Harm reduction, State, and Utopia

by Carl V Phillips

There is an interesting debate-free debate going on among vaping advocates, about how to respond to pro-ecig tobacco controllers and similar authorities. There is concern about whether it is wise to embrace and exalt tobacco control crusaders — people and organizations who have been a part of the junk science, vile tactics, and authoritarian approaches used in that crusade — because they have taken some kind of pro-ecig stance. Most of the concerns expressed about that embrace are along the lines of:

  • We can expect they will turn against vaping as soon as it is expedient to do so. Tobacco control is a relentless grinding machine with extremist goals and strong party discipline. It only moves only in one direction, taking whatever it can get for the moment and then more later.
  • Most in that pro-ecig faction do not support genuine freedom to vape, let alone use other products. They merely believe people are supposed to quit smoking by any means necessary. They have already demonstrated that they support all sorts of restrictions on e-cigarettes and vaping so long as those do not hugely impact the role of vaping as a “cure” for smoking.
  • Many vapers are not happy about getting into bed with those who were recently deploying junk science and coercion to punish them, just a few years ago when they were smokers.
  • There is an ethical problem in allying with people who never speak out against the lies and hatred flowing from their own house, except when those happen to be inconvenient for their pro-ecig political views. For anyone who supports using a scientific approach to resolve scientific questions, their unwillingness to condemn bad science is similarly troubling.
  • Vaper advocates are foolish to try to go it alone rather than allying with other tobacco product users, including smokers, as well as those fighting public health authoritarianism on other fronts. Such alliance is not going to be possible if those other populations are alienated by enthusiastic embrace of some of their avowed enemies.

Notice that these points do not argue against taking maximal advantage of actual information created by pro-ecig tobacco control organizations, agencies, and individuals. They relate to the growing “embrace and exalt” relationship, and to endorsing their normative pronouncements.

The arguments on the other side of the potential debate are fairly easy to craft:

  • When your cause faces an existential crisis, you should celebrate anyone who might further it right now, and hope you can even survive long enough to face the reckoning from that. An iron curtain later is better than having to fight the enemy on the beaches in a few months, to borrow a few phrases from an iconic smoker.
  • Those voices and power centers exist, so even though you realize they still behave like tobacco controllers and are not true friends, we might as well use what is politically expedient and try to further empower them.
  • Once someone offers any support for a cause and is exalted for it, it tends to promote genuine commitment. Asking someone to donate three dollars to a political candidate is not about the money, but about increasing the chance he will vote, speak up, and campaign in favor of the candidate in the future. Moreover, other tobacco controllers might disown their pro-ecig colleagues leaving them no choice but to turn away from the dark side.

I meant it when I said I was crafting those arguments and that this “debate” is largely free of debate. I am not paraphrasing that second list from anyone’s “The case for exalting pro-ecig tobacco controllers” essay, because there is no such. It is not difficult to see why: If only the statements about expedience are presented, it comes across as rather naive. If the caveats about anticipating a reckoning and co-opting people are mentioned, there is an “observer effect” problem: If you admit that is what you are doing, it tends to undermine its chance of working.

I am pretty much alone among those in my lane (call it, I suppose, “the opinion leaders of the opinion leaders in THR”) in having addressed these issues. I have never endorsed a particular big-picture position — it is rather too complicated and subtle to boil down to a position, especially since the situation varies based on the particular organization/agency/individual — but I have expressed several of the concerns in that first list. Some of those in this lane do not address this at all simply because they do not engage in political science or tactical analysis. But others have not addressed it, I think, because they endorse the points in the second list but do not want to openly say so for the reasons noted. Thus, there is no debate. There is instead a tendency — infuriating to many — to act as if the debate were settled in favor of the “embrace and exalt” position.

You can find more about several of these points — the overall debate and about my role in my lane — in two recent posts by Simon Clark (be sure to read my comments on each, and the very good comments by others, in addition to the posts).

What I have probably never made clear before, however, is that beyond the concerns that appear in that first list, I have a much more fundamental concern that stems from a somewhat deeper political science issue, that of process. Questions of process are generally overshadowed by discussions of immediate policy questions, but they really should not be. To appreciate the concept, consider a meme that has been kicking around, that President Trump is really going to be grateful to President Obama for expanding what is acceptable to do by executive order without the consent of Congress. Setting aside the unlikely election outcome and whatever you might think about Obama’s policies, I trust you get the idea. G.W. Bush dramatically increased the drift toward an imperial presidency, and instead of reversing that acceleration, Obama took advantage of it and further solidified it. That is great right now if you like Obama’s policies, but not so good if you do not like the preferences of the next guy. Process matters.

We can shorthand the main process question for present purposes as being a conflict between authoritarian approaches and libertarian ones. (The latter is a more complicated concept than often portrayed, which I will circle back to.)

To provide concrete context, consider a recent post by Mike Siegel in which he argues that FDA should have already stepped up to do something about e-cigarette battery safety rather than pursuing amorphous anti-ecig efforts as they are doing. I use this illustration merely because it was a recent clear example of calling for a potentially beneficial authoritarian solution to a problem (set aside questions of whether it is actually that big a problem, and whether FDA actually has the capability to craft an authoritarian solution if given the authority). The process issue is this: If FDA gets the authority to prohibit dangerous e-cigarette batteries, there is no conceivable scenario under which that process does not also give them the authority to ban “dangerous” high-powered mods or “dangerously” large tanks. Process changes, enacted in pursuit of a particular policy, change what authorities can do regarding other policies. In this case, it does not require great imagination to figure out how that authority would be used by those in power at FDA.

While endorsement of pro-ecig authoritarians is not really a process decision, it is an endorsement of a particular process and so has similar implications. It is one thing to be happy that some of your general views are shared by some tobacco control organizations (which are all fundamentally authoritarian), government agencies, and individuals associated with those operations. But exalting those actors as the definitive arbiters of the issues, as has become a common tendency, implicitly concedes that whatever they decide to say or do is right. Embracing their actions implicitly concedes that their authoritarian approaches are legitimate. As with process changes that give someone more power, such authority, once granted, is very difficult to claw back later.

It ought to be obvious that utopian fantasies that roughly translate into “if I had sovereign powers, I could fix this so easily” are not a good basis for assessing whether greater government authority and influence is really a good idea. It should be clear that when power is granted to someone to solve a particular problem by force, he or his successor also has the power to undo that solution, or to do many other things with that power. As an example, consider Sweden: Ceding the THR space to the authorities was just fine when those in power were not anti-snus and even defended it against the EU and removed the misleading “warning” labels, but it is not looking so good now that the authorities are strongly anti-snus, as tobacco controllers have relentlessly pushed them to be.

It is very easy to fall into the utopian view if you never seriously analyze governance. The history books and newspapers are all about stories of whether the right people or wrong people had power. We get happy endings whenever the “right” people have unfettered authority, so we should focus on fighting about who has power rather than about the existence of power. Indeed, it is disturbingly easy to fall into that view even if you are broadly and deeply educated.

A few years ago, I had a friend who was a professor of childhood education who contributed to some of the great innovations in the field of the second half of the 20th century, and was one of the smartest people I have ever known. He was a classic paleo-liberal utopian, despite having every possible reason to distrust government. He was a target of McCarthyism, and not metaphorically. Early in his life he was attacked by Senator McCarthy’s operations and by the United States House of Representatives Un-American Activities Committee. When I last knew him, he was winding down his career in a world where G.W. Bush and his crony capitalist colleagues were sweeping away his and most other improvements and innovations in elementary education by fiat (the “No Child Left Behind” movement was largely designed to enrich the for-profit sector that surrounds elementary education, most notably Bush’s brother’s company). Along the way, he spent his life clashing with reactionary education authorities in government who were (and are) doing a terrible job, but were secure in their positions nonetheless.

It is difficult to imagine anyone short of those who have been imprisoned or bombed being more intimately familiar with how government power is used for bad purposes. Yet he maintained a near-utopian faith in the power of government to fix the problems in his field and more generally — it was always just a matter of giving the right people lots of authority. Now in fairness, when it comes to the vast enterprise of elementary education, it is necessarily mostly about government, since universal education can only be provided collectively; indeed, some authoritarian regimes do a great job with it. There is some opportunity for fixing bad policy via libertarian options (charter schools and such), but you cannot simply refuse to accept government authority.

But there is no such argument to be made about THR and other consumer choices, where it is not necessary to have control by authorities. Unlike with schools, highways, and other mass infrastructure, almost every matter related to personal consumption choices (other than the basic rules of honest commerce that must be enforced by government in any healthy economy) includes a viable option of having no substantial government involvement. Thus every question of involvement by the authorities — including not just rules, but them merely being accepted as authoritative arbiters of information — needs to be thought of in terms of, “should we embrace authority because the net effects will be beneficial, and do we trust those in power to keep it that way?”, rather than merely in terms of “how do we make the inevitable control by the authorities as positive as possible?”

The pro-ecig tobacco controllers and other “public health” people do not ask the former of these questions about anything. In their world, everything should either be banned or mandatory, or at least — given that bans and mandates are often not actually possible — aggressively encouraged or forcibly discouraged. Embracing their approach when you happen to like their policy views is a default decision about the first of those questions. It is a momentous process decision.

Opting for authority may work out great for a moment — “rah-rah Public Health England, for taking the ‘aggressively encouraged’ position on e-cigarettes!” — but what happens when the leadership changes or gets strong-armed in a different direction? That is the “Trump’s executive orders” or “Swedish government turning anti-snus” scenario. And it may not even require that. In a few years we will hit “peak ecig”, where most of the potential smoking cessation via e-cigarettes has happened in populations where vaping took off. At that point, the natural tendencies of the authoritarians who endorsed e-cigarettes for smoking cessation will be to start clamping down on those now “unnecessary” vaping rights.

Moreover, even before any of those happen, embracing the friendly authorities as the arbiter of people’s proper intimate choices implicitly empowers rival authorities who have other ideas. Consider the situation in the UK, where this is most clearly playing out: Even as some British public health authorities go with the “aggressively encourage” approach to e-cigarettes, Wales enacted severe restrictions this week (some with the blessing of the supposedly pro-ecig ASH Wales), and the EU is bringing in major restrictions which were actively supported by the UK government’s representative to that process. Accepting that this is properly a fight among different government authorities and “public health” activists implicitly endorses the position that whichever authority carries the day has the right to decide what is proper. And whatever they decide differently tomorrow is also proper.

The conflict is more subtle in the USA because pro-ecig authoritarians are relatively rare. Still, we hear testimony at regulatory hearings along the lines of, “you, Mr. Government Official, need to stay away from our e-cigarettes and let us make our own decisions, which we can do better without government intervention …. and just look at what Public Health England says about them!”

[Update, the need for which was made apparent by one of the comments: In case it is not obvious, Public Health England made a political decision about what policy position they wanted to endorse and commissioned a report by people who support that position and would backfill the case for it. The political decision could have gone a different direction, as it has with most authorities, and that might happen next time after a regime change at PHE. Government reports of this kind are not written to “follow the evidence” but to provide science theater after deciding upon the general message (which indeed might have been based on already analyzing the evidence, but usually not). Embracing and exalting them for “following the evidence” (which, of course, really means “reaching the conclusion I already believed”) is rather naive. But more important and relevant to the present point, it contains the implicit message “when a government agency states a policy position and writes a report, everyone should defer to them.”]

Ultimately, most vapers and other consumers want liberty. An authority, be it agency, organization, or individual, that backs your particular choice for the moment is a dangerous ally. Once process decisions give them power, it is almost impossible to return to a state of real liberty. In a perfect world, the liberty of LBGT people to live their lives as they wish would not be granted by the authorities, but would just be. But because governments have asserted authority over their rights, usually in opposition to liberty though recently in support of it, those rights will always be subject to the whims of government (including the executive orders of President Cruz). Of course governments can seize new authority over most anything, but there is at least a firewall if it does not already exist or it is not widely accepted as legitimate.

THR advocates are generally libertarian in their views, in the sense of believing in full personal autonomy over purely personal matters. Indeed, I do not see how anyone can genuinely support the real principles of harm reduction without being libertarian regarding consumer choice. This libertarian view of intimate individual decisions is shared with most modern humans who do not cling to some medieval institution’s rules of conduct. Even when support is not emphatic, a grudging “so long as they are not hurting anyone else, I guess it is their own decision to make” usually emerges when people take a moment to engage in a bit of caring human thinking. Public health people, along with members of particular religious sects, are an extreme special interest in their anti-libertarian views about people’s intimate choices. There is no reason to concede that we have to accept such views.

The perennial discussion about why “official” libertarians do not win elections made its inevitable resurgence during this election cycle. The answer to the question seems rather simple to me: Even though most Americans really believe in liberty, they have very different beliefs about what level of force is needed to provide liberty. Sensible people agree that some government force is need to preserve liberty — to defend the society against invading barbarians and internal violence, to enforce contracts, and a few other basic functions. The book whose title I riffed on here basically argues that these are all government should do (to perhaps oversimplify it just a touch), but others disagree.

Liberty-versus-liberty conflicts are usually presented only in terms of simple  “…where my nose begins…” principles, but the issues are rather more complicated. To take the most obvious of many such conflicts, most people who organize under the banner “libertarian” believe in creating rules of finance and commerce (for they are created rules, decided upon by society — they don’t just happen) that give corporations great freedom and allow oligarchs to accumulate unlimited wealth and power by any means. But many others who self-identify as libertarian believe that meaningful liberty only exists when everyone has adequate means and opportunity, and that those will not exist in the feudal society that will result from the banner libertarians’ proposed rules. Thus, there can be no coalescing of a libertarian voting block because, roughly speaking, a third of all libertarians believe that more financial regulation and high taxes on the rich are anathema to liberty, while a third believe that they are necessary for liberty.

I presented that digression both because it ties closely to two other posts I hope to complete before this blog’s final curtain, and also because it emphasizes the process question I am discussing. In the examples of education or military policy, it is impossible to avoid a fight for policy control because government is inherently involved. Limits on corporations must be decided by government because corporations are a creation of government. But for THR and consumer choice more generally, the first decision lies elsewhere: Whether to concede that the authorities should be allowed to make rules (i.e., use force) or even aggressively persuade. Believers in liberty do not all agree about tax policy, but they do tend to agree that we should not be quick to concede personal liberty when we do not have to at all.

Of course it is true that governments and tobacco control organizations, as well as the activists in academic public health who are basically part of those operations, have self-appointed themselves as players in the space and will seize whatever power they can. But consumers and their advocates, as well as industry, can choose whether to welcome them as liberators or consider them to be an occupying army. Embracing their pronouncements increases their influence, and thus the chances that the process will ultimately be that whoever controls the power at the moment gets to tell us what we can consume (and keep in mind that tobacco control and other “public health” rules, once enacted, are almost never rolled back).

Of course, we can imagine an authoritarian regime in the space that creates better outcomes, such as better battery regulation. But how confident are we that the authorities will act that way, let alone stay that way? (And, to not lose other points from the above list, is it worth the cost of embracing a foul enterprise and alienating potential allies?) There are far more ways that authority can do harm in this space than there are opportunities to do good. Notice that no government authority has ever proposed proper consumer product regulation for e-cigarettes, rules designed to make the products better for the consumer. Instead, they have consistently imposed rules designed (yes, designed) to hurt consumers.

I am obviously not suggesting that a decision to consider the authorities an occupying army could stop them from being an occupying army. Nor, obviously, does any of this suggest that the details of the regime they impose do not matter; thus it is worth fighting for mindspace within the authoritarian faction. But denying the legitimacy of authority while dealing with the reality of the moment, even if the authority happens to be doing something positive at the moment, is the best way to preserve the hope that liberty can ultimately carry the day. It is probably the only way to be in a strong position to deny the legitimacy of that authority when — not if — it is later used to cause harm.

33 responses to “Harm reduction, State, and Utopia

  1. You have some excellent points. But, OTOH, we are celebrating Public Health England’s choice to study the science, and when it conflicted with their ideology, to have the courage and integrity to go with the science. It is not just a matter of having “taken our side.” Following science is also a process matter. So we hold them up as an example of how the already-empowered-to-mess-with-us authorities here should behave. In a word, until a Supreme Court decision or a constitutional amendment preventing prohibition of victimless self harm occurs, the control is already there, like it or not. (BTW, I do not view the unprescribed use of antibiotics to be a victimless crime, because, unlike nicotine use, over-use of antibiotics creates MRSA that can kill OTHER people.)

    • Carl V Phillips

      What??! PHE did not set out to follow the science that conflicted with their ideology. They (or some particular actor within the operation) made a decision to present a particular conclusion. I assumed that was sufficiently obvious that I have never even bothered to mention it — I guess I erred there. Maybe I should note it sometime. When you assign a few people who collectively have a known political position to write a white paper, that is a decision to present a particular conclusion. If we were talking about some kind of investigation that would uncover information, then the concept of an independent commission has some legitimacy. But there was nothing of substance beyond little details to be uncovered on this simple topic, so whatever opinion an author had at the start of the exercise was not going to change.

      Thus what they wrote was a combination of science theater (to trick people into thinking that the process was as you describe — which apparently is a more effective tactic than I gave them credit for), details (what exact statements to claim in the executive summary), and empowering people to argue for the preordained conclusions if they want to. If the leadership changes or gets pushed in a different direction, they will choose new authors to write a new paper that “follows the science” for purposes of reaching the opposite conclusion. There is some constraint on that from the embarrassment of reversing oneself, but that is only a speedbump.

      In any case, even if this had been science rather than science theater, if you wanted to say “McNeill et al. argue X” then you may be presenting substance on its merits. But if you touting that “this is The Official Word Of PHE!!!”, then you are effectively conceding “whatever the authorities decide the science says must be right”. That was my point.

      As for the Constitution, actually turns out that for about 50 years, the courts have been slowing “finding” protections against criminalizing victimless behavior in the Constitution. It would be rather surprising to me if they do not “find” a right to be free of prosecution for taking drugs by 2050. But you touch upon part of the problem: What is victimless? Some cases are fairly clear, but “public health” type authoritarians (or “Christian” authoritarians, or feminist authoritarians, or corporatist authoritarians) can gin up claims that there are victims (health care costs; bad influence on the children; the choice is a product of false consciousness; hurts productivity).

      …Oh, hey, I just created a good “match those from the first column to everything that applies in the second column” game! Try it! Hint: “public health” matches to everything in the second list.

      Anyway, the point is that someone has to decide that it is really victimless despite the fact that there is a special interest claiming otherwise. So we can agree that something is victimless, but there is no way to create a bright-line political process that ensures a particular outcome.

      • Well, that they followed the science was stated by the PHE rep on a panel about e-cigs at some kind of convention in the U.K. (I don’t have a saved URL for the video, sorry!) So if that’s not the way it happened at the top, that’s very sad….BUT…at the very least, that means a lot of PHE employees had to wrench their minds around 180 degrees, and managed to do it. Which is STILL a miracle compared to anything I’ve seen in ANY other country in the world, so far.

        • Chris Price

          Karyyl, nothing that comes from any official organisation in this topic area is ever based on ‘science’, which here I would define as a consensus among (genuine) scientists that the balance of evidence points in a certain direction. Statements, policies and implementations are always made for political purposes; and the evidence base, such as it is, is adjusted to suit the circumstances.

          It’s nice to think that a gov org somewhere in the world has seen the light, but the reality is their opinions are based on policy objectives, not facts or the health of the public. In this particular case, a temporary alliance with the proponents of one kind of THR – us – for strategic purposes, is of benefit to them for some reason. It will be ditched as soon as it has served its purpose. THR (which is a consumer-led process) of any kind is anathema to them, and they are gritting their teeth and crossing their fingers all the while.

          They may support Harm Management – pharmaceutical interventions, the medical equivalent of THR – but consumer processes including unlicensed nicotine consumption of any kind are completely contrary to their agenda.

          Apart from anything else, they know very little indeed about nicotine, in contrast to the significant knowledgebase now available to the vaping community. The UK’s anti-smoking head honcho wrote a blog post recently that farcically revealed him to be the leading ignoramus on the topic, so don’t expect any blinding flashes of comprehension in this area any time soon.

          They work from a position of ignorance, indeed they worship ignorance as if it were the ultimate goal; they offer opinion, and this the opinion of the ignorant, as science. Any allegiance is an illusion and of limited benefit in the long term.

          It’s nice to see them supporting us for a change, but it has limited value. You may not be aware of it but the UK government proper is working as hard as possible to implement EU regulations that will eventually strangle vaping: they have provided three separate representatives to the EU, on three separate and critical occasions, to ensure that vaping is removed as any threat to revenues; so what one organisation of marginal importance say about the issue is of no real account anyway.

          It’s nice to have someone stroke your ego, but the other hand holds a large, sharp machete. They are guaranteed to use it at some point.

        • Carl V Phillips

          “Harm Management”: Is that your coining? I like it and want to know who to give credit to, because I am going to start using it. In fact I am going to use it in reply to another comment right now.

        • Chris, what exactly is the strategic purpose that would lead PHE to form a temporary alliance with us? What benefit would THEY have?
          You allude that their true intention is to medicalise ecigs. I’ve heard this conspiracy theory before. The problem is that the report nowhere says so, it is absolutely contrary to everything the authors say everywhere else, where they vigorously defend the free consumer market. And most importantly, if that is what they truly want, why don’t they say so? What do they gain by pretending to be pro-ecig? It’s not that WE have a powerful lobby that THEY need to pander to (but whose power will disappear once they have successfully defended OUR interests against all TC opposition and it’s time for THEM to crush us – you see, once you think about their sinister plan in more detail it all gets terribly messy).
          If PHE wanted to ban ecigs to pharmacies they could have simply done what everybody else in TC does: write about the chiiiildren, formaldehyde, highly addictive, gateway etc. With the policy implication that only the NHS could supply these nukes safely. Easy. It’s the TC mainstream position anyway, no need to change their position later (changing positions is always suicidal for political opinion leaders). So why would they take the detour writing an enthusiastic pro-ecig report, if they really want to destroy vaping?

        • Carl V Phillips

          I will let Chris speak for himself, but I will jump in with a couple of observations.

          First, I think it is misguided to think of this as an alliance; it is a temporary alignment. There is no indication that those behind such efforts even care that there is an “us”, much less that they consider themselves to be working with us, and even less that there is any agreement or coordination that “alliance” implies. The bits about pandering and such imply that the preference of vapers play some role in this; but there is no indication they have paid any attention to that whatsoever. That is one of the reasons they could pivot to a different policy without any difficulty. It is also why “want to destroy vaping” is a misguided construction; they don’t care about vaping (the lifestyle) on way or another, only about how many people are using particular drugs. Right now that calculus favors encouraging e-cigarettes, but later it will not.

          Second, it is a false premise that it would be difficult for them to pivot. Politicians cannot walk away from supporting a war and cannot pivot on simple-minded issues like abortion rights. But in a nuanced case like this, it totally trivial — e.g., “we still believe that smokers are supposed to switch to e-cigarettes if all else fails; however, it is increasingly apparent that young people who never would have smoked are becoming addicted thanks to tobacco company advertising and therefore….”

        • Chris Price

          Hi Gummy.

          Politics here is not about stating an objective and going for it to the exclusion of all else. Indeed, the objective can be the least visible component, given that ‘public health’ is far more about politics than health. The most important tools are those of the strategist not the healer – it’s all about propaganda, alliances, divide and conquer, feints and counters rather than innoculation and screening. And of course in the final analysis it’s all about funding. In fact you could get seriously sidetracked into the undergrowth by worrying at all about health in this arena.

          Who knows what PHE think, want or need right now? I doubt they do themselves. What they need in that sector of the industry is funding dependent on progress toward major goals. The principal goal is destruction of the tobacco industry and therefore elimination of smoking, followed by elimination of all consumer nicotine use. THR or consumer choice or anything connected to it are anathema to them: their goal is zero consumer use of anything except carrots, as it conflicts with their general principle of enforced longevity at any cost. (On this topic I agree with a churchman for once: see this page and Bishop Holloway’s quote at the foot: http://www.ecigarette-politics.com/lifestyle-choices.html .)

          It is inevitable, in my mind, that eventually half of all smokers in the developed world will switch to THR products of some kind. Indeed, it is not inconceivable that half of the population overall will eventually be using some form of tobacco or substitute or dietary nicotine supplementation (the number of students using Adderall or the much safer nicotine in the lead up to exams is significant now – this is just one of the pressures and fashions that lead to increased use).

          Given that (a) the Public Health industry (and its partners and funders such as the WHO, FDA, CDC, EU, Legacy, and a significant part of the pharmaceutical industry) are dead set against consumer nicotine use; (b) in the near future, smoking in the West will continue to decline under the influence of black market ecig sales (most legal sales will be banned soon enough); and (c) eventually most vapers will start vaping without any prior cigarette use; then it is inevitable that the day will come where a temporary alliance (or more correctly alignment, as Carl points out) with the ecig community will come to an end.

          Indeed, one of the figureheads of UK tobacco control who has strongly aligned himself with vaping in the past is now back-peddalling as fast as his little legs will carry him – probably under the influence of a strong word from whoever in gov/pharma funds him (it’s the same thing here). Aligning with THR in any form is professional suicide for anyone without independent funds. In the end, no funds are independent: they are all controlled by those who benefit in some way from smoking. Don’t look at government (especially in the UK, where tobacco *is* government) to do anything serious about smoking; if you haven’t figured out by now that they say one thing and do another, there is no hope for you. All the pressures – and they are massive – on gov UK are to protect smoking.

          Any current alignment by the TCI with vaping in any way is purely a temporary, strategic move. It will end badly, as any relationship with zealots, barking-mad crackpots and the murderously corrupt is bound to. Enjoy it while it lasts.

        • Brian Carter

          The “pivot” Carl suggests is not merely hypothetical, but highly likely. Elsewhere Carl has estimated that, in a society where tobacco and nicotine product use are common, about 50% of the population would use them if the costs were minimal. If this estimate is correct, and continuing innovation and research demonstrates the costs of using e-cigarettes is minimal, then we can expect certain trends. The use of combustible products will continue to decline as smokers make the switch, but this trend will eventually plateau. Some smokers will simply never make the switch and there always be new smokers who find the costs acceptable compared to the benefits. However, a great many never smokers, who found some attraction to nicotine use, but declined because of the high costs of smoking, will be temped to try e-cigarettes. And many will find them enjoyable. Young people just entering the market, now having a choice between high risk combustibles and low risk vapor products, will largely choose the low risk option. In a different world, where the low risk option didn’t exist, most of these people would have declined to smoke.

          This will inevitability lead to an overall increase in “new” e-cigarette users. That is, the percentage of e-cigarette users who are ex-smokers will shrink as the number of overall users increases. This increase will be made up of those who enjoy nicotine product use, but never would have smoked due to the high costs. The FDA, some months ago, tipped their hand for this upcoming pivot by announcing that overall “tobacco product” use among youth was essentially unchanged. Smoking was at an all time low, but this was a wash because youth were taking up e-cigarettes instead.

          Imagine what will happen when overall “tobacco product” use starts to dramatically increase, as I think it will (see Carl’s 50% estimate), even though smoking continues to decline. “Concerns” about a whole new generation of “nicotine addicts” will validated and groups like PHE will start to call for ways to reverse this trend by restricting access, limiting advertising, lowering product quality, etc. Never mind that the consequences of this “addiction” will be negligible and limited to the mere state of being “addicted.” (Whatever that is.) “Public Health” is virtually in the business of taking away the liberty of people to make their own cost/benefit decisions. And they have no compunction about doing so, even when the costs are trivial. But in this case, they will be able to claim they were right all along about the “dangers” of e-cigarettes.

        • Carl V Phillips

          I heartily endorse all of that.

        • Lots of wild speculation here, but still nothing answers the relevant question. If what you say is true, then why would PHE promote vaping?
          You see, if I simply look at what PHE say they want, everything makes perfect sense. They want as many people as possible to quit smoking. No doubt about it (no libertarianism needed). To achieve that, they want as many people as possible to switch to ecigs. Makes sense, too. To promote that, ecigs need to be attractive. Check. This is best achieved in a free innovative market environment (medical ecigs as an option, but not mandatory). Quite logical as well. That’s what they say. All premises and conclusions are consistent, and will be for quite some time.
          Now you can say you don’t believe them and they want the opposite of what they say they want. So let’s see what assumptions you guys need to make it work.

          1. The PHE guys’ ultimate goal is to curb all nicotine consumption. Never mind that Britton, Hajek and others emphasise that nicotine is benign and long-term consumption is fine. In truth they are fanatically anti-nicotine.
          2. There will be some peak ecig moment. Someone declares that now everybody who might switch has done so. We wouldn’t know how to define this moment (unless no-one smokes anymore, which is very unlikely to happen soon), but it must be part of PHE’s plan. From then on everything’s different. There is no need for better devices. No vaper would ever relapse, all dual use has disappeared. For PHE, it’s time for the U-turn.
          3. In the long-term 50% of the population will consume nicotine. This is highly speculative, rather unlikely, and decades away if it happens. If anti-nicotine activists fear that this will happen, it is highly doubtful that the best response is to promote vaping now. But we can imagine such a strategy, so we assume as true that PHE follows it, despite never saying anything that points into that direction.
          4. In reality the government/pharma conspiracy wants to keep people smoking, and has instructed its PHE puppets to devise a strategy to achieve that. What they come up with is an enthusiastic endorsement of ecigs (OK, I trust that you don’t REALLY believe that, do you?)

          If you want to believe that this alternative theory is true, I can’t stop you. It’s possible. Just like it’s possible that Angela Merkel gets her orders from the Bilderberg Society or the Great Pyramids have been built by space aliens. But I’m afraid it’s one of those theories where the explanation itself needs more explanation than the phenomenon it explains. So I stick with the simpler one.
          [No, I’m not naïve. I don’t need a conspiracy theory to know that THEY are indeed out to get us. Chapman, Glantz, Frieden et al. are quite open about it. I just can’t make Hajek and McNeill fit into that picture. Perhaps people are different after all?]

        • Carl V Phillips

          While I do not censor comments here and opponents are encouraged to join the conversation, calling careful conclusions of previous commenters that are based on person-decades of experience and reams of analysis “wild speculation” (along with the non sequitur replies) gets me pretty close to doing so. If you do not understand the basis for a particular statement, just ask. Please do not translate “I did not already know that” into “it must be mere speculation”.

  2. Great thought provoking piece as always Carl. You’ve fleshed out some thinking for me concerning much of the arguments I hear from those opposed to ecig restrictions, smoking bans, graphic warning labels, etc., that’s always made me a little uneasy. It’s the disturbing acceptance of a central premise we’ve lived with for so long we’ve forgotten it was there. Decades ago tobacco control and “public health” achieved an unquestioned ethical authority to enact whatever policies they deemed proper and to employ whatever honest or dishonest means of persuasion needed to achieve it. After all, they were on the side of promoting health and well-being, the tireless crusaders against disease and suffering that they are.

    Like growing up in a house that’s downwind of the sewage treatment plant, we’ve become habituated to the stench. In reality, tobacco control and “public health” never had this moral authority to begin with. Perhaps they once did way back when their singular task was to educate people about the health risks of smoking. But those days are long gone. Not often enough, the winds change and I’m reminded of the miasma.

    It happened most recently when people began loudly questioning the scientific evidence that plain packaging “works.” Whatever metric or method one uses in an attempt to answer this question, it is completely subsumed by more important questions. Is it proper and ethical for a government, by means of force, to subject the public to plain packaging in the first place? What in-depth analysis has been conducted to support an intervention of such magnitude? When the debate focuses on the minutiae of junk science interpretation, people like Simon Chapman and Stanton Glantz have won before the argument begins because they once again have slithered away from having to explain the ethical authority upon which they base their actions. Having to do so would force them to justify their policies in terms well beyond mere estimates of how much smoking would be prevented. They would have to account for and estimate myriad other costs imposed on the lives of real people because of this policy. That they never do this, or even consider they’re obligated to do so, is astonishing.

    Thanks for the powerful reminder that attacking the junk science of tobacco control and “public health” is often secondary to challenging the malignant hidden premises that are their guiding principles.

    • Carl V Phillips

      Thanks. What’s funny, though, is that I had several aims for this essay, but that was not actually one of them. I guess it goes to show that an author is not the one who gets to decide what his writing accomplished.

      I see what you are saying, though. If you overlay what I wrote about their process being inherently authoritarian with a belief that this is malignant, you get that narrative. It is presumably obvious that I agree that it is malignant, though I was not actually setting out to argue that here. I can also see where the “always downwind so just take the stench as a given” point emerges, though I was not intentionally trying to make that point. I would have if I had thought of it — it makes my point about making a default choice stronger: Not only are we at risk of making a (poor, IMO) default choice about the process, but we have been so brainwashed into believing that is the only possible process that people act as if there is not even a choice.

      • I see this lack of a realization that a process choice is being made played out in a number of ways. I had a conversation at a vape meet with some advocates who were arguing that ecigs should be allowed on the market because they were replacing smoking. I argued that was certainly a side benefit of ecigs, but irrelevant in terms of how the government should regulate them. If ecigs pose the level of risk that we commonly allow in our society (driving cars, eating raw oysters, rock climbing, and yes, even smoking) then the government’s legitimate role (in a utopian world) ends at keeping ecigs from becoming dramatically more risky than advertised through quality control and manufacturing standards. That is, it wouldn’t matter if a single smoker ever quit through the use of ecigs, nor does it matter if this new technology attracts a whole new generation of de novo users. If the risks are low as we suspect they are, then there’s simply no justification for the government, in a free society, interfering in anyone’s choice to use them by restricting advertising, limiting access, or lowering the quality.

        I realize this may also be a point you didn’t intend to make, and you’re speaking more broadly about the dynamics of the big picture. But your post does bring home that there is a process being employed (on both sides of the debate-less debate) and far too little attention is being paid to the end points where these processes will ultimately take us.

        • Carl V Phillips

          That point I actually did intend to make, or at least something in the neighborhood, and I alluded to it but did not explain it as well as you did. Nor did I give it the primacy I am now thinking it deserved after digesting what you said. (Damn, I should have recruited you as a coauthor for this!)

          I pointed out in passing, a couple of times, that it is a fairly safe bet that the pro-ecig “public health” people will stop being pro-ecig as soon as ecigs stop causing smoking cessation. That will probably happen before too long in London (maybe already has) and elsewhere in the UK. There are only so many smokers who are going to switch. After that, vaping will mostly be done by people who quit smoking a while ago and so don’t “need” to do it anymore, and by new adopters from the cohorts that are coming of age (who the authorities are never going to agree have a right to make that choice). At that point there is not much left of the “replacing smoking” argument, and so if that was what everything was grounded on (as it will be if the authorities are allowed to lead) there will be no case for freedom to vape.

          So we have the tactical error (IMO — at the very least, it is a tactical decision being made thoughtlessly) of anchoring the argument on something that is not really the core belief or justification of the proponents. That is another dangerous game because you can lose what you really want if your tangent turns out to not hold up or if you just win the tangent. The first is like arguing that people should go vegan for their health, even though the real motivation behind that is ethical (oops, it turns out that a very healthy non-vegetarian diet is healthier than being vegan). The second is like condemning someone’s anti-abortion stance for not even making an except for rape and incest (ok, fine, you can have your rape and incest exceptions).

          In this particular case, there is then the additional problem that the tangent plays right into the authoritarian process decision I was emphasizing. Lots of authoritarians are fine with “ok, e-cigarettes can be used, but only as a cure for smoking and only after ‘real’ cessation methods are exhausted”. So no advertising — why would you need that for a medicine. Plain packaging — of course, no one cares what medicine box looks like. Only a handful of flavors — why not, since the purpose is smoking cessation, not enjoyment. Available by prescription only — hey, good idea, since the only valid use is for treatment. Regulated the way U.S. FDA wants to regulate them — no reason not to, since we really only need a few varieties to serve the purpose.

  3. Wow. A lot of meat to chew on here but I’ll try a few bites. I can only think of two American pro-ecig anti-smokers, one of whom you mention and neither of whom I trust for the 5 reasons you outline plus your overall point that they’re raging authoritarians. However, at least with S, it’s possible to pick from his objective science what you find useful and to cite it from the source of “See? Even an anti-smoking activist professor…” This does not embrace the man or his screwed-up philosophy or his wandering positions which inevitably wander towards legalized coercion.

    On the larger issues beginning with process, the guidebook on process is the Constitution; if it’s followed then the presidency is what we call in show biz an “actor-proof role” meaning no one can screw it up. Which premise should also apply to the congress and the various Agencies and even the Court itself. The problem comes in when the Constitutional process is treated as a suggestion rather than a rule.

    One final thought: Too many things that shouldn’t be legislated one way or another are turned into law and (thus) too many zero-sum games are created. A nun’s right to not-provide contraception should not be effaced by an equally important woman’s right to choose, nor a baker’s right not to bake a “Happy wedding day, Jed and Ted” cake be imperiled by Jed and Ted’s right to marry. Or a smoker’s right to smoke (or vape) in a bar and the owner’s right to welcome him should not be demolished by Stan Glantz’s “right” to breathe unscented air. But too many people, it would seem, like Authority. Or are too whipped to fight it.

    • Carl V Phillips

      I agree that the “even this tobacco controller agrees…” construction is useful and a good way to avoid embracing someone. Indeed, so long as you are talking about information and not opinion, you might not even need that (though it is still useful). Once you start trying to use someone’s opinions it becomes quite important if you do not want to be presenting the subtext “…and you should believe anything this guy says on the matter….”

      There are indeed lots more of those simple right-vs-right fights society has to make choices about. Choose to not choose will usually be a substantive choice one way or the other, so unfortunately there is usually no neutral option. Often it is decided by federal court, which means appealing to the Constitution. But even though it and the associated material are one of the most important creations in history, it could not anticipate everything, particularly modernity. I would agree that the Constitution forbids a great deal of what POTUSs have done in this century, along with some of that SCOTUS did. The problem is that the founders made it as self-enforcing as they could figure out how to do, but ultimately we rely on key people choosing to play by the rules.

  4. We have a problem that I don’t have a solution for, here. EVERYBODY wants to be effective, which is often called “will to power” by psychologists. Politicians want to be effective, and SEEN as being effective. That means, they have to DO something. Choosing to NOT do something is never going to get press, and goes against everything in al chakras, starting with the pit of the stomach. If we can’t find a way to make NOT doing something sexy and powerful, they will always “do something” about ….everything.

  5. From what you have said above and in the comments Carl, I wonder whether the concept of harm reduction itself is not an appeal to authority? Are we not asking the authorities to allow us to use these products because they are harm reducing? Is this not an appeal to their authority, an implicit endorsement of their position?

    If as you say, harm reduction is essentially a libertarian ideology then why not drop the harm reduction and just focus on the real issue – liberty?

    I notice here in Australia Chapman and Daube and others are essentially making a harm reduction argument. Their arguments are of course radically different from yours, but the difference lies in their authoritarianism. Their arguments can seem quite reasonable to people who do not understand e cigarettes (mostly everyone) precisely because they are at pains to say they are not about banning these things but only ensuring that the harm (hypothetical harms) are limited. Theirs is harm reduction in its authoritarian guise.

    The concept of harm seems essentially a public health issue which entails and authorizes their participation in the debate.

    But surely the point is to challenge their position and authority? Surely their participation ought to be challenged on the basis that until they can show credible harm, let alone harm to others, they have no right to participate as experts or authorities?

    • Carl V Phillips

      First, the underlying issue is indeed liberty. However, for the reasons I alluded to (and many others) it is impossible to fight for liberty in the abstract. It is a bunch of separate battles on a lot of different fronts. I also think we should be free from surveillance and Yemenis should be free from having our munitions dropped on them, but each has to be fought separately.

      As for harm reduction, it is not merely what might be called “harm management”, to borrow a term from another comment here. Real harm reduction includes — arguably starts with — reducing the harm created by government that increases the inherent harm of a behavior. E.g., not locking people up for using drugs and decriminalizing prostitution. It also includes a belief that people should be allowed to choose to pursue the harmful behavior if they want — just that they should be given the opportunity to make it as low-risk as possible. Thus it is very difficult to make a case that someone who wants to use government force to punish smokers can be considered to actually support harm reduction. (Not impossible, within some bounds — I need to write a whole post to explain that point.) Certainly those who delight in unfettered punishment of smokers do not really support tobacco harm reduction. At best they can be said to be seeking a technological cure for smoking.

      Thus harm reduction is inherently anti-authoritarian. To some extent, the concept has been co-opted by authoritarians. Not by who you might think, however. Zeller and company tried to intentionally hijack the term in the 2000s, but failed. However, a lot of vaper advocates — certainly those who are authoritarians but even others who are simply new to this world — have effectively co-opted it to just refer to risk reduction, even if imposed by force and punishment for not doing it.

      Harm is definitely not sufficient for something to be a public health issue. For one thing, it has to have public implications (e.g., the spread of infectious disease). That is not the case here. People who abuse the concept of public health have, of course, asserted their authority to control intimate private health decisions, but that does not actually make them public health matters.

      I certainly agree that people who have no credibility deserve no authority. I would go further and suggest that people who do not even attempt to claim that they are making lives better (not just longer) have no business messing with people’s lives. The best way to stop that from happening, as you and I both allude, is to deny their authority to dictate how people live.

  6. natepickering

    Your central thesis in this piece is something I’ve been harping on for quite a while (though it often falls on deaf ears); namely, the fact that the worldview of a public health apparatchik does not allow for any arguments based on the rights of the individual. They are mutually exclusive philosophies that can never be reconciled to any useful degree.

    In fact, the existence of the individual as an autonomous, thinking, feeling, discerning organism is something public health types view only as an annoyance, to the extent that they even think about it at all. The only purpose of the individual is as a component of the collective, and collective outcomes (or, more specifically, changes in collective behavior from politically undesirable to politically desirable) are the only things that matter.

    In a worldview based on public health (even a non-cynical one), individual rights are nothing but a spanner in the works.

  7. A little sidenote: it may not be clear to those outside the UK that the relationship between Public Health and vaping has moved a little beyond an alignment, and has some elements of an alliance in the UK: members of the vaping community are being actively employed in Public Health conferences and even in smoking cessation clinical settings. (Though ’employed’ may have the wrong connotations since it is unlikely anything more than basic expenses will have been paid.)

    Such arrangements will be terminated when the relationship is no longer profitable. This will come as an order from above, to those at the lower levels such as personnel actively engaged in real smoking cessation work, and will no doubt cause some distress when it happens.

  8. Chris, it’s the same problem as above. Why would it be “profitable” for PHE to engage with vapers? A mega-grant from Kangertech? Unlikely.
    You cannot square your assumption that PHE are viciously anti-vaping with their behaviour that we observe. Chapman, yes. McKee, yes. But Hajek? Britton? No. From what we see we must infer that they are pro-vaping, genuinely and sincerely. They are not saints, they are (probably) nasty in other respects (smokers’ rights, for instance), but true ecig-haters? Even indifferent? That just doesn’t add up.
    Again, if you want you can find a way, but as soon as your theory involves the CIA, Mossad and the Illuminati it is probably wrong. OK, in this case it’s not these three, but some unspecified “profits” coming from following unspecified “orders” from an unspecified “above”. Not much more compelling.

    • Carl V Phillips

      None of those people decide PHE policy.

    • Gummy, you speak as if you know nothing about the history of tobacco control.

      I’ve tried to explain it, but if you don’t know the history then debate is pointless. A discussion about a subject where everything that has been happening for the last thirty years is completely ignored is not a discussion, it is pointless gibbering.

      If you can present a case that argues why things will now, inexplicably, be very different then I will listen. Your case appears to rest on an attempt at ridicule, which only detracts from your credibility, which has a negative value currently.

    • Potential TC aligned vapers -TC(vapers) – would need to recognise that they are making an alliance with a collectivist, authoritarian group. A group that will remain true to its aims regardless of vaping support or not.

      Chris mentioned as long as it profits (‘is beneficial to’) TC they will welcome vapers. The vaper becomes useful, however in a direct conflict between e-cig use and TC aims which wins out? If a TController(pro-ecig) loses an internal argument about e-cigs they will tend to fall in line with TC aims. e.g ASH Wales claims to be supportive of e-cigs but fully supported the ban on smoking and vaping on a Welsh town’s beach.

      The arguments in favour of alliance rely on TC changing, yet there is no evidence that is possible in the long term. The TController(pro-ecig) is on-board as long as the e-cig is seen as a smoking cessation device. TC(vaper) groups, such as the NNA, support them in this. The existential threat to recreational vaping remains whether vapers support TC or not. Is the medicalisation of vaping acceptable? If a TController(pro-ecig) really saw the potential of the e-cig as recreational would they then have to leave TC? If that were the case why would a vaper align with TC?

      The classical liberal (libertarian*) view, giving individuals choice and letting them take their own decisions, is problematic for TC as it undermines its aims and authority.

      The individual vaper needs to decide whether the expediency of aligning with TC to gain short term relief is defensible when it clearly disadvantages another group (people who smoke). This raises further questions about that individual’s tendency to a collectivist/individualist worldview.

      It becomes less defensible when there is little relief or, in the case of the TPD, it does not advantage vapers. What has been achieved by this alliance and what will be achieved in the long term?

      *libertarian seems to have many meanings which can be confusing. The US and UK do seem to have differing associations with this label.

  9. I have the impression that Carl is talking about what a (late) friend of mine used to call an “auto-conspiracy.” And Gummy is talking about a true conspiracy. Sadly, auto-conspiracies are drastically harder to fight, which I believe is the reason people find true conspiracies so pleasant to imagine (even though they are quite plentiful in reality, people also see them when what is actually there is an auto-conspiracy.) An auto-conspiracy is what you get when a group of people have genuine interests (such as income, power, security, or even survival) and are gathered into a group large-enough to make a system which behaves somewhat like an organism. Vaping faces an auto-conspiracy of multiple auto-conspiracies and a few true conspiracies. The thing is, just as logic is much smaller than a full brain working with logic AND intuition AND creativity, an organism has a full range of behaviors and creativity to defend it’s interests. To bring that back to PHE, I do not believe they have a plan to pretend to support vaping and later turn on us. I also do not believe Carl said they did. He said they would pivot some day. Which is strongly suspect is true, because they are big-enough to form an organism, which will eventually react if it feels threatened. But the individual cells of the organism, as of today, are only cells and the organism today is more-threatened by the specter of being abandoned by vapers than by the specter of vapers quitting smoking, so they are, TODAY, sincerely trying to bring vapers into their funded stop-smoking services. Not a plot. A reaction. Of an organism capable of other reactions at other times.

    • Carl V Phillips

      You are correct that I never suggested there is a conscious plan by anyone, much less a conspiracy, to pivot on the occasion of some pre-determined event or time. It is theoretically possible, but it does not seem terribly likely.

      Your metaphor of an organism seems to be fairly accurate, though I am not sure it is necessary to go down that path. But the choice of terminology invites the error that we have seen here, of someone — anyone who assumes the world is run with much more thought and foresight than it really is — misinterpreting what it means. Also, organisms include humans (with foresight and near-unitary volition) and trees (no awareness, totally automatically reactive). I am guessing you are thinking at about the squirrel level: no conscious learning or planning, and will hang out as long as you are tossing food, but the next time it notices you it will assume you are a dangerous predator.

      It is not necessary to use a metaphor of an organism to recognize that institutions have natural behaviors. Also, organisms tend to be all about just survival and reproduction, and while that is definitely part of the story here, there are genuinely other motives. However, the “cells” bit, however, does seem to offer additional insight. A lot of the problem here seems to be conflating the behavior of a few “cells” (individual people) with that of the “organisms” (institutions) that spawned them and that control what happens in the future.

      In any case, with or without the metaphor, your model represents a deeper understanding of institutional behavior than seems evident in most actors in this space. I often jump too far ahead of the zeitgeist in my analysis. It just did not occur to me to explain that a unitary rational actor model of institutions is hopelessly misguided. You provide a nice backfill on that point.

      • I was thinking more along the lines of a meta-person, or meta-organism, almost like GAIA theory. Also, Public Health is not a single institution, but is much like a single organism worldwide. And vapers as a group are not …quite..there yet. If we don’t want to be crushed in the future, it is to our best interests to kindly, genuinely, inform the future growth of the Public Health movement…towards, perhaps, more-honest science as a part of a goal for the organism itself. And to recognize that dragon-slayers need dragons — I do not believe we can change that part of the nature of Public Health. Dragon-slaying is a passion: in fact, you appear to also be a dragon-slayer, out to slay the Dragon of Bad Science. But Public Health has some big problems that need to be addressed, partly from inside and partly from outside, so that they will be a defender of the Public instead of a danger to it. 1. They need science in order to learn to distinguish Dragons from Dinner (or, perhaps, Dessert?) and from small lizards. 2. They need to recognize that crushing individual discernment of one’s needs is also a Dragon. 3. They need to be pointed at existing Dragons that still roam the world. For instance, my sister, who is very poor, informs me that the bulk of poor kids on the street go for several years with very painful untreated Wisdom tooth issues and impaction, and buy black-market Vicodin pills to try to get through the work day, then get busted for drugs. So we have angry, disenfranchised, 16-to-24-year olds in excruciating pain, often being supplied with black-market guns. And neither dental nor medical gov’t plans allow for the treatment of this. Having lived with someone in this state of pain for 4 months until she found someone who would pull the offending teeth with a $200 down payment borrowed from me, I believe my sister is correct that this kind of pain, routinely untreated, in THAT angsty age group, is a PUBLIC health risk. There are, I’m sure, other issues, including, perhaps, the need for the behavior-control branch of Public Health to be cross-trained in infectious disease control, given that the birds over North America now also carry avian flu, as of early 2015 or late 2014.

  10. Pingback: Smoking is normal, and acknowledging that is part of proper tobacco harm reduction | Anti-THR Lies and related topics

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