by Carl V Phillips
Some of you may have noticed my new subtitle on the blog (which I am rather proud of), “because cultivating the truth requires both seeding and weeding”. CASAA and others spend a lot of time seeding — presenting the correct information about THR — but the unique role of this blog is to work on the weeding. No matter how many seeds we plant, there is no way we are going to educate people about THR if we do not aggressively confront the weeds out there, the anti-THR liars.
But not every truth is of equal value in fighting this fight, so I thought it would be worthwhile to use this blog to think seriously about which points to make, and to whom.
I will bracket this with an example of an argument that probably never does much good. On many occasions we see someone who is new to the politics of vaping or THR insist, “we just need to get them to understand that e-cigarettes are not tobacco”, where them is the FDA or another regulator. There are two problems with this. Whether or not it seems like a natural use of language to call e-cigarettes a tobacco product (and views differ on this), a regulatory or law-making institution can declare any definition they want. They can declare the vapor from an e-cigarette to be smoke if they choose. It does not matter what the real nature of something is.
The second problem is that the audience is not the right target for information like this. The regulators seem to genuinely not understand some important points, but they understand basic points like the nature of the products. If their view on the matter does not match yours, it is not because they are missing something; they are doing it deliberately.
To a large extent, regulators function as lawyers (regardless whether they style themselves as scientists) and exist in an artificial construct of rules that offers little room for honest thoughts and feelings. There definitely are arguments that can be aimed at regulators, but they need to be chosen strategically rather than focusing on “common sense” and humanity. On the other hand, most politicians, medics, pundits, and other influential people — despite all the criticisms they often deserve — quite often act like normal people, based on thinking and feeling. Some are in thrall to the anti-tobacco extremists or otherwise hopeless, but only some.
So, when dealing with people who can be reasoned with, what truths should we focus on?
The obvious point that we always start with is that e-cigarettes are clearly very low risk compared to smoking. (The argument for that is even stronger for smokeless tobacco, but I will focus on e-cigarettes. Also, I am focused here on restrictions on the very availability of e-cigarettes; I will address place-based use bans later.) We should immediately take that one step further and emphasize the difference between nicotine (low-risk) and smoke (almost all the risk). A good observation is that nicotine is quite similar to caffeine in terms of both its appeal and its health risks. The starting point for thinking about the health risk from e-cigarettes should thus be that they are not much different from Coca Cola, whereas they are extremely different from cigarettes.
But we can go further with the argument about comparative risk, even when presenting it to people who will not understand the scientific details. There is another point that is easy to make, is scientifically solid, and can be very convincing: It is useful to point out that the risk is so low that a lifetime of use of the smoke-free alternative poses less risk, on average, than just a couple of months of smoking.
Why is this so critical? The answer to that can be found in the title I chose for my paper that pointed out this tradeoff, “Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative”. The almost inevitable response to “it is a lot safer” is “but it is still not completely safe and so smokers should just do the safest thing, which is to quit entirely”. But pursuing abstinence is not actually the lowest-risk option.
Our usual response to the “they/you should just quit” argument tends to be one or both of the following: (1) We try again to pound it into their heads that the risk of the smoke-free alternative is down in the range of various other consumer choices that we normally allow. But if they understood that, they would already be won over. (2) We point out that some people “cannot” quit nicotine/tobacco (which really means will not choose to be abstinent if abstinence and smoking are the only options) or would return to smoking if they did not have e-cigarettes. But that argument inevitably leads down the rabbit hole of claims about “proven” methods for quitting and how some people do quit or would really prefer to quit nicotine entirely, followed by responses about how those methods do not work for everyone, which leads to tangential wanderings into the weeds about evidence about smoking cessation success and so on.
One form of that second argument does often work, it turns out: personal stories from smokers who only quit when given the option of THR often carry the day, as well they should. That is why the ANTZ are working so hard to suppress those stories — they know that normal thinking feeling human beings will respond to them, and such thinking and feeling just cannot be allowed. When that works, great. But when trying to present the structured scientific argument, the wandering off into the details about success rates for various cessation methods and other details is unlikely to be helpful. In a longer written analysis, those are fine. In a discussion or short written piece, they are a distraction.
I believe that the more effective response to the “everyone should just become abstinent, so we do not need THR” argument is to focus on how trying to become abstinent is usually not the someone’s lowest risk option. Ask, “you are suggesting that all those smokers who switched to e-cigarettes would have eventually quit smoking without using any substitute, but do you think they all would have done it in a couple of months of when they switched, or might it have been a year or two more?” The ANTZ might claim that every switcher would have quit the day they switched had the alternative product not been available, but normal people know better. Having established that it might indeed take years to quit instead, we can point out that smoking for just a few more months on the way to becoming abstinent is a greater health risk than a lifetime of e-cigarettes. Or put another way, trying to achieve abstinence poses greater health risk than switching. Or put yet another way, “if you prohibit or discourage switching to a low risk alternative, not only are you causing many smokers who would switch but will never quit entirely to die from smoking, but you are also killing many of those would eventually quit because any delay in stopping smoking is far more important than how they stop smoking.”