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.
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):
 Do electronic cigarettes (ECs) help smokers to quit?  Are ECs as innocuous as their advocates claim?  Is duplicitous and unscrupulous Big Tobacco cynically manipulating naïve EC supporters in their avaricious search for profits?  Do ECs normalise smoking, thereby providing a gateway to increasing smoking?  Have some EC advocates with murky links to the tobacco industry or pharmaceutical companies attempted to conceal these ties?  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?