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.”
I think that you forget another important argument: the fact that ‘real’ quitting may also induce non-physical damage like psychological and social damage, something that THR will not have as it is closer to the habits and ‘ceremonies’ around real smoking and satisfies the impulses for a cigarette which arise during the day.
The ‘quitters’ mood will be better and therefore the appeal on their housemates (to cope with their mood swings) too. That will also increase the support from their relatives for their choice as well that they don’t need to fight the ‘ quitters’, often unusual, rages…
I will get back to that in the intermediate-level course. The first bits are the novice course — not meaning that the target readers here are novice, but trying to figure out how to deal with people who can only understand the simple side of things. Unfortunately, too many people we deal with are not ready to accept the obvious fact that smoking has benefits, some of which take the forms you mention. Ultimately I consider that the strongest argument for THR (that many people would *prefer* to use an alternative rather than be abstinent or smoke — if they had good options and knew about them), and I kind of hate having to focus on the others. But unfortunately we have to start with the others.
Carl, sometimes I find it helps to move the argument to a different area where some things are similar enough that a comparison can be drawn.
Looking at one of my favorite subjects: Chocolate. :>
I would imagine that a nice slice of chocolate cake may, in some way, increase your risk of diabetes by a certain amount — since thousands of slices of chocolate cake are, I believe, pretty much accepted as being causal in that regard. ( sad… :/ )
It’s also possible that gallons and gallons of sweet blueberries would have a similar effect.
I’d say eating a piece of chocolate cake might be analogous to smoking, while eating a strawberry might be analogous to vaping or snus. Now, would any doctor in their right mind try to dissuade a pre-diabetic patient who walked into their office one day and said, “Doc, I’ve finally found a way to avoid scarfing down two slices of chocolate cake after dinner every night! Instead I have two nice blueberries!”
Yes, the blueberries have a similar deadly ingredient (fructose I guess, as opposed to sucrose) and it’s possible that even two tiny blueberries could be the straw that breaks the camel’s back. But on the other hand, the quantities of all the other sweet high carb quickly converted to blood sugar ingredients in that chocolate cake simply aren’t there for the most part in the blueberries (and even if they were, they’d be in much smaller quantities.)
Of course occasionally you’ll get a blueberry with a few nanograms of some “blueberry eating bug” killer on it, but on the other hand, the chocolate cake will have all sorts of hundredfold larger quantities of all the various pesticides and chemicals used along the way in the production and care and tweaking of all its ingredients.
The Anti-e-cig folks are like extreme anorexic, bulimic, anti-sugar/carb nuts who’ll condemn the fellow eating the two blueberries and demand that the doctor ban the patient from making the substitution.
Chewing tobacco, as opposed to snus, does have a fair amount of carcinogens in it, but within this analogy the comparison to smoking might be like having your two blueberries dipped in a light chocolate shell…. still a lot better for you overall than the chocolate cake.
As long as you never forget that some of us *LIKE* chocolate cake, and the anorexic atmosphere that might be prevailing against it isn’t one that we all agree with: some of us are willing to increase our risk of diabetes because we like that cake, we have the right to eat it, and the government should NOT be overtaxing it and trying to persuade us from our evil ways by forcing us to eat it out back behind the dumpster after our meal.
They’ll pry my chocolate cake from my cold, dead, fingers.
P.S. Forgot to mention what started me on that. LOL! Your statement,
“e-cigarettes are clearly very low risk compared to smoking. (The argument for that is even stronger for smokeless tobacco,…)”
I’d say the e-cigs vs snus would be sorta like blueberries vs. blackberries or possibly even strawberries. Yeah, it’s possible that one is safer than the other (and I think I’d reverse the likelihood that you outlined in that quote) but the safety difference, if it exists, is so small compared to gulping chocolate cakes that *normal* people shouldn’t be worrying themselves about it at this stage.
I should have clarified. I have said this one enough times in enough places that I forget that it is not obvious. The risks from the two products are about the same as far as we can tell — far too close to each other to be worth worrying about. However, the evidence about how low the risk is for ST is totally solid, while our knowledge about e-cigarettes is much less certain. It is because of that uncertainty, not the point estimate, that the argument is somewhat weakened.
a delicious analogy!
“a delicious analogy!”
Thank you Art! I always try to make my analogies as delicious as possible. Sometimes I even add candy flavors to them to better attract The Children. Once I get them hooked on analogies, I then move them on to similes and sometimes, if I’m feeling really wicked, outright metaphores!
Carl, would it be correct if I quoted you as saying for example: “continuing to smoke for 6 months entails more risk than a lifetime of e-cigarette use”? Or is this incorrect, or an over-simplification? You do imply ‘a couple of months’ above so I thought 6 would be a safe (and nicely chunky) number to use… This sort of comparison will have its uses, if it is safe to use.
Chris, The breakeven is actually 2 months, so 6 is definitely safe. (I had originally reported 1 month, but there was an error in the calculation for somewhat complicated reasons. I posted a correction which is what scientists, though not anti-tobacco people, do when they learn of a mistake.) The simplification there is the following: The comparison is not every single 2 months of smoking, but the average 2 months of smoking across all people (or, equivalently across each person’s lifetime). That is, it is the risk from smoking averaged across all the months people smoke, even though not all months really pose the same risk. To explain that, it is probably the case that the 12th and 13th month of someone’s smoking do far less damage, on average, than other months (any initial damage is already done, but the point at which life-threatening disease is caused has not yet been reached). Or even more extreme, smoking by someone who is already dying of cancer is harmless.
So I tend to just slip in the words “on average” to make it technically correct, as in: “three months of additional smoking poses a greater risk to someone’s health, on average, than a lifetime of using a low-risk alternative”.
One night I smoked for the heck of it. I went to bed and wheezed just as I did when I smoked before e-cigarettes 2.7 yrs ago. My lungs cannot tolerate smoking and my health is at risk!
Thank you. I’ll use three months in that case.
I may have to change how I comment on the various facebook pages and news stories. Thank you Carl. I would also like to ask is it beneficial to ask “them” Would you rather I went back to smoking or continue to use a less harmful alternative?
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I used your pithy comment about relative risks in an update of the ECCA page on THR:
It ends the piece and is the final word on the subject. Thanks Carl.
Thanks. Though I would like to think that your characterization of “knows more than most” understate by about six sigma. :-)
If you can help by translating that into Orders of Magnitude for this simple engineer, I might understand better.
Keeping in mind that I was not seriously giving you a hard time, of course, six sigma is a common reference to the portion of the tail of a standard deviation that is six standard deviations from the mean, which is about 1 in 500 million. I think that is rather closer to the range of my relative expertise in THR science than the “better than 1 in 2” (“knows more than most”) you gave me credit for.
Ah yes, of course – you converted my common speech understatement of the relative advantage you have in knowledge compared to the Glantz’s, Hahn’s and Gratziou’s of this world – “better than most” – into a precise mathematical value of >1in 2.
Arghh. Darn statisticians…
I am almost convinced of your 500 million times superiority if applied to punchy quotes, analogies, and pithy analysis, at any rate.
(Please do not convert ‘at any rate’ into a statistical value.)
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