by Carl V Phillips
Finishing up the series that starts here, I pick up the discussion of how providing clean needles for injection drug users is a poor analogy for tobacco harm reduction. I used it myself for a long time, but now I tend to avoid it.
First, the reduction in harm is not nearly as impressive. Switching to smoke-free alternatives lowers the risk from smoking — which THR’s most vocal opponents insist is the absolute worst health scourge in the world — to very close to zero. Clean needles do a lot to reduce risks that dwarf those of that “worst” scourge, but that alone leaves IDU quite dangerous. The fact that Philip Seymour Hoffman was (presumably) using clean needles obviously was not enough. There are more serious harm reduction strategies for IDU, that include safe injection sites, or distribution of rescue drugs combined with avoiding using heroin without someone else there to administer them. But even in the best case, the residual risk dwarfs that of using smoking-free tobacco products (and indeed, by any reasonable measure, still exceeds that from smoking). Thus, the analogy sells THR short.
But more important, it implicitly buys into the “everyone should quit, but [shake head, let out a sigh] if they will not, we should make it less harmful” mentality. That is sometimes described as the philosophy of harm reduction, but this characterization is incorrect. As I noted previously, the public debate – as exemplified by articles like the one under discussion – covers the range of opinions from A-through-P, with P being merely accepting that statement in quotation marks. Injection drug use is, in the opinion of almost everyone (almost – keep reading) something everyone should be pushed to quit.
But if we continue a few letters beyond P, we find a recognition that THR is more like harm reduction for sexual behavior, particularly encouraging condom use. No one in their right mind claims that “everyone should quit having sex, but if they will not….” (I have to specify “in their right mind” because some public health advocates actively suggest abstinence is the best choice in anti-HIV education campaigns.) Like tobacco use, sex has great benefits (for many people) and potentially great health costs that can be largely eliminated. Yes, there are people who believe that sex is usually immoral and so pushing for abstinence, the lowest risk option, is reasonable. But not nearly as many who have the same deranged notions about tobacco. For both behaviors it is clear that if you get the risks low enough, abstinence not only harms happiness, but harms health also.
It is worth continuing the digression one step further, to consider the views of those who are the most genuine supporters of harm reduction for illicit drug use and sex work, rather than just using it as a rhetorical point and a way to claim broadmindedness. They are far past P on the spectrum, and generally do not condemn the high-risk version of the behaviors even as they promote harm reduction. They also support decriminalization of the behaviors, in sharp contrast with the P-level advocates for e-cigarettes who actively advocate further creeping criminalization of smoking. Harm reduction is not just about health risk, but about defending people’s rights to not be punished or demeaned for their choices (whether they be high- or low-risk). The traditional harm reduction community also includes, within the core leadership of the movement, many people who engage in those behaviors, or once did and still strongly identify with them. By contrast, the influential people and ostensible experts who appear in the public THR debate, as exemplified by the article being discussed, include almost no one who uses tobacco products. The exceptions tend to be when someone from CASAA (whose policies embrace the true harm reduction philosophy) or from the e-cigarette industry is allowed to have a voice. This would not happen if the discussion were really about harm reduction.
Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches. “The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.
The first sentence of that is so vague that it is meaningless. The rest clarifies what it – naively – means: We do not have useful tightly regimented experiments about smoking cessation using e-cigarettes. That is true. And it will always be true. The conditions “tightly regimented experiments” and “useful” are mutually exclusive in this context. The success of an “in the wild” harm reduction method, something that requires no formal intervention, and indeed is probably hindered by a regimented intervention, cannot be measured that way. Anyone who thinks that trial (rather than the real world) is the most reliable study to date clearly knows so little about scientific inquiry that they do not deserve to be called “researcher” (let alone “expert”).
We measure the effectiveness of seat belts in reducing harm not by putting people in seat belt clinical trials, but by observing what portion of the population use them (and crossing that with data about how much lower their risks are). That “nothing to write home about” quip is a gross understatement. If it were true that e-cigarettes have barely more impact on smoking than NRT, they would be a dismal failure. But obviously they perform far better than NRT, and thus that study primarily serves to demonstrate the irrelevance of studies like that for understanding what really matters.
In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.
More developed? Yes, the UK has an “indication” for THR in their medicines regulation system, which could allow for an e-cigarette to be approved as a medicine. But none have been, and it is not clear when one will be (and it will likely be no more than one or two for a very long time). At the same time, the national regulators arbitrarily issued a threat to ban all non-medicalized e-cigarettes in the near future, which will probably not be implemented but will be fought over. Of course, that will become moot if Brussels overrides them and issues rules that cripple or effectively ban e-cigarettes, which is a distinct possibility despite the proponents of that action offering no cogent arguments in its favor. If that is what “more developed” regulation looks like, we are better off taking our chances with anarchy.
“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”
I have nothing to add to that, other than it is so nice to see real scientific reasoning in a discussion about e-cigarettes. One wonders whether West went so far as to suggest that, though there cannot be certainty, there is decent support for the hypothesis that e-cigarettes did indeed contribute to the trend. Such knowledge would have ruined the suspenseful movie script narrative of the article, so he might have said it and it was intentionally omitted.
The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”
The first sentence of this is the leading reason why I credit Tavernise with writing a genuinely good article. Though buried, this is really the most important thesis of the entire piece, and it takes an insightful neutral party to say it because partisans are too busy seizing scraps.
The insight is further buried by being tacked onto a paragraph about dueling interpretations of a study, neither of which actually looked at the real science. The scientific reality is that the study was fatally flawed, and should be mainly interpreted as worthless. This further bolsters Tavernise’s observation about “scraps of new data”, though the reader would never know just how how paltry those scraps are because the he-said-she-said approach omits any scientific analysis.
That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates. …blah blah blah…
“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”
Usually the seemingly-mandatory references to evil big tobacco in a story about THR is a tangential throwaway. In this case, something very insightful comes out of it: “Part of the furniture.” It is just there. It is there because someone put it there a very, very long time ago (we are talking about English university furniture, after all) for purposes that have nothing to do with present reality. No one thinks about whether it ought to be there. No one considers moving it. It just has to be – tradition and all that, mate.
Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.
Back to the furniture themes about how “public health” has to exert control over the dumb animals (us), and how everything good comes results from commands from the top, not from free choice. Still, I have to think that Abrams is clever enough to know that large successful corporations are not large and successful because they are stupid enough to let their strength be used against them.
Perhaps what he really meant is leveraging their inclination to promote their low-risk products at the expense of cigarettes (not at the expense of themselves). That makes a lot of sense. One could go further and speak of assisting their organic efforts to promote the alternatives. This is certainly part of the most effective road toward greater THR. But many anti-industry activists (not so much “advocates” and definitely not “experts”) have hardened their violently anti-THR positions (“skepticism” grossly understates it) because of this. The A-through-P debate has thus become even more impoverished because the only acceptable opinions about the role of “Big Tobacco” are the ones embedded in the furniture.
“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.
Dr. Glantz disagreed.
“I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.”
Siegel is obviously correct. Glantz scores about 1/4 correct: The evidence will show more-and-more over time, of course, as he says. But he is wrong in believing that very much new will be learned this year. His innuendo that the new evidence that will somehow be contrary to all the evidence so far is about as anti-scientific as you can get (call it faith-based Bayesianism: having such a strong prior belief that, no matter what the evidence says, your posterior believe is still that all future evidence will show you are right). Perhaps “genuinely delusional” needs to be added to the list of hypotheses, alongside “sociopath” and “senile”. But most wrong of all, as he would know if he could correctly analyze even himself, is the notion that the fault line will not be gone. He and his tiny cabal of extremists will say the same thing in February 2015 (and 2016, and 2017…) as they are saying now, no matter what happens in between.
And, unfortunately, the press will still be reporting their rants as if they represent an expert view. Even in the surprisingly good articles.