NEJM: insight into the narrowness of public health views about THR

by Carl V Phillips

A commentary about e-cigarettes in the New England Journal of Medicine by three professors from the Columbia School of Public Health is remarkably educational.  This is not because of the content, which is all well known to anyone who follows and understands THR or e-cigarettes.  But by not spouting the usual tired, lying dogma, and presenting an intelligent view, the authors unintentionally give us a window into the genuine naivety of the public health community.

The magazine article (yes, magazine — any publication that has a sidebar with an interview of a politico, advertisements, etc. is a magazine, not a journal), entitled The Renormalization of Smoking? E-Cigarettes and the Tobacco “Endgame” by Amy L. Fairchild, Ronald Bayer, and James Colgrove is not anti-THR or anti-ecig.  It is not lies.  It borders on being pro-THR.  Thus, it is genuinely interesting.  After starting with some of the usual boilerplate about e-cigarettes, the authors write:

But e-cigarettes are the subject of a public health dispute that has become more furious as their popularity has increased. Whereas some experts welcome the e-cigarette as a pathway to the reduction or cessation of tobacco use, opponents characterize it as a dangerous product that could undermine efforts to denormalize smoking.

Perhaps it was a Freudian slip, but maybe it was intentional:  Notice that those on the side of THR are experts, while those on the other side are merely opponents.  I like that.

They then discuss several local place bans (with information that was already out-of-date at the time of publication — score one for blogs over magazines) as a lead-in to:

This debate occurs as tobacco-control advocates have begun examining policy options for a tobacco “endgame” — the implementation of radical strategies for eliminating tobacco use globally.

I am not sure whether this is naive, pandering, or foreshadowing.  I will circle back to it.

Marketing campaigns for e-cigarettes threaten to reverse the successful, decades-long public health campaign to denormalize smoking. The chief advertising officer of one e-cigarette company has spoken explicitly about the “renormalization” of smoking in the form of “vaping” — the popular name for e-cigarette use.

This is where the authors start illustrating how out-of-touch the public health establishment is with the real world.  When “public health” people (the scare quotes referring to those who embrace the term, but are really concerned about controlling people, not their well-being) lie about THR, as is typical, it is difficult to disentangle knowing falsehood from ignorance and innumeracy. These authors are being honest, and are smart, literate, and numerate people, so that means we can separate out the effects of buying into their lying colleagues’ propaganda and the resulting naivety it creates.  Do they really believe that an e-cigarette company would want to renormalize smoking?

Vaping does, of course, normalize tobacco use while further helping to denormalize smoking.  The anti-tobacco extremists object to this because (a) it tends to denormalize smoking without demonizing tobacco users, which is what they really are seeking to do, cloaking it in the nicer-sounding word, and (b) they do not really care about the impacts of smoking, but about eliminating what they consider to be an immoral choice of behaviors.  Real public health people — perhaps because they share the top-down control culture of  that field and of the ruling class in general — get taken in by their lies, and believe that the modern tobacco control industry is really about public health.

Even Big Tobacco dared not utter such words as the image of smoking was transformed over the decades.

“Big Tobacco” was fine with the status quo.  Companies lost some business to competitor products, and they lost some business to the demonization campaign.  It was just another competitor.  Occasionally companies find that the best advertising strategy is to go head-to-head with a competitor, but usually they do not.  Usually, simply trying to better sell one’s own product without reference to the competition is the best strategy.  The view from “public health” (and public health) is so self-centered that there is little recognition that others do not see the world in the same way that they do.  In particular, they genuinely do not realize that their warfare mentality is not shared by those they have declared war on.  Anti-tobacco extremists are obsessed with tobacco companies, and apparently have no idea that tobacco companies do not reciprocate, and merely consider the extremists to be just another part of the market environment.

As information about the hazards of sidestream smoke was publicized in the 1980s and 1990s, the imperative to protect “innocent bystanders” moved to the center of tobacco-control efforts, and public smoking bans pushed smokers into the shadows. The once-widespread habit didn’t simply become denormalized or marginalized; it became highly stigmatized. The pervasive became perverse.

Notice the passive voice here.  There seems to be no recognition that this was an orchestrated campaign by the extremist group to intentionally stigmatize smokers (not smoking, smokers).  It was successful.  The will of most smokers to defend their choice to smoke was broken by it (a simple fact, not a judgment about whether this was good or bad).  The misplaced emphasis on the industry and advertising means that the people who are taken in by the tobacco control propaganda do not recognize the significance of this:  Smokers have been mostly broken, like many downtrodden minorities (religious, racial, etc.) are so often by those in power; vapers are not.

The authors discuss some examples of e-cigarette advertising and go on to observe:

The tobacco-control community has responded to these messages with alarm. In 2009, the World Health Organization warned that e-cigarettes threatened bans on public smoking, which have been key to tobacco control. Similar concerns were raised by anti-tobacco activist Stanton Glantz and his colleagues: “Given the substantial research demonstrating the effect of viewing smoking in the movies on adolescent smoking initiation, the addictive nature of nicotine and the lack of regulatory assurance of their quality or safety, it is important to keep ENDS [electronic nicotine-delivery systems], and other similar products, from being sensationalized through the use of celebrity promotion or product placement in movies or other entertainment media.”

Naive or pandering?  These authors are not clueless like Glantz.  Surely they must realize that this “research” is pure junk and the claim that a large fraction of all smoking initiation is caused by portrayals in movies and such, as Glantz claims, is obviously batshit crazy.  Even more troublesome is the willingness to uncritically repeat the absurd claims about threatening bans on public smoking.  How, exactly, does replacing smoking threaten bans on smoking?

The authors then repeat the misleading claims about the CDC data about children using e-cigarettes, which have already been covered here at length.   They continue the naive/pandering repetition of obviously false claims by serial liars (which I will not bother to address yet again), but their lead-in to that is very interesting:

Invoking images of terrorism, two tobacco-control advocates claim that “smoking bans and clean air advocacy are being hijacked….

This is amazingly insightful, but unfortunately they do not follow through.  Terrorism, as the word is commonly used these days, refers to violence inflicted by zealots on innocent people who are just trying to live their lives. The most obvious extension of this theme is to observe that such “terrorist” actions in this world are largely perpetrated by the tobacco control activists. More subtly, this further illustrates the ruling-class view from public health, that consumers are mere targets in the war they have declared, not stakeholders and certainly not intelligent adults making decisions for themselves.

Also note the failure to analyze the anti-tobacco extremists’ rhetoric and note even its most obvious dishonesty:  If “clean air advocacy” is threatened by people choosing to not smoke, then it is really not about clean air, is it?  (Note that the same people also condemn smokeless tobacco using the same language, so there is no defense for them to be found in exaggerated claims about the environmental impacts of vaping.)

The most vocal supporters of e-cigarettes, other than those with commercial interests in them, have been public health professionals who’ve embraced the strategy of harm reduction — an approach to risky behavior that prioritizes minimizing damage rather than eliminating the behavior.

This, I think, is the key observation about the ruling-class mentality.  Yes, I am happy to take credit for the handful of us public health (without the scare quotes) professionals who did research on smokeless tobacco and tobacco harm reduction long before e-cigarettes happened.  Without that work, it is difficult to believe that e-cigarettes would have succeeded.  But we are hardly the most vocal supporters, and neither is industry.

Building on the foundations we built for THR, e-cigarette users themselves (who, interestingly, are largely unaware they are standing on a platform built by public health professionals) have become the most vocal supporters.  The top-down obsession of the public health community, and the notion that some ruling class — either industry or people like them — controls this conversation, is fascinating.

People who only read journals and magazines — who are out of touch with the popular culture and mass communication channels — end up looking like the older generation that has no idea who their kids’ favorite pop idol du jour is.  Of course, that is just fine for the case of the pop idols.  It is not, however, acceptable for those who presume to analyze the world of tobacco product use, let alone to dictate policy.

Although the evidence is limited and contested, some studies suggest that the majority of e-cigarette users treat them as cessation aides and report that they’ve been key to quitting smoking. For example, in one study, e-cigarettes compare favorably to nicotine-replacement therapies in terms of the likelihood of having returned to smoking 6 months after a cessation attempt.

This is a great example of why that naivety is a fatal problem.  There is exactly one useful “study” of e-cigarettes out in the world, and it is the world — a world that most in ivory towers seem unaware of.  Clinical studies like the one they cite can be a little bit interesting, but they are ultimately almost useless for figuring out what will really happen in a case like this — let alone what is actually happening!  Tobacco control extremists take advantage of the fetishization of clinical trials (which is to say, conferring on the object itself magical powers that cause the tool or symbol to displace the actual goal or reality) to attack anything that is not medicalized or top-down.  Real public health people are tricked into this because they often do not realize that social science (which they should be doing) is not medicine.

We do not do clinical trials to figure out, say, the effect of unemployment insurance on the labor market.  It should be obvious that while you could concoct such a trial (and people do), that such an artificial study of the non-representative individuals who volunteer to participate is far less informative about the world than watching real-world natural experiments.  The results from the real-world natural experiment about e-cigarettes are most definitely not limited.

Given the near unanimity of the public health community in pressing for harm reduction for injection-drug users in the face of relentless political opposition, some harm-reduction advocates find it stunning that their allies in that struggle have embraced an abstinence-only position on smoking…

Yup.

…These advocates claim that a strategy of reducing, though not eliminating, risk is a moral imperative, given the certainty of harm associated with continued tobacco smoking.

Yes, but not quite.  The harm reduction philosophy is not just about finding a substitute for the failure of the abstinence-only approach.  Harm reduction is about letting people choose to do what makes their lives better, trying to make it less harmful to do it.  The better analogy is not IDU, but sexual behavior, and the comparison to IDU is inherently (and often intentionally) inflammatory, invoking a behavior that is often terribly destructive and legitimately dissuaded.  Sexual behavior harm reduction is about making an unhealthy but also highly-beneficial behavior less risky (obviously sex is more beneficial to most people than is nicotine, but the basic characteristics are similar, and quite different from IDU). In both cases, encouraging harm reduction rather than demanding abstinence is only condemned by a special-interest group of “moralizers” who, due to some quirk of their wiring or unfortunate upbringing, deeply resent that other people out there are enjoying something they find objectionable.

The debate’s stakes are heightened by the current discussion of the tobacco endgame, which aims to eliminate smoking or reduce it to very low levels. Most endgame strategists have advanced prohibitionist policies, from complete bans on traditional cigarettes, to regulatory strategies that would reduce and eventually eliminate nicotine, to efforts to manipulate pH levels in tobacco to make inhaling unpleasant.

Take a careful look at the language here, and in the foreshadowing above.  The phrase “tobacco endgame” is juxtaposed with “eliminate smoking”.  I suspect that these authors really believe that eliminating smoking is the goal.  They just do not realize that most of those who talk of an “endgame” really want to eliminate tobacco use, not merely the high-risk version.  Indeed, many of them are more worried about THR than they are about smoking because they realize that low-risk tobacco product users — as opposed to smokers — have little reason to become abstinent, and thus probably will not do so.  Also note the charitable use of the word “strategy”.  As Ken Warner (who is featured in their next paragraph) implicitly conceded, with unintentionally ironic phrasing, the mentioned tactics hold little promise of success.  A goal is not a strategy.

As for the stakes being heightened — um, no.  Just because a few hundred thousand people in the world are into this “endgame” does not substantially change the stakes.  The stakes for tobacco harm reduction are whether hundreds of millions of people are happy (part of which is being healthy).  The opinions of a few extremists matter only to those extremists and those who are sucked into their ruling-class mentality.

From the glowing tip to the smokelike vapor, e-cigarettes seek to mimic the personal experience and public performance of smoking. But ironically, the attraction of the device is predicated on the continued stigmatization of tobacco cigarettes.

The authors go on to conclude with some pro-THR observations, but I will end my analysis here in order to emphasize my response to this, which is: Nononononono.

It is true that the adoption of (all) THR products is encouraged by the stigmatization of smoking and smokers (to emphasize once again: it is the people who are stigmatized, not the products).  But “predicated”??  Tobacco users, contrary to the views of tobacco control, are not morons or automatons who depend on the ruling class to manipulate them into better behavior.  This may come as a shock, but they are thinking people who care about their overall well-being (which includes health) and thus many (not all) of them are interested in choosing a low-risk alternative if they find one of sufficiently high quality.  And, contrary to the view of the ruling class, “quality” will be defined by those individuals.

In their conclusion, the authors suggest that opposition to THR is “dangerously close to dogmatism” (emphasis added — probably not meant to be funny, but it made me laugh out loud).  What is actually dangerously close to dogmatism (which is to say, trapped in their thinking by some of the views of the still-embraced dogmatic extremists) is the top-down ivory tower view of THR.  It might be that more genuine public health people can play a positive role in the THR revolution.  But they are unlikely to do so until they recognize the dogmatism that prevents them from understanding what is really happening.