CTFK threatens researchers, but you should not really care

by Carl V Phillips

My tobacco control amusement for the week (other than my nomination to TPSAC) comes from a letter sent from the notorious Campaign for Tobacco Free Kids (CTFK) and the obscure ENSP (which is apparently not actually a phishing site for people mistyping their sports news search, but rather a pliable recruit that gave CTFK an excuse to hassle Europeans too), to Christopher Russel and an unknown number of others. Christopher posted it here. The letter seeks to intimidate the recipients from attending the GTNF conference this month. Continue reading

Extraordinary claims

by Carl V Phillips

Fairly often (e.g., in the previous post) I make reference to the concept that extraordinary claims require extraordinary evidence. That is, if something seems extremely unlikely based on a great deal of accumulated knowledge or an understanding about how the world works, and you wish to claim it is true, you really need to have done some tight work. It is a good principle in science. Research does not produce scientific knowledge without adherence to principles like this (note that there are no “rules” in science, so we have to make do with evolved principles).

Today I am thinking of that in terms of a new study that was reported in this BBC story, “E-cigarettes ‘help more smokers quit'” (quotes from there). Continue reading

Sunday Science Lesson: Misconceptions about the gateway effect

by Carl V Phillips

Disturbingly close to 100% of writings about whether there is a gateway effect among tobacco products, particularly about e-cigarettes being a gateway to smoking, are nonsense. That includes most metas on the topic, where someone tries to explain what mistakes others are making. Perhaps addressing a few simple misconceptions can clear some of this up (and it is a favor to a few of my tweeps — I hope I have addressed all the points our conversation left hanging). I have written about all of this much more extensively and comprehensively (see this in particular), but not in soundbite form. Continue reading

Weaponized Kafkaism

by Carl V Phillips

I think I have come up with a good description of the functioning of the FDA Center for Tobacco Products: Weaponized Kafkaism. The term is fairly self-explanatory, but to unpack it: Kafkaesque is, of course, refers to a system that brings to mind the situations faced by Franz Kafka’s characters, particularly including being trapped by a baffling and inscrutable system (particularly a government bureaucracy), where one is punished for doing something wrong as a result of having no idea what would satisfy the authorities, and as the rules begin to become apparent they are revealed to include self-contradictions, making it literally impossible to comply. (I converted the word to its seldom-used noun form.) Weaponization refers to taking something that in its “natural” state is harmful or potentially harmful, and then intentionally deploying it in order to do harm.  Continue reading

My new paper: Understanding the basic economics of tobacco harm reduction

by Carl V Phillips

In case you missed it, my new IEA paper, Understanding the basic economics of tobacco harm reduction, is available here. You should go read it. The summaries do not do it justice. (Not really joking there — the summaries have picked up on one particular conclusion, but the value of the paper is laying out how to think about the whole issue.) I am posting this here primarily to create an opportunity for comments, since that is not available at the original.

Speaking of summaries, you can find this one at CityAM, which was kind enough to also run my op-ed that was based on the paper. (Needless to say, I did not choose the headline nor the link in the first paragraph — can you imagine me citing the RCP report as if they were the source of that information???)

FDA Center for Tobacco Products (mostly) know exactly what they are doing.

 

by Carl V Phillips

Clive Bates recently posted about the e-cigarette deeming regulation which started to take effect this week. Most of the post is just the 10,000th thing you have seen, dating back to before the first draft of the regulation was released, about the unfortunate consequences[*]. But in the last line he says:

I’m prepared to believe they aren’t doing it deliberately, but I just have this feeling that the big players behind the FDA’s intervention, such as Mitch Zeller and Matt Myers, do not have the faintest idea what they are actually doing.

It is a reasonable starting assumption. Never assume malice when incompetence or laziness would produce the observed result. In the comments that followed, however, enough people asserted disagreement (albeit largely without analysis) that Bates tweeted in search of anyone who agreed with his assessment. I am afraid I am going to half-disagree also, or perhaps mostly disagree, though it takes some analysis to get there.

First, we need separate the crafting of the Tobacco Control Act, which created the Center for Tobacco Products, and the current behavior of CTP. The TCA accomplished what it was supposed to at the big-picture level, while being a “not the faintest idea”-level failure at the detail level. The big-picture goals of the TCA were:

1a. Do something to please the various anti-tobacco busybodies and federal legislators who were screaming “do something!” without doing anything that would evoke serious opposition from not-anti-tobacco legislators.

…which is roughly equivalent to…

1b. Inflict substantial harm on tobacco product users, along with modest hassles for the producers, while creating barriers to market entry so that the main organized interests in the space (the incumbent major tobacco companies) favored the law.

2. Create some modest restrictions and a create a base for further operations, as per the standard nanny state script: Impose any restriction on people’s choices that is politically possible at the moment, reasonably counting on it ratcheting, before moving on to the next restriction.

3. Impose various hidden taxes on consumers and capture the money as patronage payments for tobacco control supporters.

4. Counter efforts to promote harm reduction by effectively denying different tobacco products, with their different levels of risk should be treated differently, as well as by inflicting further caused-harm on consumers.

All of these were successful. However, at the detail level the TCA was an incompetent clusterfuck, and while that has worked out just fine for the tobacco controllers and does not interfere with the above list of primary goals, it does not appear that was by design. The law contains many details about completely failed processes, such as applications and approval systems (SE, MRTP, PMTA) and assessing and regulating the chemical composition of products. As I have recounted numerous times, the approval processes are utterly dysfunctional, and have simply been a series of arbitrary ad hoc decisions. The chemistry and other scientific goals have gone nowhere. The TCA did not facilitate the creation of the necessary infrastructure to do what it claimed it would do.

The CTP that was created cannot (and thus, of course, does not) function at all as a proper regulator. It reminds me of corrupt third-world frontier guards who are just levying fees, collecting bribes, and making self-interested decisions about whether to allow passage. This week CTP tweeted that the deeming regulation now made selling all tobacco products to minors illegal. I replied by congratulating them on doubling the number of real regulatory actions they had taken in their seven-year history. In reality I was being generous, since the new rule is basically redundant with state laws.

Of course this still fails to answer the incompetence-vs-design question.

My assessment is that all those detailed rules and processes would not have been written with the expectation that they would not function at all, and would merely serve as acts of market sabotage. Those goals could have been accomplished with far less detail. The details clearly feel like an attempt to create something, whatever the motives, rather than to create a morass. So here we have a case of pure incompetence: people designing systems that simply did not work. The key problem is that they violated one of the rules of making good public policy, incrementalism. They tried to design an untested system that was a huge departure from the status quo or anything that anyone had worked out before, rather than testing smaller steps or creating the foundation for an evolving system. Of course it failed. The fundamental incompetence was not being bad at designing systems, but not understanding that almost no one is good enough at designing systems to be able to pull that off.

That is the story of the creation of CTP. What about the current behavior of CTP?

There I would say they know exactly what they are doing at the level of impacts, though they are remarkably bad at the games they are playing at the detail level. The application and approval processes were designed badly. But CTP has taken advantage of that to hand-pick exactly the approvals that serve their goals (interfering with THR, mission creep, making sure future bans were politically palatable). On the other hand, they have been needlessly ham-handed about it (letting applications languish for years, offering really stupid rationalizations for decisions when it would not have been difficult to say something more defensible).

I would say the same about e-cigarette deeming. Yes, many of the details of the deeming regulation look like they were written by interns or out-of-touch activists rather than the savvy lawyers and career operatives that CTP has. These have opened all manner of possible legitimate legal challenges that need not have been left open (some — but not all — of which the current lawsuits take aim at). Their failure to secure their own gates against obvious legal challenges can only be seen as incompetence.

But as for the broad sweep of the deeming, those supposedly “unintended” consequences are exactly the sensible thing for CTP to be imposing. CTP has developed no capacity to actually regulate, nor any apparent capacity to develop capacity. They consist of a bunch of highly-paid people who have no particular responsibility. They show remarkably little knowledge about the simple products they were originally charged with regulating, and e-cigarettes would represent a more-than-doubling of how much they need to understand. Therefore, a regulation that bans all e-cigarettes other than a few fossilized closed systems is exactly the rational thing to do.

I trust it is obvious that I mean their action is rational in terms of their own personal selfish interest (with the added bonus of pleasing the anti-tobacco busybodies). Obviously it is a terrible thing to do from the perspective of the people’s well-being, good government, public health, and so on. Our government’s agencies get a lot of criticism implying they are like the stereotypes of patronage backwaters and department of motor vehicles offices from c.1980. They get undeservedly accused of not trying to serve the public interest merely because they (inevitably) do so imperfectly or in a way that does not fit a critic’s personal political goals. But sometimes the stereotype fits.

The current rules are bad for harm reduction, but that is a feature for CTP, not a bug, because they are demonstrated opponents of harm reduction. The rules will replace a thriving legal market with a thriving black market. But that is exactly what CTP needs because they do not have to deal with the black market beyond sending out a few cease-and-desist letters when something becomes too glaring to ignore. They lack the capacity to regulate the legal market. They could not even process all the product registrations for all e-cigarette products, let alone do anything of substance. So their only (self-interestedly) rational choice is to pare the legal market down to a level they can handle. (Note that this does not imply they will handle what remains in an informed or public-interest manner, but at least they would have the capacity to create an illusion of doing so that will fool non-experts.)

None of that will come as news to anyone who has paid attention to what I have written on this topic for the last two and a half years. But because most of the stakeholders and pundits in this area do not pay much attention, they can be persuaded by CTP’s sort-of-pro harm reduction rhetoric, claims that the black market will be minor, and so on. At the very least, they can be persuaded that CTP really believes their own statements.

But I find it impossible to believe that CTP actually believe what they are saying. When looking at the statements, we are not talking about someone taking on a task and not being competent to pull it off. We are not talking about the musings of random Dunning-Kruger-ized “experts” who have spent a few tens of hours reading about the topic. We are talking about a simple matter of understanding, and about professionals whose full-time job is working on this. Assuming incompetence is a good default hypothesis, but the sheer enormity of the required incompetence in this case, along with the fact that the outcomes are in the actors’ selfish interest, argue strongly for “know exactly what they are doing”.

 

[UPDATE – an extended footnote that is a bit of a mini-post on a different topic: In response to Clive taking some offense at middle sentence of the first paragraph, I wanted to expand upon it. I am not sure whether this will eliminate the offense, but at least if offense remains, it will be based on what I really think, rather than an attempt to interpret those few words.

It is true that this was motivated by me not wanting to recommend reading the post. Please note that this contrasts with 90% of Clive’s posts which I strongly recommend. This includes the ones I take issue with — they are still worth reading. In this case, however, I was basically trying to placate my own not wanting to link to a post that I did not recommend. I felt like I had to say something, even if it was impenetrable.

Why did I feel that way? Part of it is my concern about the flood of generic “deeming [or whatever restriction on e-cigarettes] is bad because it encourages smoking” posts. Even when there is nothing wrong with the content, I feel like the churning of the generic message is contributing to a harmful echo chamber. Moreover, I think the hundreds of monologue posts written without reference to what has been previously figured out create further harm by under-informing readers about the knowledge base. There are way too many commentators (Clive not among them!) who try to write big-picture analyses when they would be much better off just posting “go read this which someone else has already written”, rather than badly reinventing the wheel as an act of self-indulgence, and thereby leaving their readers believing they have a better understanding than they do.

There is a tiny fraction of what is written in this arena that I would ever recommend reading. This probably consists of many works that I never actually recommend because I do not see them. That too is part of the problem: there is so much pabulum that important new insights get lost. Note that the preceding is generic observation; Clive is one of those who advances knowledge, presents new observations, and draws upon and references the knowledge base. So read his stuff if you don’t. Still, because of these concerns, my default reaction (to tie to a theme of the actual post here) is that such a post does little good and possible harm.

(Note that this refers to insider communications. If you want to write something for a newspaper, or slip it in as an off-topic post in your blog about dog training, thus reaching a new audience, by all means do it. But if the only people reading something are already well-read in the field, then more generic broadsides are not useful.)

So, taking this back to the particular post, what did it contain. The content was mainly quotes from the RCP report and a security saleswoman. The former quote was standard generic stuff, but it was anchored on an actively harmful misuse of the concepts of precaution and risk aversion. (This misuse suggests that restrictions on e-cigarettes have potential legitimate justifications that they really do not.) The latter author is has a rather, ahem, dubious record of making proclamations that are wrong and/or based on nothing.

But the real problem here is the tendency — common in public health as well as poor journalism — of suggesting that something is informative or persuasive just because it was written down. Clive is more of an expert on these matters than either the authors of the RCP report or the banker. He could make better and more authoritative statements on these exact points than those he quoted. Indeed, he has done so. Thus the presentation of them mainly serves as an endorsement of the toxic mentality of “I believe something; someone else wrote down a generic brief assertion of the same sentiment; therefore my own opinion is vindicated”. (For a good example of why this is so toxic, see Clive’s own next post.) It is especially toxic when it is done by someone whose analysis should be more trusted than those he is quoting.

Anyway, I was not sufficiently motivated by that to write this as so much as a comment on Clive’s post, let alone write a post about it. However, since this turned into a Twitter discussion/debate, here it all is.

End update.]

What harm reduction really means

by Carl V Phillips

The best thing I have read about harm reduction in a very long time is this post at The Influence by Shaun Shelly, “The Harm Reduction Movement Needs to Rediscover Its Soul”. The post, the publication, and the author all focus on illicit drug harm reduction, but almost everything in it applies to tobacco harm reduction also. Read it if you fancy yourself a supporter of harm reduction. As I have noted here previously (example), many — I would say a large majority — of those who fancy themselves THR advocates do not really support harm reduction.

I will highlight a few bits. Shelly’s thesis is:

Officially, harm reduction can be described as ‘‘policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption’’ (Harm Reduction International, 2011).

In my opinion, this definition does not capture the true spirit of the original harm reduction movement. Harm reduction is about meeting people where they are at, without judgement, and helping them find them achieve their drug use aims (including abstinence) in the way that causes the least harm to them, irrespective of the current legal and policy framework.

I am not sure I agree that HRI (which had not actually yet changed its name from IHRA in 2011) gets to “officially” define anything. I can say that I have a few serious differences with them (despite being a long-time member the editorial board of Harm Reduction Journal, which is the semi-official journal of HRI, and which endorses a definition of “harm reduction” that basically the same as HRI’s). But from the THR perspective, you do not even need to go on to Shelly’s next paragraph to see the disconnect with the soul of harm reduction.

Almost every time you see the phrase “harm reduction” used in the realm of tobacco today, it is referring exclusively to the substitution of lower-risk products or policies to encourage that substitution. Moreover, this inappropriate narrow usage narrows further still: It is almost exclusively about substituting for cigarettes (e.g., I can think of only a couple of us who have tried to get some traction for extending it to substituting low-risk smoke-free products for the high-risk smoke-free products that are popular in South Asia). Also, due to the odd twists of history, these days the term is almost always used to refer specifically to substituting e-cigarettes for cigarettes, rather than substituting some other low-risk alternative. (Note that I expect that will change soon, with heat-not-burn cigarettes getting a lot of attention.)

This is a remarkably close parallel to Shelly’s lament that illicit drug harm reduction has descended into just being about getting injection opioid users to reduce their risk of catching or transmitting HIV.

But notice that the IHRA/HRI definition — and that of anyone else who really believes in harm reduction — refers to also reducing the “economic” (read: financial) and social costs of drug use. In the case of tobacco use, as with many drugs, the great majority of the financial and social costs come not from the drug use itself, but from government actions. Smoking is expensive because of taxes and restrictions on the free flow of goods. More social harms from smoking are caused by government restrictions than by the act itself. Unlike with illicit drugs, few people are imprisoned or executed over tobacco (though not none), but unavoidable punitive taxes are not necessarily less harmful than rolling the dice on a small chance of getting arrested.

And yet, many people who fancy themselves supporters of tobacco harm reduction actively support most of those caused harms. They actively support punitive taxes on cigarettes, social opprobrium heaped on smokers, prohibitions against publicans being able to offer smoking sections, etc. Indeed, those individuals often celebrate or advocate for the caused harms because they create further incentives for the only aspect of harm reduction they actually support, switching products. It reminds me of the Orwellian themes of about half the anti-smoking propaganda I see these days: “Quit because it is so expensive and forces you to take breaks from hanging with your friends!” Um, yeah, and whose fault is that? It is the same as those messages of “if you smoke weed, you might lose your student financial aid and future employment prospects, so don’t go saying it is not bad for you!” Needless to say, you will never hear a peep of condemnation of this hypocritical “concern” for users’ well-being from the faux supporters of harm reduction.

The bottom line is simple: Anyone who supports punishing smokers does not actually believe in tobacco harm reduction. None of those “but for the greater good we need to…” protests changes this. Causing harm is not harm reduction.

I would also add a clarification to the last words of IHRA’s definition, and rephrase it as “without necessarily reducing the consumption of that drug”. The soul of harm reduction does not say “we support reducing the harm, so long as people stick to using only the specific drugs we approve”, as might be considered to be conceded by the original phrasing. There is little interest in helping those who smoke use their chosen drug with less harm (even setting aside the caused financial and social harms). Indeed, there is active opposition to it. Heat-not-burn cigarettes are, arguably, a method of smoking, in contrast with the use of e-cigarettes or smokeless tobacco, which are alternative drugs that can be substituted. There is a lot of hostility toward the introduction of heat-not-burn products from many e-cigarette cheerleaders and others who pretend to support harm reduction.

I have not even gotten to Shelly’s thesis paragraph, where he points out that HRI’s techy and bureaucratic definition does not capture the soul of harm reduction. Most of the supposed support for THR does not even qualify as supporting harm reduction under the techy definition.

Many grassroots supporters of tobacco product substitution live up to the additional consideration Shelly presents, of meeting smokers where they are. At the grassroots level, where a lot of e-cigarette advocacy lives, people are really very good about this. The vape shop operator or friend who has switched products is usually all about appreciating the current experience of the smoker standing before him. This seems to contrast with Shelly’s point,

People who use drugs have been ignored by those who loudly proclaim they are “leaving no one behind.” (Then again, is it possible to leave behind people who were never recognized as part of the group in the first place?)

On the other hand, the contrast may not be all that great. Much of that meeting of smokers where they are is focused on how to most effectively persuade them to stop doing what they are doing. It is not without judgement (their current choice is usually judged to be something that should be changed). It is only about helping them find them achieve their drug use aims if those aims include quitting their current drug, one way or another. And it certainly does not consider that the current legal and policy framework might be the problem and should be in play.

Moreover, I said that was the grassroots level. At the level of the self-appointed grandees who have come to dominate e-cigarette advocacy (particularly in the UK, which has, perhaps unfortunately, come to dominate e-cigarette advocacy), there is not even that. Yes, there is attention to where people are, with respect to their drug use. But that is not about meeting them there. It is more like the attention devoted to figuring out what motivates vermin that are eating the crops, to determine how best to manipulate them into not doing it. Shelly makes what will be a familiar reference in the context of the e-cigarette wars:

…opioid substitution therapy programs designed in a way that makes them more a form of social control than an aid to those accessing them.

Shelly also notes:

Disturbingly, however, people who use drugs are being marginalized even within the world of harm reduction advocacy.

How many openly dedicated users of high-risk tobacco products are included in any discussions of tobacco harm reduction? The discussions are mostly among those who despise smokers, those who switched from smoking but are humane enough to not despise smokers though they despise smoking (yes, they are people who use drugs, but not the same drug), and only a small handful of nonsmokers who rise above being motivated by despite. When representatives of smokers are offered a token seat in the discussions, they tend to be cigarette industry employees or (my friend) Simon Clark from FOREST. None of them are smokers! I cannot claim any identity politics points here either: I am not a smoker, nor someone who quit smoking via product substitution.

Nevertheless, I have actively tried to build bridges to those who defend their choice to smoke and whose primary interest in tobacco harm reduction is eliminating the government-caused harms. Yes, they too are harm reductionists. They are key harm reductionists. Yet only the best-read of them even realize they are in the harm reduction space because of the aforementioned perversion of that term. Many smokers (mistakenly) think that harm reduction is their enemy because that term has been misappropriated by many who support harming them and merely want to “fix” their behavior by whatever means necessary. Smokers (correctly) think that they are marginalized in the discussion of tobacco harm reduction. They hate harm reduction. Some of them even take time out of their day to make clear they hate me, of all people.

Perhaps it is understandable:

I, too, am guilty of using this platform to sell compromise to policymakers. In pitching to them, I regularly use examples that show how HIV can spread from people who inject drugs into the wider community—drawing the conclusion that in order to protect the wider community, we need to protect drug users.

Not an exact parallel, but I am certainly guilty of trying to help THR “pass” in “respectable” quarters by pitching it as being the best response to the scourge of smoking. I think I probably leaned in this direction the least of any of my colleagues in the field. I would like to think anyone who was really paying attention to me would recognize my true commitment to harm reduction. But I understand that most judgments, especially these days, are made based on a few snippets, not an awareness of someone’s full corpus.

Finally, I particularly like Shelly’s observation,

The fact that US Drug Czar Michael Botticelli can receive a standing ovation at a harm reduction conference tells me that harm reduction has become mainstream and compromised.

There is a hint here that harm reduction has its natural home as an insurgency: mainstreaming results in it being compromised. At a gut level, I kind of feel like that is true, though theoretically it need not be. But the overt message is that someone whose role is mostly about judging, punishing, and preventing is no friend of harm reduction. “Pro-harm-reduction tobacco controller” is an oxymoron.

As I said, go read Shelly’s whole piece; there is more that should ring a bell. In particular, you will also notice those most responsible for destroying the real commitment to harm reduction are the UN/WHO and other powerful funders, a bunch of Western 1%-ers who pretend compassion while really thinking of most of the people in the world as, at best, serfs, and often merely as disease vectors. That also seems rather familiar.

New paper on CASAA survey results

by Carl V Phillips

In case you missed it, I posted the new paper EP-ology and comments are welcome there. It is an upgrade of the report that appeared on this page a few months ago. Nothing really new, but more detail and analysis.