by Carl V Phillips
Continuing this series from the previous post, I want to start with an explanation for why the opinion leaders genuinely oppose THR that may not make for good inflammatory rhetoric, but is a critical part of the narrative. Though it is not a dominant force anymore, I believe it represents the origin story for why anti-THR became established in the first place.
The one-sentence version that I often offer is: Those who spent their careers trying to get people to stop smoking, but accomplished almost nothing[*], resent the possibility of smoking being substantially reduced in spite of their efforts rather than because of them.
This is a sufficiently compelling and self-explanatory narrative that nothing more is really needed to make the point to any open-minded audience. So you can stop reading here if you are just interested in messaging. But the underpinnings of that behavior and its role in the history of anti-THR are interesting.
[*As I have noted in detail before, the widespread education about the harms from smoking that was developed in the 1960s and 1970s and is now universally understood in educated populations made a huge dent in smoking prevalence and continues to explain most of the downward trend in smoking prevalence. Punitive taxes also make a measurable dent, whatever you might think of the ethics of them. But nothing else (other than THR) has any measurable impact. Thus almost everything that tobacco controllers spent their lives on for the last few decades has accomplished close to nothing.]
NIH Syndrome — “not invented here”, not to be confused with the National Institutes of Health, though it so happens that they are among the most guilty in this particular case — is the common phenomenon of rejecting an idea because it was not your idea, even if it is obviously right. It results from a combination of reward structures and psychology. NIH occurs in business, science, and personal relationships. Examples include, everything from “you marketing guys should just leave product design to us engineers; the end-user will get used to hitting control-shift-F6 to go back to the menu screen” to “I have been driving for decades, so don’t tell me to watch out for that pedestrian.”
A lot of effort in science and science-related policy is spent to trying to support a personal pet hypothesis rather than admit that someone else seems to have come up with a better one (indeed, such NIH behavior is the most important conflict-of-interest problem in scientific research). Rewards — both in terms of personal satisfaction and material payoffs — are much higher for winning the war of hypotheses than they are for becoming right by accepting that you were originally wrong. Indeed, this incentive actually increases as it the evidence builds up against you because “everyone scoffed at your idea but you hung in and proved you were right” pays off much bigger than offering an insight that everyone quickly accepts and thus just thinks of as common knowledge.
While I am not aware of any formal analysis of NIH, it seems safe to make a few generalizations. The NIH urge does not require that the source of an idea is an active rival; rivalry can create a conscious incentive to not endorse someone’s ideas, but the gut-level NIH tendency is often directed at someone whose correctness poses no threat. The more self-image someone has invested in a topic, the more they might want to deny that someone else has a good idea. On the other hand, if they are confident of their abilities and contributions in a field, they are not likely to be so defensive; the anti-NIH phrase “I wish I had written that” is almost always high praise because it tends to only be written by those who are the highest-quality contributors to their field. (There are also some oddities about what triggers NIH reactions, such as many people resenting any suggestions about how to drive safer but welcoming suggestions about a television show they really ought to not miss, even though those are both cases of someone saying “you appear to not get this, but I do, and what I know could make your life better.” But for present purposes we can set those aside.)
The situation at the dawn of concerted anti-THR efforts, c.2000, could not have been much more perfect for triggering NIH reactions. For the reasons noted above, people working in the field had little reason to be confident of their abilities or contributions. Tobacco control was dominated by a generation that were not the lavishly-paid fanatics who dominate now, and who had been working hard to try to make real contributions even though it was not an easy career path (the big-money spigots had only just opened). They were not yet living entirely in the echo chamber that insulated them from reality. Thus they could not entirely delude themselves about the fact that they had added nothing consequential to what was done the pioneering researchers and educators from the previous generation. At the same time, however, the continuing effects of the earlier generations’ work, as well as the war stories of the remaining clan elders who were part of those generations, made it possible for this generation to believe that they were going to succeed in getting everyone to just quit tobacco use. That seems quite silly in retrospect, and was not very plausible then, but it was just plausible enough to trigger the NIH reaction.
The anti-THR backlash began after a few scholars — Brad Rodu and colleagues, a handful of Swedes, Lynn Kozlowski — along with Swedish Match and U.S. Smokeless Tobacco Company (with some early stirrings from BAT) began pushing for recognition of THR as a promising way to reduce smoking. At the time, the touchstone was Sweden, where snus use had mostly replaced smoking (which remains true today, of course). But it was also promising in the USA, and even employed widely, though mostly under the radar. Even Canada seemed promising, though those who know my history know how well that worked out. There was a lot of focus on Europe, since the only thing that seemed to stand in the way of THR, given the cultural and market ties with Sweden, was the EU snus ban. (Witness the other great national THR success story, snus’s success in Norway in the 2010s. It took disturbingly long, but it did happen.)
But that backlash mostly did not take the forms we see today. The leading anti-THR sentiment from the opinion leaders was pure NIH: “sure, smokeless tobacco is low risk, but all smokers are just going to quit any year now, so we do not need this poor substitute for abstinence.” This absurd on its face, of course. It is not as if promoting THR — or merely not actively opposing it — would interfere with the expected abandoning of smoking. Indeed, it would obviously help. That sentiment only makes sense when you add the observation that they were concerned that THR would be so clearly more effective than their pet approaches — as it had been Sweden — that they would not be able to claim credit for the elimination of smoking. Indeed, there is an interesting case to be made that Sweden served not just as the proof-of-concept for THR but also as the cause of anti-THR; without the success story, tobacco controllers might not have feared being shown-up.
I do not want to overstate by implying that NIH the only reason for the origins of anti-THR. There were some opinion leaders who were pushing flatly anti-scientific claims that smokeless tobacco poses substantial risk, though mostly it was the useful idiots who bought into that story. (Obviously they succeeded, since most people in most populations still believe this.) There were anti-tobacco extremists, the topic of the next post in this series. There were profiteers and anti-corporate nuts. But unlike today, tobacco controllers then were still mostly decent honest people. But being people, they were victims of unfortunate human tendencies.
I recall vividly a conversation with Brad Rodu in 2003, at a bar in New York following a meeting of key players and factions in the THR fight which was organized by ACSH (the first public education organization to actively embrace THR). I was a relative newcomer, having been working on the topic for about two years (thanks to what I learned from Brad’s decade of work and from USSTC), but it was a small world then. The possibility of something useful coming from that meeting was intentionally torpedoed by the representative from CTFK (I forget who) and the de facto representative from pharma, Jack Henningfield. But though those factions (anti-tobacco extremists and profiteers) could derail a single meeting, we did not think of them as particularly influential. Instead, Brad and I discussed our prediction that tobacco control would soon come around to embracing THR and claiming it was their idea all along. Because anti-THR was still sufficiently fringe, we genuinely believed this would happen and mulled over what it would feel like when those of us who were pushing the idea against tobacco control’s resistance experienced an Orwellian elimination from the history.
Obviously it did not play out that way. Tobacco control doubled-down on anti-THR and within a couple of years it became clear that they could no longer back down. It is possible that our error was underestimating the influence that fanatics and profiteers held even then. But I am strongly convinced that what we really underestimated was the power of NIH Syndrome. Absent that, it is quite possible that THR would have been grudgingly accepted by the honest and serious opinion leaders to a degree that would have kept the fanatics and their useful idiots from demonizing it.
Flash forward and NIH appears again in the story of e-cigarettes. It is easy to imagine a world where e-cigarettes were introduced and promoted by tobacco controllers as a cure for smoking. But because e-cigarettes were an insurgency, they triggered the full NIH reaction. I definitely do not want to overstate the importance of NIH at this juncture. By the time e-cigarettes happened, tobacco control was dominated by the anti-tobacco extremists and was a lavishly funded industry, and “public health” had entrenched as a special interest political movement that had little to do with health. Also, most of the factors that created the recipe for NIH a decade earlier had changed. There would have been substantial opposition from tobacco control even if e-cigarettes had bubbled up from within their ranks (and, indeed, that is probably why it did not come from within their ranks — it is not as if the concept was either novel or complicated). But it is notable that there are several tobacco control opinion leaders who have embraced e-cigarettes as a cure for smoking even though they do not really support THR. The difference between them and some of their (non-extremist) colleagues might be explained by them having less of the NIH tendency.
The next posts in the series will address the most important explanation for fanatical anti-THR, anti-tobacco extremism. But even though this and, to a lesser extent, money are sufficient explanations for anti-THR now, it is still a useful part of the narrative to recognize the importance of NIH in establishing anti-THR, and that it still contributes to the tribalism that perpetuates it.
Thank you for this post Carl, this is what people, (real people), are up against:
Yet more junk science from the liars in the tobacco control industry.
Meanwhile….. possibly hundreds of thousands of people are suffering and dying needlessly. Someday the current big names in anti-THR may perhaps be judged criminally responsible, how can they be blind to this possibility?
Very interesting indeed. It is enlightening to get the history of THR in such detail and it explains so much of what is going on today. There can be no doubt that we have to take on board the complexities inherent in the task which faces us – Reading this demonstrates the variety of attitudes of those who are anti-THR and also the ability to change for better, and worse, and how we must be aware of this at all times in order to combat or take advantage of each developing situation. (And keep in mind that we too are open to change – for better or worse, and that we need to self-aware to keep ourselves on the right track)
“Those who spent their careers trying to get people to stop smoking, but accomplished almost nothing[*], resent the possibility of smoking being substantially reduced in spite of their efforts rather than because of them.”
While smokeless tobacco and vapor products have helped several million smokers quit smoking and have reduced cigarette consumption, most of the huge decline in US cigarette consumption (from 138 packs/person in 1982 to 45 packs/person in 2014) were due to the implementation of smokefree indoor policies and cigarette price hikes (due to many different federal, state and local excise tax increases, as well as lawsuits/settlements/verdicts against cigarette companies).
No, that is clearly not true. Most of that decline was still effects of the basic education effort from the 1960s and 1970s (which continued, of course), even though the education itself was saturated by then. This came via cohort replacement as well as …well, call it denormalization, as ugly as that concept is. In 1982 the majority of the population had come of age when smoking was still common and not feared, young adults had gotten the message in childhood but not so thoroughly, and those coming of age were still fairly likely to see their parents et al. smoking, which has a huge impact. All of that changed over 32 years. Pretending that is not the case is like attributing the huge increase in the percentage of black Americans and women with a college degree over those 32 years to university policies during that period.
Punitive taxes also contributed measurably as I noted.
You chose a measure that gives inappropriate credit to place ban policies. Forcing smokers to smoke fewer cigarettes lowers that statistic but you would be hard put to find any impact on smoking prevalence — which is what matters most — with anything resembling legitimate science. Indeed, both such restrictions and taxes create the incentive to smoke more efficiently and shift purchases into parallel markets, so that disappearance data will overstate even the reduction in consumption. Undoubtedly place bans, along with various other games and restrictions, shaved a bit off of the prevalence, but not enough to keep any honest person tobacco controller from recognizing that their enterprise was a failure.
I should add, to tie this back to the subject of the post, that c.2000 most opinion-leading tobacco controllers were of a generation that had lived through the sea-change reduction over four decades but were dealing with the patent slowing of it. The generation that was then in their prime could not help but notice that were working furiously while the year-to-year progress was still most a ripple of the actions of their forebears (who did what they did with 1% of the then-current the manpower and budget). The frustration was palpable and the search for scapegoats was desperate. They desperately did not want the history books to read that the first wave of smoking reduction predated them and the second wave was thanks to THR.
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Regardless of what Carl wants to believe (and wants others to believe), indoor smoking bans and cigarette price increases are the two key reasons why cigarette consumption has sharply declined during the past 35 years.
Bill, if you ever offered a substantive argument rather than just repeating your assertions again after someone points out why they do not hold up to scrutiny, you might convince someone. As it stands, you are just paying one side of an eight-year-old’s game of “nuh-uh” “uh-huh” “nuh-uh” “uh-huh”…. The thing is that on the other side of that dialogue is someone making cogent substantive arguments, while you continue to reply with nothing more than the equivalent of “uh-huh”.
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