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.