In the debate about vaping, asking the wrong “right questions”

by Carl V Phillips

Making the rounds today is this post at The Guardian entitled, “In the polarising debate about vaping, we’ve forgotten to ask the right questions”, by Alex Wodak. You can read a quick Wodak biosketch, about his history as an Australian drug policy reformer of a certain stripe, at the Guardian or on Twitter. I find this piece quite interesting, both because of the good things that is says and in how and why it fails to fulfill its stated mission. It is much better than most of the ostensible “big picture overview” analyses in the blogosphere or academic press, which are not even worth reading. But I think what is most interesting is that the laudable sentiment starkly emphasizes where the common laudable sentiments come up short.

Recently I noted that the “debates” about e-cigarettes within the “public health” community may be perceived by those involved to be (on a scale of 1 to 10) the 9s squaring off against the 1s, 2s, and 3s, but on the scale of how people in the real world think, the they are merely those sitting at 2, maybe sometimes 3, versus those sitting at 1. 

Wodak begins:

A furious debate has been taking place in recent years over electronic cigarettes, and the debate can unfortunately become quite nasty and polarised. Public health practitioners who have fought together for decades are now often opposed.

Wodak has been in debates that are just nasty and polarized, so is clearly not so naive as to suggest this is unusual. But I suspect he is genuinely unaware that the debates and policy fights about all tobacco products have been this nasty and polarized for two or three decades. He is oblivious to this because all of his friends were on the same side of the nasty polarization until recently. Since that polarization was the public health grandees versus mere plebes and those annoying defenders of liberty, it did not count. It was only when some public health grandees took opposing positions that those viewing the world from the 2 and 3 seats even noticed that anyone was objecting.

He continues (I have added the numbers for convenience):

[1] Do electronic cigarettes (ECs) help smokers to quit? [2] Are ECs as innocuous as their advocates claim? [3] Is duplicitous and unscrupulous Big Tobacco cynically manipulating naïve EC supporters in their avaricious search for profits? [4] Do ECs normalise smoking, thereby providing a gateway to increasing smoking? [5] Have some EC advocates with murky links to the tobacco industry or pharmaceutical companies attempted to conceal these ties? [6] Are ECs yet another in a long list of failed harm reduction attempts for tobacco?

These are among the most common questions debated and they are all important and legitimate questions. The problem is that they are not the most important questions. And in complex arguments, it is especially important to try to focus on the most important questions before trying to answer less important questions.

The answers are: 1. Yes, obviously. 2. It depends on which claim, obviously. 3. What the hell are you talking about? 4. There is simply no reason to believe this is true. 5. I have never seen evidence or even any concrete rumors to this effect; there are certainly murky links to pharmaceutical interest among anti-ecig operatives, but I am aware of no example in the last four decades where serious advocates with links to the tobacco industry have tried to conceal that.

Wodak says that these are important questions but not the most important questions. I find it rather difficult to agree with either of those claims. 1 and 4 are among the most important questions. Perhaps they are unimportant as research questions because, to a policy-practical degree of precision, we already know the answers. But since denial of those answers is central to the “debate”, they remain important. 2 is a lousy question as asked; what we want to know is how harmful -e-cigarettes are, not what any particular advocates are claiming. But once corrected, it seems difficult to suggest that how harmful e-cigarettes actually are falls short of  “most important” status. 3 and 5, on the other hand, are not important to anyone who is really interest in the truth; they are only important if what you really care about is studying the debate antics or political game itself, and not in scientific or ethical analysis.

As for 6, it is difficult to take seriously anyone who says this. What long list of failed harm reduction efforts? Name two. A case can certainly be made that the ill-conceived “light cigarettes” gambit public health people pursued in the 1970s was a failure (though even this case is not quite the slam-dunk as it is often portrayed). But the one evidence-based effort to promote THR before e-cigarettes, promoting the substitution of smokeless tobacco, was a failure only in the sense that “public health” people successfully discouraged most smokers from trying it. It was definitely a success for those who did try it, as in Sweden.

So what does Wodak think are the most important questions?

Are they effective? The effectiveness of ECs depends on what we decide the objectives should be….

Most would interpret this question to just be his “not important” question number 1, do they help smokers quit. Wodak is apparent suggesting otherwise. He subtly almost endorses a different interpretation, for a moment, but then retreats into interpreting it as question 1. I would suggest that as soon as you use on the word “effective” you have put yourself in an Orwellian trap, with language limiting the range of possible thoughts, preventing asking several of the most important questions.

He next introduces the popular fictitious origin story of e-cigarettes (which is not material to the present analysis, but it is seldom a good sign about the robustness of someone’s knowledge) and tortures that into his first candidate objective:

…to allow people to be able to continue consuming nicotine while avoiding a premature tobacco-related death or serious illness.

He continues with:

Tobacco control (TC) experts then added the objective of ECs as possible quitting agents and made this the key objective.

I am rather at a loss as to how these differ from each other or from question 1. Perhaps Wodak has something in mind, but he does not make a case. The TC objective is exactly the “helping smokers quit” from question 1, and allowing people to continue to consume nicotine while avoiding disease is also obviously about quitting smoking.

He concludes his list of candidate objectives with:

But surely the paramount objective for ECs should be the preservation of life and wellbeing. If ECs can also be shown to also assist smokers to quit, then achieving this objective should be regarded as a bonus.

Recognizing the existence of  “wellbeing” as a goal is what makes Wodak’s post more promising than most you will see from the public health community. A recognition that people care about something other than life expectancy, perhaps. Unfortunately that word just sits there — he does not explain or defend it, and when he circles back around, every hint of the concept is gone. While recognizing that the most vocal — or rather, the most amplified — voices in the debate have other ideas, Wodak tantalizes the careful reader that he might recognize that the vast majority of the people, who occupy seats 4 through 10 on the scale, consider the “effectiveness” of a consumer product to be how much it enhances welfare. But the average reader will probably not even notice he said it.

Moving on to the next “important question”:

Are they safe?

Um, yeah. Not a good way to phrase that. I trust I do not have to explain why.

There is general agreement that tobacco smoking is much more dangerous than vaping ECs. While more and better research is always welcome, few still debate the relative dangers of smoking cigarettes or vaping ECs.

Sadly, this is not true. Of course It is true for anyone who is honest and knows what he is talking about, but a lot of the amplified voices do not fit that description. I like his tactic of just stating this as fact, much the same way you would not give creationists even a mention when suggesting interesting questions about evolution or planetary origins (subtext: those stupid flat-earthers are not even worth acknowledging). But an analysis of what we should try to answer in the debate cannot ignore that the real-world debate is hobbled by the influence of those who are still questioning this (or pretending to).

Whether ECs are 20 times safer or, say, only 5 times safer than tobacco cigarettes is still argued.

Here, when he goes on to discuss where the “general agreement” end, he gets it rather unfortunately wrong. Setting aside the grammar (“it is twice as cold today as it was yesterday”), no one is seriously suggesting that e-cigarettes cause 1/5 as much risk of smoking. The most plausible risk estimates range from a few percent of the risk from smoking to less than zero percent (that is, it is plausible vaping is somewhat beneficial on net — certainly far more plausible than it is 1/5 as harmful as smoking). A risk 1/20 of that from smoking, or even 1/10, is certainly possible, but those levels are quite a stretch based on the available evidence. While this is not material to the thesis of the post, it definitely does not advance the goal of pursuing the right questions to anchor this question in totally the wrong range.

After an aside about how issues of politics and association are irrelevant to this question (a solid point, though tangential), Wodak continues:

It is clear that ECs reduce some of the harm from tobacco smoking and that means they are effective.

With this, he gives up the tantalizingly enlightened notion that he thinks “effectiveness” refers to something other than being less harmful than smoking (and being able to replace it). This is unfortunate in itself, but also creates a serious problem with the mission of identifying the key questions.

The final “important question” is:

Are they cost effective?

And with this, the whole illusion of trying to ask the really interesting questions collapses. The very act of invoking the phrase “cost effective” locks the conversation into being about achieving some single outcome (reducing smoking, of course, or the more-or-less synonymous goal of reducing health risk — there is no other candidate in sight). Cost-effectiveness analysis about assessing the expenditure required to achieve some single outcome. There are sometimes ways to kludge in other considerations around the edges when there is clearly another huge concern (e.g., out of the alternatives, one medical intervention cures the most cases of a disease for a given budget, but it inflicts a lot of pain on the patients), but there is basically no way to escape the built-in assumption (Orwellian language again) that goodness is measured entirely in terms of one outcome.

Consider the question: Are smartphones cost-effective? Good luck trying to figure out what that would even mean. Or consider the implications of “is cherry flavoring in e-cigarettes cost-effective?” Unsurprisingly, Wodak does not offer any suggestion for what his “important question” even means in the context of e-cigarettes. Instead, he switches to discussing illicit drug harm reduction efforts, a context where the cost-effectiveness question is not so absurd: Many specific interventions in that realm can be usefully considered in terms of a clear single goal and expenditures (e.g., needle exchanges with the goal of stopping transmission of infectious).

However, even that is a facile position to take in what is supposed to be a discussion of the big questions. This is telling. In debates about needle exchanges, there are still a few people — the 1 and 2 range of the scale — who do not agree that reducing disease is the One True Goal; they object to needle exchange programs, no matter how inexpensive. They do not like the concession, which is built into such programs, that not all intravenous drug use behavior is equally universally horrible; some of them even actively want the sinners to die rather than be helped. The rest of us may not like it, and may characterize their position as a genuinely evil, but that faction clearly exists. No serious discussion of the “polarizing debate” and “important questions” can ignore this. Anyone who just assumes this opposition away, by stating that the only possible goals do not include theirs, is not making a serious effort to identify the real important questions; he is merely espousing a political position.

Much of what there is to like about his commentary, and presumably why it is today’s darling of the vaper social media, is contained in this bit from the discussion of illicit drug harm reduction:

Second, opponents of harm reduction often mount quite vicious ad hominem attacks and sometimes harm reduction supporters respond in kind. Third, opponents of harm reduction emphasise the quality and quantity gaps in research long after it is clear that there is sufficient evidence of reasonable quality to establish the effectiveness and safety of the intervention. Fourth, in the debate about illicit drugs and harm reduction three decades ago, harm reduction advocates were a minority ostracised by governments and the World Health Organisation.

Can’t argue with any of that, nor the implication that these are factors that interfere with having any sensible debate. Oh, but what was first?

First, there is often confusion about objectives with secondary or tertiary objectives argued about furiously while the primary objective is ignored. In harm reduction, the paramount objective is always trying to reduce health, social and economic costs. Reducing drug consumption is often welcomed but is regarded as a bonus.

This, I think, is a fundamental fail. Most readers of this blog will already agree that the “reducing drug consumption” goal is a terrible goal when the drug is nicotine. But for nicotine and other drugs, the debate does exist about whether this is a goal, or even the goal, rather than a mere bonus. It exists because there are the 1s and 2s who feel otherwise. Perhaps this passage was intended to be a poke at the “public health” people who despise the 1s and 2s in the Drug Wars but are the 1s and 2s in the Tobacco Wars. That is a good message, but it needs to be explicitly shouted to get anyone’s attention. I cannot imagine there is much value in slipping it in like this, if that was indeed the intention.

But there is no confusion about objectives. Those who oppose THR know exactly what they are doing (…know exactly what they’re doing…know exactly what they’re doing…know exactly what they’re doing). It is not useful for Wodak to just suggest that those who disagree with his stated view about what is best for the world (for ultimately this piece is more an advocacy of that view than a genuine discussion of the questions) are confused. That is a naive premise that is very unlikely to be the foundation for much progress.

It is also a fail because harm reduction thinking has long-since left Wodak’s 1980s-style narrow top-down view behind. The “paramount objective” of harm reduction cannot be phrased in terms of an imperative verb that is about outcomes rather than process (“to reduce”). Harm reduction is ultimately about empowerment. It is a liberal worldview, not an illiberal one. The view from medicine (or authoritarianism) is about top-down reducing of health and other costs: Impose a treatment that gets the job done. The view from harm reduction — and from the vast majority of the population who occupy seats 4 through 10, or 6 through 10 anyway — is about options and choice: Eliminating the harm from behaviors (both the very harmful and the reduced harm versions of the behavior) that is created by criminalization, providing options and information, making sure the options are real in the lives of the people in question rather than just understood by and available to an elite few, and letting people do what is best for themselves.

In that context, it is worth noting one sentence which is basically a throw-away, but it rather telling:

By any measure, tobacco smoking is by far the most important cause of drug-related deaths, disease and economic costs.

By any measure? By some measures that is true, of course (except for the bit about economic costs, by which he presumably really means financial or resource costs to society; those are a myth). But measured in terms of striking people down in their youth, smoking does not even crack the list of worst drugs. Though it shortens lives, it does not ruin them as many other drugs do (sometimes, of course). Smoking does not destabilize any governments. It does not turn neighborhoods into war zones. It does not finance warlords. Smoking causes few traffic accidents or violent altercations. Of course you will note that some of these are caused not by the drugs themselves, but by the criminalization of the drugs (and the rare cases where smoking contributes to crime and such, this is also the result from government actions like taxes and vilification). But that brings us back to something at the core of harm reduction that seems to be missing entirely from Wodak’s view: putting an end to harms that are not inherent to the behavioral choices, but are created by government action, such as criminalization or disinformation campaigns.

So long as harm reduction — for anything — is interpreted in narrow literal terms, it will fail. While the typical shorthand definition is often pretty literal, just referring to lower-risk alternative behaviors, if it misinterpreted as meaning only that when exploring the big picture, problems ensue. Merely doing what is less harmful is perfectly consistent with authoritarianism. Indeed, tobacco controllers (notably led by Mitch Zeller) make a brief effort, in the 2000s, to try to hijack the concept based on this narrow definition. After all, if it is just about behavioral outcomes, then why not just use government coercion to make it happen — and then, of course, coerce a continuation to abstinence. Whatever you might think about the use of government coercion as a general principle, it is difficult to not notice that as soon as it is applied to individual consumption choices, the extremists (the 1s) capture the levers of power and only heroic efforts, following utter disasters, can pry them loose. Harm reduction cannot be just about cost-effectiveness or effectiveness, because it never survives in an environment where those concepts dominate.

Finally, I will suggest some obvious candidates for the list of the most important questions in the e-cigarette debate. It would be hubris for me to sit in isolation and claim to be able to create the list of the Most Important questions; even the most thoughtful among us cannot overcome our assumptions about what is not even in question. (And any actual dialogue is woefully lacking in the space. I am not expecting anyone to pick up on my response to another blog and keep the conversation going, as would be expected in other blogospheres.) (Any takers?) But I find it impossible to imagine any list of the most important questions that does not include these:

  • Do consumers make the choice to use e-cigarettes based on accurate knowledge about the tradeoffs and uncertainties, or are they deluded?
  • If the answer is they have accurate knowledge, what is the basis for intervention in the market? If they are deluded, how should we respond to that?

Taking that one step further:

  • What is the justification for governments playing any role in this market beyond the roles they play in the market for food?
  • Taking whatever answer to that as given, do the policies actually further that aim?
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30 responses to “In the debate about vaping, asking the wrong “right questions”

  1. Glantz recently stated something like “80% safer” on a radio show IIRC, and he’s been heard over the years to say anything from 50% to 90%.

    Your questions regarding the government miss 2 things: 1. “Sin taxes” are already there for alcohol, gambling, and tobacco, so the precedent is there as long as someone can convince the public it’s a sin. From a taxation viewpoint, “sin” means
    –Demand is inelastic in severe recessions and depressions, so the taxes are extremely reliable when most-needed
    –A majority of the population feels that they can cut down on their use in a recession so they’ll accept taxation knowing someone else will pay most of it.
    — And, hopefully: a significant proportion of our historical religions have preached against it. (If this is missing, I’m sure Public Health will somehow arrange to institute it.)

    2. The other is that, per _The_ Righteous_ _Mind_ , where brains were studied wrt political and moral values, the results showed that liberals value fairness and care, vs. conservatives who value liberty, sanctity, loyalty, fairness, and care. Your particular arguments rest on liberty, so they ignore one political party. Haidt, the author, would say they (well, WE, because I’m a liberal) have no taste buds capable of detecting the validity of those arguments. That is one reason why, when fighting in blue states, we keep focusing on harm in the sense of health consequences, and need to be more aggressive in pointing out that the harm falls disproportionately on already-stressed populations (in order, GED holders, LGBT, African-Americans, and other minorities.)

  2. Excellent post. Thank you.

    I’d be interested to know what you think/thought about Daniel Wikler’s presentation in Stockholm the week before last. It was another “flavour of the day” in the vaping community, and he made some good points about THR to be sure. But very few vapers seemed concerned about what I thought was a rather large Public Health elephant in the room. See: http://argvargen.com/2016/02/13/the-mask-always-slips/

    Are we experiencing a kind of collective Stockholm Syndrome with high-profile PH/TC figures, where we’re so relieved to get some positive attention from our authoritarian TC “captors” that we forget what they have been doing, and will continue to try to do, for years?

    • Carl V Phillips

      Just read your post. Very well put. I thought about writing something about that talk, but I could not stand the thought of watching all of it, which seemed only fair (I watched a few segments that were recommended to me, and I agree with your assessment.)

      I also agree with your assessment that there is a lot of Stockholm Syndrome, exactly as you describe (and it is a really delicious coincidence of city names too). I would say that this is not the entire story, though. Part of the problem is that some e-cigarette advocates at the grassroots level, and even more so among ecig corporate interests, do not actually care about harm reduction. They only care about e-cigarettes. It is not difficult to understand why, of course: Some individual advocates are really only concerned with their personally beloved products; like public health, they are a special-interest. Even more so many corporate interests (far from all! — some are very enlightened and socially conscious). For those who only care about e-cigarettes, anyone who favors keeping the market more free, or at least in existence, is an ally. Authoritarian tendencies are not part of the equation. Enemy of my enemy, and all that. Of course, like all “enemy of my enemy” alliances, this is a dangerous game for obvious reasons. But some people cannot think two moves ahead and those who are desperately fearful about survival, as it were, tend to not even bother considering the future.

      • I wonder how much of it is to do with wanting to be seen as seperate from tobacco products? It never fails to astonish me how “well” the anti-THR propaganda has worked. Many Swedish snus users switched to vaping on the assumption that it’s far less harmful, and I’ve seen similar sentiment expressed on the Swedish vaping forums. Having said that, with the exception of Atakan, you rarely hear a peep from Swedish snus advocates or industry about vaping either, so there’s definitely something in the “each to their own” phenomenon.

        One other thought – Wikler mentions (between 22 mins and 24 mins) a “big”, “great” plan that the FDA are working on. Any idea what it is? I assume he can’t be so daft as to mean the deeming regs…

        • Carl V Phillips

          I often watch with dismay as snus users decided to switch to vaping because they mistakenly believe it is healthier. To each their own, as you say, in terms of what makes them happier. But it is painful to watch people make the wrong choice based on propaganda (from whatever source). Of course, this error is dwarfed by the error of people who are tricked into smoking rather than using something low risk.

          I am not aware of any good plans FDA are working on. The big plan is the deeming, of course, as well as a boatload of other regs that are going to follow that. There does not seem to be much recognition that the latter is inevitable.

    • Carl V Phillips

      I just ran across where I suggested Stockholm Syndrome in a post last year https://antithrlies.com/2015/03/26/cdc-prepares-to-launch-massive-anti-ecig-lie-campaign/ (Note that it was just a passing aside. I am not claiming credit for the concept :-)

      • Ha! So it’s probably been sitting dormant in the dark recesses of my mind all this time. And it supports the theory that all writers are thieves, deliberate or otherwise ;-)

  3. I have noticed that for many ordinary people, (not including rabid anti-(fill in the blank with whatever their hate is directed at), simply ignore much of what comes from PH these days. Alex Wodak’s article is much the same. It smacks of talking over the heads of most people, its somewhat confusing, (although you have cleared some of this confusion for me at least).

    Many people, me included, feel that these discussions “about” them, go on around them, but with no input from the very people being discussed. I’m reminded of smokers and vapers I’ve spoken with recently, who find my advocacy interesting, but have no interest themselves, because they believe that they are ignored anyway. They will work out their own way to do what they have always done, despite the various restrictions, and persecutions the government, at the behest of various lobby groups. A kind of passive civil disobedience. A comment recently heard from a vaper friend, ” F*ck em, if they bring in prohibition, or vaping bans, it wont make any difference, I’ll just become a criminal and buy from the black market”, what are they gonna do arrest everyone?”. I have seen this in practice with many smokers, who laugh at those in the government and PH, crowing over how low the smoking rates are, knowing how blind those in TC are to the reality of a world that surrounds them, but they simply cannot, or refuse to see.

    • Carl V Phillips

      One of the things that black market options (or other methods of circumventing) do is increase disparities. Of course the “public health” people who really like to bang on about disparities ignore this. Illicit drug use, and even low-level trafficking, almost never result in criminal penalties for those who have money or connections. Abortion restrictions are easily circumvented by those with connections or some resources (e.g., our last two POTUSs). In both cases, those rules would not last a month if those who are most rich and powerful (or their daughters) had to obey the same laws that are imposed on everyone else.

      For the case of e-cigarettes, it is not exactly the same (there may not be rich/powerful utter hypocrites because there is little political reason for that), but it has clear similarities. Those who are best positioned to be politically active (they care, they know) are best positioned to just ignore the ban. I have noted before that if they were not, we would have a full on ACT-UP movement in the works, with storming of FDA meetings. The good news is the harm from bans and such will be attenuated. But the downside of the quiet disobedience (which does not qualify as real civil disobedience when it is kept hidden) is that the less empowered will suffer the harm from the laws without and not get the benefits from those who might have fought it harder.

      • thank you for mentioning this. These disparities in enforcement are 1000+ times worse than most folks realize. Little-enforced laws are used, daily, to start young black males on the road to the arrest/ jail /probation/ arrest-for-violating probation (which can be as little as setting foot in a bar) that soon leads to things slightly more serious, which get ‘charged up’ to felonies for anybody being represented by public defenders. The result: 25% of black males permanently banned from voting in many states, and my black relatives (who are middle class) have lost 2 family members and 4-5 friends to violence. Poor minority folks have usually lost many more, you’d never recognize your own country in their experiences.

        Anybody who accepts these kinds of laws because they know the cops won’t stop them should think about Martin Niemoller’s saying from the aftermath of WWII: “First they came for …”

        We cannot sit back and compromise on this.

        • Its not a matter of “accepting” these laws, people are powerless to stop them. Ordinary people in my country have no power, only the rich do, as Carl pointed out. Passive disobedience is about working around the laws, or simply ignoring them, the black market is one work around, staying under the radar is another, I’m not saying that this is a good thing, its just how it is.

      • I agree Carl, but I also acknowledge that in our increasingly atomised society, for the vast majority they are just trying to get on and live a life, they have different priorities to those who are comfortable enough, to have the time and energy to fight for things like the right to use THR. Its also interesting that in my country Australia, there is little or no discussion on THR, as government has banned snus, and severely restricted the sale of vapour products, including making it illegal to sell liquids containing nicotine, and in my state, it is illegal to even sell the hardware. People here simply ignore the laws, source what they want or need, because they lack the means or the energy to fight. There are people fighting on the front line here, but we are few.

        • Carl V Phillips

          Don’t get me wrong: I totally understand that mostly you just have to survive as best you can. That is nothing to be ashamed of. Yes, someone could stay home and fight for Aleppo, but it makes much more sense to try to get one’s family out. (And, yes, I am suggesting that tobacco controllers play the the role of Assad.)

          Part of it (not all of it, for sure) is a collective action problem — if only one person acts, chances are it will accomplish nothing, so it is all cost and no benefit. But organizing to overcome the collective action problem is a collective action problem in itself.

  4. You chose a curious target for your take-down given he is likely one of the few in his country with the influence and credibility to shift the dialogue in favour of e-cigarettes. Which is evidently what he is seeking to do (despite your obsfucated attempt to suggest otherwise?)
    http://rightnow.org.au/writing-cat/interview/interview-with-dr-alex-wodak/

    • Um, if you think that is a takedown, you must be new here.

      Anyway, it was not. It was an analysis of what was self-identifed as an analysis, and it found it coming up short. It was also an analysis of how sometimes things that kinda sound like they are what you want to hear turn out, upon closer examination, to not be what you should want to want to hear.

  5. I had read Alex Wodak’s contribution before having seen Carl’s excellent analysis/commentary, and noticed some strange “inconsistencies” at the very same place where Carl indicates to be “rather at loss”:

    “I am rather at a loss as to how these differ from each other or from question 1. Perhaps Wodak has something in mind, but he does not make a case.”

    My interpretation is the following. In many discussions with people unfamiliar with THR, a recurrent theme is that a) vaping is still a kind of (less unhealthy) “smoking” and b) that “real quitting” implies not only quitting tobacco smoking, but also, in a next phase, quitting either all nicotine use (vaping without nicotine), or quitting vaping altogether. To illustrate this, one of the lead questions by our Health Minister (who happens to be a former general practitioner) to the e-cig workgroup of the Superior Health Council (Belgium) was:

    “Can an e-cigarette without nicotine help tobacco smokers through the final stage of “stopping smoking”?” (http://www.health.belgium.be/internet2Prd/groups/public/@public/@shc/documents/ie2divers/19105017_en.pdf)

    If Wodak (either implicitly or explicitly) works form the same assumptions, than it would make sense somehow that he describes:

    “Do electronic cigarettes (ECs) help smokers to quit?”

    as not belonging to the set of “most important questions”, and at the same time as different from the (more important) question:

    “First, do ECs achieve their objectives – in other words, are they effective?”

    Namely, I guess in Wodak’s philosophy, the first question refers to the “complete/real quitting” interpretation, whereas the second refers to THR (vaping and keeping vaping instead of smoking).

    Also, this would explain the comment that:

    “If ECs can also be shown to also assist smokers to quit, then achieving this objective should be regarded as a bonus.”

    If using e-cigs (as THR) ultimately leads to “real quitting” ( = also quitting vaping), than this is a bonus (but not the primary aim).

    And it would make clear the further mentioned analogy:

    “In harm reduction, the paramount objective is always trying to reduce health, social and economic costs. Reducing drug consumption is often welcomed but is regarded as a bonus.”

    Just my interpretation…

    • Carl V Phillips

      Ok, I see what you are saying. Yes that would seem to mostly resolve the opacity of what he wrote. So translating what he wrote into clear exposition based on that, he is saying…
      -in the point I labeled 1: it is not an important question whether e-cigarette use lead to abstinence;
      -candidate measure of “effectiveness” in the origin story point: do they replace smoking;
      -candidate measure of “effectiveness” supposed endorsed by the TCI: can we hijack ecigs to lead people to abstinence;
      -his personal measure (“surely the paramount”!) of “effectiveness”: do they improve health and welfare, whether or not they lead to abstinence.

      That is a bit different from these all saying the same thing. That seems like a good translation of what he wrote, so I will buy that. However, it is still redundant and unargued. Then the third is just really the first repeated (with my embellishments), and the fourth is just a personal assertion of endorsement for the second since substitution is the only way you get to health and welfare improvements when abstinence is a mere bonus. So basically this was a lot of confusing words to say “there are two candidate goals, and I prefer the substitution version.”

      However, with that, I take issue with the third of the points. Yes there were a few in the TCI who toyed with the idea of hijacking e-cigarettes before switching into pure hostility. It is probably what some of the “pro-ecig” public health people are really thinking. But this is a tiny niche view, contrary to his characterization.

      Also if the goal is welfare, why exactly is continuing to total abstinence a bonus?

  6. Yes, basically (3 = 1) and (4 more-or-less = 2) in a recursive movement, and I agree with the issues you have with 3.

    At the risk of becoming excessively exegetic, “(the preservation of) life and wellbeing” might well be rephrased as “(preservation of) life and absence of disease” in the context of this piece. So, no welfare improvements intended; but abstinence as a bonus of preservation of life and absence of disease…

    That’s the only way I can make sense of Wodak’s position (at least, as expressed in the Guardian’s post).

    • Carl V Phillips

      Yes, that makes sense. If he cannot see “quitting” as anything other than abstinence, he probably cannot see “wellbeing” as anything other than the absence of disease. So perhaps I gave him too little credit in terms of simply not making sense, but too much credit in terms of having enlightened views.

  7. The important question I “would this faux debate exist at all if public health wasn’t inherently dishonest?”

    • Or broadening that a bit and not incorporating the answer into the question ;-), how about: “Why is there even a debate in the first place?” While this is a question about the debate rather than within the debate, it is a good suggestion that it needs to be on the table. Often a question is such that answering it accurately is actually harmful to the greater truth or the big picture. Asking questions about, say, the percentage of smokers who quit smoking after trying e-cigarettes distracts from the fact that some of them have very good outcomes. Indeed, even allowing the conversation to focus on “effectiveness” assumes a (very difficult to justify answer) to the question “what business do you people have restricting our access to these products?” That is why even the public health “moderates” that some vapers have so embraced are still extremists; if they did not get an answer to the “effective” question that they liked, they would not hesitate to prohibit people from choosing for themselves.

      • Yes, sorry the question did contain the answer, or at least what I consider to be the answer.
        I do believe that the question about rather than in the debate is important, as without it the agenda can get hijacked. This I believe to be fundamental to the problem of “public health”
        If we are asking about effectiveness we have let would be interventionists off on first principles justification.
        This is evident in what little I have witnessed of the ecig debate.
        Many of us who don’t really have a fundamental grasp of the science have been drawn into arguments about statistics in quitting or gateways mouse experiments, in effect trying to beat them at a game for which they have already rigged the debate. Even if “public health” had got the science right it still would not justify their intervention, because if I am aware if the risk then there exists no failure for them to correct.

        • Carl V Phillips

          I totally agree. A huge portion of attempts to try to defend vaping (including basically all of those from the public health “moderates”) implicitly endorse the worst extremist claims about process and political philosophy.

          I should probably say more about this. I have repeatedly made the various component points in various contexts, of course. (Don’t get sucked into playing their game on their terms. When they claim “if X is observed then Y must be true” focus on the fact that this claim is not true; do not be tricked into arguing whether X was really observed. Etc.) But I have not really pushed hard on this point explicitly, even though it is the subtext to a large portion of what I say.

        • The liberty-only argument, while entirely valid in this case (vaping does not harm others, unlike polluting rivers oceans, denuding watersheds, etc) is not sufficient for influencing liberals. Sadly. If you rule out any lay-understandable rules about science, AND rule out arguing on the benefits, then vaping rights will be a one-party issue, and we’ll lose too much. I think it is important to get legislators to consult their SCIENCE staffers in addition to their health staffers on this, because if X was NOT observed, then they need to know that. The subtler X/Y issues might require higher-level scientists and mathemticians, which of course I’d love to see, but so far I have not convinced ONE legislative staff to even let me TALK to a science staffer. I suspect the health staffers run the local offices tightly-enough to prevent that message from ever even reaching the ears of the science staffers, let alone the actual legislators. Apparently the health staffers think they DO understand the science, and consider it insulting to claim otherwise.

        • Carl V Phillips

          When referring to anti-liberal liberals, be sure to use scare quotes on “liberals”.

          “consult their SCIENCE staffers” Assumes facts that are not in evidence (and almost certainly false).

          Anyway, the point was obviously not “never argue the science”. But the common practice of arguing about it in a way that implicitly concedes that “if the scientific claim is right” (or even more commonly and worse: “if I cannot convince you that it is definitely wrong”), then “my opponent’s conclusions are right” is an epic fail. Focus on the disconnect. Re the current series of postings, about the Eissenberg shop’s unethical research, several people have suggested to me technical problems with their measurement methods. Um, yes, definitely true, but not really important compared to the fact that the results do not matter at all and the conclusions could not follow from the study. Also it is unwise for those who cannot argue the science accurately (as with about 99% of those trying to argue the science) to focus on it; when they do not understand it, it is almost certainly not their real motivation. If someone would keep vaping even if X were true, and be better off as a result, that is probably his much more useful argument, rather than him trying to dispute whether X is true.

        • Sorry, being a liberal myself, I didn’t think of the scare quotes. It is one thing to expect true liberals (which I’d like to think I am) to give liberty thought after “care” and “fairness.” It is something else to expect us to put it AHEAD of care and fairness. That is why liberty as a stand-alone argument, will not work with that group. FIRST you have to show you are not harming others. Which means we have to be able to argue the big points of the science even if we don’t get the fine points. The big point about the Eisenberg study is that the droplets were not particulates. You can get lots and lots of conservatives to consider that a fine point, but NOT a liberal, if you’re talking about banning vaping indoors in public. There are also a lot of fine liberty points that could be, and are not, made. For instance, even if the particle sizes were for particulates, AND additionally, actually harmful for only a few hours exposure (both are false!!) liberty should allow either closed meetings or very effective ventilation as alternatives. We no more argue ventilation than we argue statistical minutia of science (as opposed to giant statistical lying.)

          As far as not consulting science advisors, I only have 2 samples, but both came out blocking me from talking to them on the grounds that “they don’t handle health issues.” If someone has had a different result, PLEASE tell us about it!

        • mark entwistle

          Just to reiterate what Carl said, no one was saying not to argue the science, but to be aware that there are inherent dangers un the non expert doing so, and that as concerned individuals rather than scientists our strongest defence is to promote our own agency.
          It appears that your “liberals” have hijacked the term in the same way “public health” has hijacked public health. Any liberal who is not concerned with liberty is in fact illiberal. I am struggling to stay relevant to the thread now as this is a much bigger philosophical question, but remains pertinent to the question at hand.
          The starting point for this or any other debate is that the existence of harm does justify intervention, this applies whether we are talking vaping or pollution. I cannot hope to do justice to the discourse that generated that conclusion, but in simple practical terms, if one acts to mitigate against one harm how can you ensure you are not creating another, if you have two competing harms, how do you decide which is the greater?
          In my opinion the answer to this question is normally based in the personal preferences of the “liberal”
          As such this is not a debate about science but about why one set of individuals feel they have the right to impose an intervention on others.
          If we go straight to the science we cede this very important first principle.
          Even were the interventionist able to formularise harm, why are they then the right person to mitigate that harm.
          In the case of eCigs, or perhaps more illustrative is the case of cigarettes, ir equally pollution. People know the downsides or risks and care on anyway.
          In an economic interaction in the broadest sense, people gave already chosen a preference for chez petro chemicals over clean rivers, ir nicotine over longevity. This economic voting happens millions of times daily. We, the actors who are effected by the impact of competing harms are already mitigating these harms without the help of idiots.
          Without any science we have ti fundamental arguments against intervention in which we are all experts, relating to our own agency.
          The science comes into it inly when someone is corrupting the information we have, and it us likely to expert rather than lay opinion to identify and correct.
          I will admit that the science if “public health ” is so bad that it I an easy in for the lay advocate

        • I got my definition of what folks care for not from what they say, but from EEG tests reported in The Righteous Mind, by Jonathan Haidt. I believe reading that book is critical to successful political action. It basically tells you that ignoring what drives the person you are talking to is a recipe for failure.

        • mark Entwistle

          Sorry, I should proof read what I write.

  8. Pingback: The Week in Vaping – Sunday, February 21st, 2016 - E cigarette Reviewed

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