoking.  That makes such a smoker the perfect candidate for THR.  Indeed, it is difficult to think of any more compelling reason to support THR than this notion of “addiction”.

If you can get to this point in a conversation with any thinking and feeling person (i.e., most any non-ANTZ), I venture to say that you will almost certainly win them over.

This argument renders the point about whether someone is “still addicted” rather moot.  But should the conversation continue to focus on addiction, the argument only becomes stronger:

Not only is THR a good way, and perhaps the only way, to help such an individual fulfill their stated desire to quit smoking, but it is the only way to actually overcome the addiction.  The abstinent ex-smoker whose preferences fit this pattern is still addicted by this definition, because his preferences have not changed — he still would prefer to smoke even though he is forcing himself to act like someone who prefers to not smoke.  However, if he is satisfied with THR, then not only is he no longer a smoker, but he is no longer “addicted”.

Just pause for a moment and let that sink in, because I think that these points might well be the strongest arguments for THR that are almost never made.

Having let it sink in, I have to finish with one caveat.  Arguably it is necessary to add something about the impact of past use to answer #6, since some reference to past use is part of most notions of what addiction might mean (recall definition #5 in particular, and also #4).  Thus it might be that the full version needs to be something like:

6a. Someone is addicted when he prefers taking particular action even though he would prefer to prefer to quit, and the reason he prefers the action is because of past consumption.

That is, someone is “addicted” to smoking if he has that pattern of preference and second-order preference, and because he ended up with that pattern because of past smoking.  It should be immediately apparent that this is of no practical consequence if we are talking about someone who already fits this description.  There is no changing the past.  The only change required is to add the phrase “since he is already in that situation” to the above arguments.

However, if this describes someone’s belief about tobacco/nicotine use (which I believe is the case for many who are anti-tobacco but not ANTZ, and who are thoughtful enough to figure out what they are really claiming), and they believe that the creation of the second-order preference disconnect is truly a terrible thing in itself, then this concept of “addiction” remains an argument for preventing anyone from initiating use of even a low-risk product.  I do not actually think that this is a good argument, but I will acknowledge that it could be defended because, unlike the ANTZ, I am not just spewing propaganda, but am seeking honest understanding of these issues.

The reasons I think it is a very weak argument start with the observation that, as noted in the previous post, there is nothing inherently terrible or unusual about having a second-order preference to have a different preference about some choice.  I used to drink orange juice that I mixed from those little cans of frozen concentrate, but then I got in the habit of buying the jugs of “premium, never frozen” juice, and now strongly prefer that.  But I would prefer to still like the frozen concentrate just as much, since it is cheaper and easier to carry and store, but my experience changed my tastes.  But that experience also left me happier, since the premium stuff really is better.  My indulgence caused a second-order preference disconnect, but did not make me worse off.

The typical response to that observation would be that tobacco use is different because it causes not merely the discovery you like something and an evolution of tastes, but rather it causes some strange massive reprogramming of your brain.  It is not clear why that even matters, though, and moreover  I am not entirely convinced by these claims.  Most of them come out of the notoriously dishonest ANTZ “research” literature or the brain porn research in neurochemistry that is currently in vogue but is widely derided for not actually supporting the claims that are made.  Yes, tobacco/nicotine use changes our brains, but so does acquiring a taste for orange juice or reading a book (if you remember what you read, it changed your brain).  The bottom line is that there is a possible argument against tobacco to be found here, but even the factual claims are far from definitive, and the ethical and economic conclusions are much shakier still.  After all, there is also a valid case to be made that someone’s exposure to tobacco/nicotine can improve their life by making them susceptible to the benefits, so long as they can get those benefits without the high cost of smoking.  So perhaps I should complain that I was denied that opportunity to reprogram my brain at an early age, just as I wish I had learned to speak Mandarin when I was still young enough to do it easily.

But I digress.  That is a topic for another day.  At the end of this day I will sum up the thread by saying that if you can get an open-minded person to discuss their concerns about “addiction”, and you can offer the responses presented in this series, there is a very good chance that you can show them that the concept  of addiction offers much stronger arguments in favor of THR than it does against it.

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“Craving” and other annoyances from the FDA meeting

Posted on 18 December 2012 by | 5 Comments

by Carl V Phillips

The FDA hearings that I mentioned previously went fairly well.  Two of the panel members were anti-tobacco extremists from the Center for Tobacco Products (CTP), and were looking for any excuse to further their crusade.  But the majority of the panel appeared to entirely professional and interested in doing their job.  They paid attention to the testimony, and seemed to consider almost all of it to be productive and almost all of it to represent useful contributions to a shared cause.  In other words, it was really refreshing, and very unlike the CTP; notice in particular that I am not suggesting that this corner of FDA are liars.

Not that there were no liars present.  The most striking thing about the meeting was that the speakers representing the tobacco industry and the pharmaceutical industry, as well as the consumer advocates (in my obviously biased opinion) were all serious, honest, and science-oriented.  They all had their own agendas, of course, but all were on the side of public health, as was the majority of the panel as far as I could tell.  This contrasted markedly with the NGO representatives (American Cancer Society, American Legacy Foundations, and a few others) who were doing anti-scientific rhetorical backflips in their dishonest attempts to claim that allowing broader marketing of pharma products for THR was a good idea, but the exact same logic somehow did not apply to smokeless tobacco or e-cigarettes.  I have to think that any honest observer could see right through their lies.

One particular annoyance, a fundamental anti-THR lie that FDA was dealing with (though not their own fault, except perhaps historically) was the concept of “cravings”.  This shows up in claims like, “NRT products are designed to reduce smokers’ cravings for nicotine.”  What is interesting about this concept is that in a better world, it would be spot-on and potentially useful.  That is, the common language meaning of the word does have relevance and particular usefulness:  It could be that someone genuinely would prefer to be abstinent from tobacco and nicotine, but keeps coming back because of some short-term urge that is different from a genuine preference.  The word is not well-defined, but you could see how it could be wrapped up with withdrawal symptoms rather than what we would call benefits of using the products.  In that case, offering a drug that eliminates that craving would have obvious value.

The reason that this is a backdoor invocation of one of the fundamental anti-THR lies (specifically, that there are no benefits from nicotine) is because that “different from a genuine preference” caveat is ignored by the tobacco control industry.  Instead they use the word “craving” as part of their fiction that no one actually prefers to use nicotine, and that there are no benefits of smoking and other product use, and so users smoke just because of something the call a craving.

I was surprised to learn that the FDA, in this context, is statutorily required to deal with the concept of craving.  That explained why they asked a series of seemingly nonsense questions about cravings to Johnathan Foulds, who answered in the same terms before finally getting a bit frustrated and pointing out that there was no definition of the term that set it apart from “a desire to smoke”.  (Prof. Foulds, a good scientist who is a long-time supporter of THR, was there representing the Society for Research on Nicotine and Tobacco, which is very much an ANTZ group posing as a scientific organization.  Thus, he might have felt a bit trapped in terms of what he could say.)

If there was honest research on this topic, then maybe we could make use of the specific concept of craving and deal with it.  But given that most of the “researchers” (e.g., most members of SRNT) are just activists who are pretending to do science, such words just create problems, not value.  There is certainly something to the notion of craving, but it is less important than normal consumer preference.  As I had already noted in my testimony, nicotine is much more like any other high-value consumer product than it is different.  Low-risk nicotine products are a good substitute that fulfills that preference, but NRT as a method to merely reduce cravings fails miserably as a method for stopping smoking.  Why?  Because those cravings are largely unimportant compared to the preferences.

This brings up a lie that lay just beneath the surface of the whole discussion, mentioned only by the consumer advocates and vividly recounted in the personal testimony of individuals who testified as stakeholders:  NRT does not work for its currently stated purpose, even though it works pretty well (though not nearly as well as higher-quality products) as a substitute.  But this initiative is progress in terms of dealing with that.

More generally, it was frustrating to observe the FDA panel asking questions as if there is legitimate and useful science not just on “cravings” but in a variety of areas related to the topic.  The representative from Legacy, in particular, presented testimony and answered questions for longer than anyone, pushing the lie that most of what is published by the tobacco control industry is science and not junk.  The ANTZ can get away with that when being judged only by their fellow ANTZ, including the CTP unit of FDA.  But it might be that the more serious and scientific side of FDA, the drug regulators whose policy on NRT could carve out space for other THR products, will not fall for it.  We shall see.

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Fundamental lie: tobacco has no benefits, only marketing

Posted on 6 December 2012 by | 1 Comment

by Carl V Phillips

The ANTZ often appeal to the “think of the children” argument.  But when they say that, what they are not saying is that they consider all tobacco and nicotine users to be children.  And not just children, but either mere toddlers or children who have not been raised in a commercial culture where merchants try to tout their wares and the rest of us work hard to ignore them (which is to say, they were somehow not raised in any post-agrarian human culture).  This is the only possible interpretation of their persistent claim that marketing by merchants is the reason that people use tobacco products.  It is a fundamental anti-THR lie because if there are actually no benefits, then it must be that everyone really wants to become abstinent, so there is no value in THR.

Yesterday, Brad Rodu posted a great analysis of the actual evidence about tobacco advertising and consumption in the US.  He notes that the persistent lie is backed by no evidence and goes on to present some of the evidence that affirmatively argues against it.  This begins with the observation that tobacco use was popular long before there was a marketing effort as well as the fact that Sweden (with a complete tobacco advertising ban) has usage levels that are similar to other rich countries.  His new analysis points out recent US Federal Trade Commission reports that show there is a strong correlation between advertising expenditures and changes in smoking.  A strong inverse (negative) correlation, that is:  advertising expenditures increased as total consumption decreased.

Of course, the ANTZ have a response to that:  Due to their own terribly impressive anti-smoking efforts (i.e., telling people smoking was unhealthy four decades ago and waiting for the obvious effect, plus a little fiddling around the margins) the cigarette companies were desperately spending on advertising to try to counter their efforts.  Indeed, Rodu partially concurs with that, suggesting that the sharp drop in advertising after 2004 was the result of the companies giving up on what they had discovered to be a futile effort.

But assuming that is true, it is clear evidence that the main conclusion (that marketing is the primary or only cause of consumption) is clearly false.  The perception by merchants that they could reverse the slow downward drift in consumption with a massive increase in advertising, even if they were right, would do nothing to support the original lie.  Given that they were wrong, it is affirmative evidence against it.

Further evidence can be found in the increasingly desperate and silly measure that the ANTZ are pursuing to defend it, like insisting that logos on packaging and even the tiny arcane batch identifying codes printed on the cigarette paper are the “advertising” that causes the consumption.  In case it was not clear that the ANTZ were just making this all up, their claim that it was not the glossy magazine ads and billboards (now banned) or television (long banned) or sponsorships that kept 1/5th of the population smoking, it was the three-letter codes printed just above the filter in 4-point type that kept tens of millions enthralled.  If only we had figured that out sooner!  (“Liars” really gives them too much credit sometimes, huh?)

Rodu points out that the situation with smokeless tobacco (again, in the US) is a bit more complicated.  Advertising for snuff/snus did increase at the same time that consumption was increasing.  He points out that snus consumption was increasing at about the same rate that chewing tobacco was decreasing, so that substitution explains a lot of the trend.  What he does not note is the common challenge in analyzing economic data, simultaneity problems.  These are cases where X may affect Y and also Y may affect X, and so it is difficult to measure the independent effects.  In this case, there is no doubt that the increasing popularity of spit-free smokeless tobacco, as people learned about THR and also sought an anywhere anytime alternative, caused more advertising.  Merchants have more incentive to advertise in a larger market, especially one that is emerging and brand loyalty has not yet been established.

Did the advertising also increase consumption of this low-risk alternative to smoking?  Perhaps, and if it did then it provided important public health benefits.  It would be possible to try to estimate how large this effect was, trying to sort out the causation in the other direction and other factors.  But it would require a rather sophisticated analysis that apparently no one has done.  Of course, the ANTZ are not interested in doing honest economic analysis any more than they are doing honest epidemiology.  To them, “science” is a rhetorical tool to be manipulated for activism, not a way to really find things out.  Moreover, as I have pointed out previously, they are clearly incapable of doing even remotely passable economic analysis.

The real economists who worked in tobacco control exited a long time ago.  They have been long-since replaced by people who assume that people pay a very high price for something that has no benefits for them because… er, well, um… Just Because!  Needless to say, sociology and “public health” curricula do not require even freshman-level economics.

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