Smoking is normal, and acknowledging that is part of proper tobacco harm reduction

by Carl V Phillips

Audrey Silk, via her CLASH organization in New York, recently launched a “Smoking is Normal” campaign (CLASH Facebook page, campaign Facebook page, press release). All the talk we hear about e-cigarettes “renormalizing” smoking is premised on a claim that something that about a fifth of the U.S. population does (and a larger portion in most rich countries) is not normal. In terms of prevalence, it is much more normal than being gay or being an American muslim. But think of the outcry — from very people who tend to be anti-smoker — that results when someone so much as points out those statistics, let alone suggests anything is abnormal about being in one of these minorities. Smoking is more normal than marrying outside one’s race or even marrying someone whose height percentile differs markedly from one’s own.

Of course, “denormalization” rhetoric is not an empirical claim about prevalence. It is a political tactic, an attempt to denigrate some people as being abnormal, in a sense that means abhorrent or deviant. In that sense, it is every bit as anti-THR as the most visited topic of this blog, attempts to convince people that a low-risk alternative to smoking is more harmful than it really is. No one who supports “denormalization” of smokers can be said to genuinely support tobacco harm reduction.

Harm reduction is a much broader concept than mere risk reduction. If you imprison a substance user without access to his drug of choice, you may have reduced his risk, but you have, except in rare dire cases, caused substantial net harm. One of the fundamental goals of harm reduction is trying to reduce the extra harm that is created by the actions of governments and others acting in a quasi-governmental role. If you magically eliminated that user’s substance of choice from the world — thereby reducing his risk without inflicting any harm other than depriving him of that choice — that also would not be harm reduction. It is only a slight oversimplification to say that if you are denying someone a choice he might want to make, you are not practicing harm reduction.

Anyone who reads discussions of drug harm reduction will have observed how often they call for decriminalization — i.e., allowing someone to make the choice while reducing the harm to users that is caused not by the drug itself, but by government actions. While smoking is not out-and-out criminalized, it is still punished with taxes and various restrictions. Worst of all, it is punished with psychological warfare that actively tries to make smokers feel not only abnormal, but like they are weak-willed victims of demonic forces that any decent person would resist. Compare the rhetoric often leveled at American muslims, or that successfully kept many American LBGT people in a state of fear and self-loathing for generations. This is harm creation at its worst.

Reasonable people (the few that can be found in this realm) can debate what the right tradeoff is between harm reduction and risk reduction. Educating people about the risks of a behavior does create some harm, via psychological distress, for those who choose to do it anyway. But basically no one would deny that the resulting benefits of ensuring informed choice (and thereby discouraging the action if it has net negative impacts for someone) outweigh the costs. Few people — though some — argue against adding a bit of messaging that overtly discourages particular behaviors, even though it probably amplifies the distress. The debate heats up when we start talking about punishment (e.g., taxes) to discourage the behavior or aggressive campaigns to declare it to be A Very Bad Thing. But whatever one’s position is about the optimal level of attempts to discourage the behavior, it is important to recognize it represents a tradeoff between risk reduction (via usage prevalence reduction) and harm creation (i.e., anti-harm-reduction).

Tobacco controllers have unsuccessfully tried to blatantly hijack the term “harm reduction” to just mean risk reduction. They sought to claim that their efforts to bludgeon smokers into quitting constitute harm reduction because it will reduce their risk. But now e-cigarette advocates — mostly, though not entirely, inadvertently — are reintroducing that failed hijacking. In part that consists of embracing tobacco controllers who are disdainful of (real) harm reduction approaches, but happen to favor the use of e-cigarettes for risk reduction. Those tobacco controllers are finally realizing their goal of misdefining THR to mean mere risk reduction, imposed by whatever means.

But in part it consists of pure misunderstanding. No better example can be found than a recent defense of real harm reduction thinking, written by a vaper opinion leader. In a bit of truly painful irony, it was subtitled “There’s much more to vaping than harm reduction.” [Update: Note that this subhead and the quoted line before were not written by the author, but added by the publisher. Someone has a fundamental misunderstanding of the concept, but I pleased to learn it was not the author. See comments.] That essay (which covers some of the same ground I do here, and could be read as an extension of what I had delved into more technically in the previous link) argues that vaping has benefits that should be accepted, not decried. (Unfortunately, it strays close to suggesting that the reason for embracing these are they make e-cigarettes more effective for smoking cessation, but set that aside.) It describes the tobacco control position as “think[ing] of vaping principally in terms of harm reduction”. But thinking of vaping as an activity that some freely choose, and arguing that the authorities should not try to inflict harm on those who choose it — the thesis of the essay — is the real harm reduction view. That view from tobacco control — that vaping should be thought of only as a “cure” for smoking to reduce risks — is almost the diametric opposite.

I will be the first to concede that I have played a role in contributing to this harmful misinterpretation of the meaning of THR. Along with others who developed the concept of THR, I often use a shorthand definition of the concept that just refers to product substitution without reference to the freedom of choice, empowerment, and minimization of needless created harm that are also part of the concept. The subtext was always there for those who looked for it. For example, a favorite example of harm reduction is automobile seat belts, which have not only the property of reducing risk, but also the property of not denigrating or discouraging the risky activity people wish to engage in. Indeed, the added safety reduces the incentives to avoid the behavior. Similarly, the canonical example from illicit drug harm reduction is the provision of clean syringes; again, inherent in this act is facilitating the chosen behavior, not discouraging it, let alone denigrating it.

Along the way, there were certainly some advocates for tobacco product substitution who adopted the term THR while maintaining support for authoritarian harm-creating anti-smoking measures. Blurring the lines a bit was partially political pragmatism and partially a recognition that someone can support harm reduction but consider the optimal tradeoff, as discussed above, to include some harm creation to reduce population risk. But the explosion of e-cigarette advocacy, and cadre of opinion leaders who are not familiar with the history, made that dependence on subtext and those concessions to pragmatism rather a problem. Many vaping advocates, and certainly their friends in tobacco control, now widely misuse the term to just mean risk reduction. This has led to an understandable hostility on the part of smokers toward not just anti-smoker vapers (of whom there are remarkably many, given that they were oppressed smokers just a few years ago) and pro-ecig tobacco controllers, but to the phrase “tobacco harm reduction”.

This is particularly unfortunate, bringing this back to the original point about “denormalization”, because the denigration that smokers feel coming from some of these faux “harm reduction” advocates is such an antithesis of harm reduction. It is difficult to think of something more contrary to the harm reduction philosophy, which when properly defined embraces empowerment and minimization of unnecessary harm, than actively trying to make people feel terrible about their choice. Intentional marginalization of a population is no way to empower them to consider altering their behavior. Taxes at least have the advantage that the intentionally caused harm has a straightforward incentive effect. Denigration is a purely a tactic for punishing sinners. Yes, occasionally it will cause someone to say “I am not going to be one of those awful drug users anymore”, but just as often it saps the empowerment that might lead to a harm reducing decision. But ultimately it should be judged not for its incentive effects, but for its toxic effects on the humanity of all involved.

To put this in perspective (and introduce some of the ridicule my readers have come to expect), I will offer a simple substitution of some other denigration efforts into a few passages from tobacco control advocacy for “denormalization”.

Consider the abstract of this recent gem, openly titled “The potential of shame as a message appeal….”, from Tobacco Control. I have rewritten it in the context of efforts that are probably more widely supported than tobacco control is. (The italicized words are my substitutions. All other text is original. For readability, I am not putting in ellipses for omitted bits.):

As homosexuality is increasingly de-normalised, different messages may become more appropriate for use in advertisements. To date, more commonly used messages have included fear appeals relating to physical health and guilt appeals focusing on the effects on loved ones. This study investigated the relative effectiveness of varying advertising appeals to discourage open homosexuality. The study was conducted where only a small portion of the population is openly homosexual and legislation restricts open displays of homosexuality in many public places. The aim was to provide insight into ways to motivate the small segment to consider quitting. Methods: Across a qualitative phase and an ad testing phase, shame was found to be highly salient to open homosexuals and those who had closeted or repressed recently. On the basis of these results, a television advertisement featuring a shame appeal was developed and broadcast. The ad featured various scenarios of individuals hiding their homosexuality from others. Results: The shame appeal television advertisement was found to resonate and encourage quitting/reducing behaviours. Conclusions: The use of shame appeals may be an effective method of motivating open homosexuals to quit in an environment where they are members of a small minority and supportive legislation exists to discourage openness in public places.

Modern day Australia, where this shaming was inflicted, is one of the few places and times in recorded history where the rewritten version would seem less likely than the original version about smoking. The fact that smokers already “feel like lepers” is invoked in the analysis, not as an unintended consequence, but as a foundation to build upon: “Antismoking advertisements that explicitly focus on feelings of shame may therefore be building on the effects of existing strategies that are achieving the same outcome”.

Or consider a rewrite of the inevitable passage about “renormalization” that appears in every tobacco control piece about e-cigarettes, no matter how irrelevant to the research (this one is from Nicotine & Tobacco Research):

The popularity of Islam is leading to a renormalization of the act of displaying non-Christian religious devotion in public — a renormalization that has the potential to reverse decades of progress in establishing norms and a general expectation of cultural homogeneity in public places.

Or to create a variation on the phrasing that appears in almost every discussion of outdoor smoking bans (this one is my own gestalt from reading hundreds of those, not from a specific one):

Prohibiting the open display of miscegenation in our parks and beaches is an important part of denormalizing it. Children should not be given the impression that it is adventurous, rebellious, or socially acceptable.

Few readers may know that there even is a word for interracial sexual relations and marriage. But you just know that tobacco controllers are the type of people who would use such a word to denigrate the choice, characterizing it as being so deviant that it warrants a word. As with anti-gay hatred, there is undoubtedly more anti-miscegenation hatred in the world than there is anti-smoker hatred.

(As an aside: In pulling those examples, I happened to notice a trend toward the term “denormalization”, once quite popular in anti-tobacco rhetoric, becoming relatively rare except in the context of the “renormalizing” effect of e-cigarettes. I am not sure whether this represents an implicit declaration of victory by tobacco controllers or a recognition that this ugly concept has been turned against them. The term now appears to be far more widely used by opponents of the strategy than proponents.)

The takeaway from these analogies should be that “denormalization” is not just harm creating, but is inherently a nasty weapon that can be used for nasty purposes. Once deployed, the harm it causes is horrific, and the spillovers — everything from pub closures, to constitutional violations, to the loss of basic humanity that results on both sides — are inevitable. It is the spiritual equivalent of using poison gas on the battlefield; even people who are trying to kill each other in clashes of civilizations reach agreements that they are not going to go that far.

Smoking is normal. Trying to encourage smokers to consider a lower risk choice is normal. Even anti-smoking taxes and aggressive anti-smoking messages are normal, whatever you might think of them. But denormalization is a deviant inhumane behavior.

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85 responses to “Smoking is normal, and acknowledging that is part of proper tobacco harm reduction

  1. “[denormalization] is the functional equivalent of using poison gas on the battlefield; even people who are trying to kill each other in clashes of civilizations reach agreements that they are not going to go that far.”
    About time somebody said that. (As a soundbite, I’d want to see it polished a bit, maybe “moral” equivalent or “spiritual”.) As an essay ending, it’s golden. And golden-rule-relevant.

    • Carl V Phillips

      I will accept the friendly amendment and make the change. (so the text will no longer read like you quoted — haha ;-)

      Note that I just fix typos I notice in the text, but do not change anything else without noting it is an update. I figure the post is new enough and that is a small enough change that I will just make it.

      • I wish I knew a better word for the spirit-crushing damage of denormalization. It’s demonic. But “spiritual” equivalent will turn off a lot of people, and “moral” equivalent doesn’t capture the deep damage.

        • natepickering

          1. Insipid
          2. Diabolical
          3. Monstrous
          4. Malevolent

          I’m sure I can think of some others; these were just the first that came to mind.

        • Malice Disguised as Virtue
          Noted author Taylor Caldwell originally wrote this article for a magazine in 1967. Her words are dead on:

          “There are those in this world whose ‘love’ is not only a wicked lie, but is a cover for unpardonable vindictiveness, a secret desire to cause pain, a sadism. There are those who are not to be trusted for a single moment, for they are innately malignant as well as hypocritical. They are the “whited sepulchre” of whom Our Lord spoke with such anger and scorn. Give in to them for a moment, doubt that they are entirely evil, tolerantly admit they might be right in one thing — and they will fall upon you, believing your defenses are down and you have surrendered yourself as a victim. They love victims.”

  2. Carl, re your comments on my article in Spiked – neither the byline “There’s much more to vaping than harm reduction” or the other part you quote “Naturally, the public-health community, including many of those who are pro-vaping, think of vaping principally in terms of harm reduction” were in the copy I approved for publication. What I actually approved was “Reducing e-cigs to a smoking cessation aid misses much about why they are popular.” and “Naturally, the public health community, including many of those who are pro-vaping, seize upon harm to health as being the problem to be solved and a casual observer could be forgiven for thinking that is the only issue.”

    Presumably the Spiked editorial team chose to amend those parts because that is the way that they, and presumably they think their readership (not to mention 90% of the public), understand the concept of harm reduction – purely as a means to reduce the physical harm to health. If the rest of the message isn’t getting out there then clearly the THR team have much work to do, which was after all, the point of the article.

    • Carl V Phillips

      Thanks for the clarification, Sarah. I will add an update in the text. It is still the case that someone is getting it totally wrong, but I will make clear that it was not you.

  3. I think it’s more that some are ignoring (or are ignorant of) half of the picture. THR only works if you accept the whole principle, as you’ve pointed out and I hope the article conveys despite the edits.

    • Carl V Phillips

      The article conveyed the message well. That was what was ironic about the vocabulary (the implicit definition of THR). As noted in the update, it is good to hear that this was someone else’s fault.

  4. “Worst of all, it is punished with psychological warfare that actively tries to make smokers feel not only abnormal, but like they are weak-willed victims of demonic forces that any decent person would resist.” So much addressed in this tightly packed sentence. I… ahem… “borrowed” about 3 line from Frank Davis (who amazingly coincidentally blogged on the normality of smoking at the same time I was working on the same theme) in crafting CLASH’s press release and see I will now have to… ahem… “borrow” one more from another. (Attribution provided whenever possible, of course.)

    Most of all Carl, I again thank you for running with the idea. Or rather I should say a “debate technique.” So many people are so busy looking for the “sexy” (aka complex) way to combat the anti-smoker/ratz material when the simple is staring us right in the face. It’s as if trying to be sooooo clever and SOUND more intellectual by being so clever scores someone more points. In that case the “simple” completely eludes them when it’s actually more effective.

    Let me put that last this way: Imagine two kids being told to cut out a figure of a person from paper. The first kid comes running back all excited, “Mommy, mommy, look what **I* did! First I found two blades and a screw and put them together to make a scissor. Then I got my crayons and used a picture from a magazine as a model for the picture I drew on this envelope I pulled out of the trash because who else would think to use an envelope! And now here is exactly what was called for!” The second kid comes back with a picture of a figure he cut out of a magazine with the scissors he took from the draw.

  5. Something you didn’t mention in the above, though I know you have touched on it in other places, is the medicalization of behavior. It seems to me that medicalization goes hand in hand with denormalization. One supports the other.

    I notice this in the essay you reference, that many of the points being made simply do not register in the world of TC because they simply do not recognize pleasure as being part of smoking.

    Prof Chapman exemplifies this attitude in his latest article where he claims “Many studies have documented that the “pleasure” of smoking centres around the relief smokers get when they have not smoked for a while.”

    One could say the same about food of course. Indeed it would be easy to demonstrate, as anyone knows who has gone without food for anytime, that just about anything tastes good when one is ravenously hungry. So pleasure in eating is just relief from craving?

    Of course, nobody would make such an argument, Except TC of course. How they get away with it I don’t know. Except for the tendency that once you have demonized certain groups, people will believe just about anything so long as it confirms their prejudice.

    But I think the way medicalizing behavior dehumanizes the subjects to whom it is directed, opens up denormalization as the natural outcome. After all, being less than human is indeed abnormal.

    This goes back to your point about how the narrow interests and preoccupations of the medical profession has corrupted public health.

    Anyway, thanks for another great article.

    • Carl V Phillips

      Thanks. And thinks for tying it back to previous points.

      One thing that is important to note is that it is not just Chapman who says that. He is a clown and says countless demonstrably false things; anyone who would listen to him is pretty clearly already lost from the world of informed people. But the loudest voice behind the claim, that nicotine’s only benefit is relieving the acquired craving for nicotine, is Robert West, darling of the ecig advocacy community. It is a batshit crazy claim. More technically, it is an extraordinary claim, with as much contrary evidence as you could ever want to gather (just ask people!), and so any support for it calls for extraordinary evidence. Instead, it is based on the most tenuous grasping at straws.

      I am not sure it is quite isometric to the willingness to demonize people. You actually do see similar (perhaps not so obviously wrong or harmful, but similar) claims from other quarters. E.g., the 1970s-style feminist claim (which you can still hear from those who act as if it were still the 1970s) that boys and girls differ in preferences for toys and actions only due to social pressure, which almost every parent can tell you is obviously wrong. E.g., the claim that people would not like soda/added salt/fatty snacks/meat if they were not given it as a child. And so on. In all cases, it seems to be an extreme egocentrism, which is the antithesis of being capable of being a social scientist: It is pretty clear such people personally do not like something or feel a particular way, so assume that anyone who experiences the world differently must be deluded or a victim of something. This does not always lead to disdain and hatred as it does with tobacco controllers, though it certainly smoothes the path toward it.

      • He is a clown and says countless demonstrably false things; anyone who would listen to him is pretty clearly already lost from the world of informed people.

        Indeed. But Chapman and his prohibitionist buddy, Mike Daube, have received an Order of Australia (a major honour bestowed by government) for their services to Public Health and, more specifically, Tobacco Control.

        In Australia where the prohibitionists have been given a red-carpet ride by government for decades, smoking is banned in all indoor places, including workplaces and those open to the public [including pubs, restaurants], smoking is banned for most hospital premises, including outdoors, and smoking is banned for most, if not all, university campuses, including outdoors. By next year smoking will banned in all outdoor dining areas countrywide [all but one state already have this ban in place] and smoking is being banned in more and more outdoor areas, e.g., parks, beaches. By the end of 2016 the cost of a pack of [20s] cigarettes will be at $20 due to [baseless] ever-increasing, extortionate tobacco taxes. Both major political parties have indicated that, if successful at the forthcoming election, they will hike tobacco taxes by another round of 12.5% hikes for each of the next 4 years raising the cost of a pack of cigarettes to $40 by 2020 [that’s $400 for a carton of cigarettes].

    • Carl V Phillips

      So thinking a bit more about the link to medicalization you suggest: One thing that is quite different is that when something is completely medicalized, public health type people tend to insist that the patient not be condemned for having the disease. So that works for something like choosing to use heroin, where they medicalize it and demand compassion for the user. Something quite different is afoot with tobacco control. On the other hand (and I think this may be part of your argument), anyone who inflicts a disease is doing a terrible thing, even if he is inflicting it on himself.

      Even with the stunningly bizarre denial that people like to smoke and use other tobacco products, I think the points about denormalization are undeniable. Taking any one of the medicalization view, a civil rights view, or a simple human compassion view, it is impossible to justify abusing people who (respectively) are victims of a disease who are just doing it because they desperately need to feed their addiction; people making choices for themselves; or human beings who should be treated as such.

      • “One thing that is quite different is that when something is completely medicalized, public health type people tend to insist that the patient not be condemned for having the disease. So that works for something like choosing to use heroin, where they medicalize it and demand compassion for the user.”

        I am not a sociologist or historian or anything so my answer here is very much a ‘Just So Story’. But I think at least part of the story here lies in the difference in class and background. Many of the older members of Public Health grew up in the counter-culture of the 60’s where drug taking was part of the anti-authoritarian ethos of the time. It is very hard to write a story of drug users as being dupes of big business when there are no big business selling it. There is really no anti-authoritarian handle to oppose drug taking.

        I think the same thing is happening here to drug users and tobacco users. One cannot be the author of one’s own actions without at the same time being responsible for the consequences. The concept of addiction (medicalization of behavior) takes away and removes the autonomy (authorship) of the user and hands it over to the expert. This is both taken and given, Users of drugs (or tobacco) are easily seduced into giving up their autonomy to the experts as it relieves them of their responsibility. The experts on the other hand gain power and an increase in autonomy – for people like Robert West for instance, a decades long career as an ‘expert’ with all the associated benefits.

        The difference in response you describe above (lack of compassion for smokers) is I think attributed to those in public health identifying with the anti-authoritarian ethos of drug taking. Clearly there is no such identification with smokers who are now days mostly from a very different class to those in public health.

        • Carl V Phillips

          There is a lot packed into that comment. I like your point that the embrace of “addiction” and whatnot is a way of accepting a relief of responsibility. Packaged with that, of course, is accepting one’s own infantilization and yielding to one’s “betters”. That is one of life’s major dilemmas — the struggle about whether to do give in for relief is perhaps the most pervasive theme in literature.

          There is definitely a class issue now, though there was not always. This may explain why tobacco control turned evil. It was once made up substantially of ex-smokers, because that is what most people were, and thoughtful people who learned their way into it. Now it is made up of a cadre of people who grew up thinking of themselves as better than anyone who smokes. Keep in mind that anyone who experienced the 1960s was born c.1945, and few of them are still active players. (Of course, much of what people call “the 60s” took place in the 1970s, so I will grant that there are quite a few who lived that in positions of influence in public health.)

          But this cannot explain nearly everything. Few in either the older nor the younger generations in “public health” have much experience around typical “hard” drug user, let alone *as* such users. They may smoke weed and take Adderal (or smoked weak weed and tried acid in the 1970s) but that hardly gives them empathy. So they are choosing to extend arm’s-length sympathy to serious drug users, but not choosing to do so for smokers. Some of that is the “big business” aspect, but that is purely delusional — even the worst stories anyone tells about the tobacco industry make them saints compared to the businesses that supply illicit drugs.

        • natepickering

          “Smoking is the worst thing about you, but it’s not entirely your fault. ‘Big Tobacco’ exploited your weak will and inherent moral deficiency in order to lure you into a lifetime of servitude to the Demon Nicotine.”

          In addition to offering an absolution of responsibility for what people have been conditioned to believe is their single greatest failing, it provides tobacco control an inversely proportional assumption of power over the individual. It is tantamount to an abuser convincing his victim that he’s really their guardian and advocate.

  6. Thank you. Making choices about the available agricultural products that we like to consume is normal. They can’t de-normalize something that is normal. And to unnecessarily over-regulate human behavior threatens autonomy (self-regulation), which is important for adaptation and survival of the species. This is why Tobacco “Control” will fail, just like attempts at alcohol and weight “control”. Normality can not be de-normalized.

    But consider that the attempt to de-normormalize might be considered normal in some sub-populations that feel threatened (Insular stroke patients), as futile as it might be. “The ETS emanating from the electrical outlet is killing me.” Would it be constructive to de-normalize de-normalization.

    If anything, de-normalization might need a “harm reduction” strategy.

  7. Why is the persecution of a significant minority enthusiastically embraced by officialdom? Carl, I can’t provide a link but remember reading this somewhere. The idea of “addiction”, albeit a fabrication, is critical to the prohibition crusade. Addiction is considered a physical disease. Addicts are not afforded the usual human rights. They must in no way be accommodated socially. In Public Health parlance, they need to be “cured”. And so there is all this very nasty “help” – bullying of all sorts – in coercing smokers to be “cured”. That’s the perversity of it all.

  8. This excellent piece of yours seemed to so parallel the themes of Mills’ “On Liberty” and to remind me of a quote within it, that I pulled it off the shelf. First, as an echo to your thesis, the title of its Chapter 3 is “Of individuality as one of the elements of well-being” and he meant “well-being” in the same sense that you do.

    But aside from his descrying the tyranny of the majority, the “despotism of custom” and the know-all’s use of coercion, here’s the quote of his I was after;

    “If there be among those whom it is attempted to coerce into prudence or temperance any of the material of which vigorous or independent characters are made they will infallibly rebel against the yoke. No such person will ever feel that others have the right to control him in his concerns…and it easily comes to be considered a mark of spirit and courage to do with ostentation the exact opposite of what it enjoins..”

    I believe this is the boomerang effect of the exclusion and denormalization of smokers. For many, there is now no choice but to rebel by “ostentatiously” smoking because a freely-chosen option to stop has been removed and has become instead a mark of mere knuckling-under. This is what Tobacco Control can’t fathom–that element of personality, or perhaps person-ality. The harder they push, the harder they fail.

  9. Roberto Sussman

    Very enlightened comments. The consequences of the social engineering effort that goes under the name of “de-normalization” of the act of smoking are quite scary and worrisome. As you correctly mention, this type of policy causes a lot of harm (stigmatization, guilt, marginalization, etc) to millions of smokers (who are human beings), and thus cannot be supported by honest and ethical advocates of THR, regardless of the possible benefits that may entail jumping into the bandwagon of tobacco control by promoting e-cigs as smoking cessation devises. While the THR effort can benefit from the fact that some tobacco controllers seem to be open minded about the benefits of vaping, collaboration or alliance with them must reject any concession on accepting (or not criticizing) extreme policies against smoking and smokers and the junk science and propaganda waged by tobacco control to justify these policies. Some pragmatism may be needed, but not the pragmatism that could turn THR into the vaping branch of TC.

    Also, your analogy with other forms of discrimination are spot on. I would specially highlight the analogy between ideological anti-smoking and homophobia. As late as the mid 70’s medical science described homosexuality as a mental disorder, thus rendering homosexuals as mentally “sick” (ie not “normal”) folks needing medical (psychiatric) cure, just as tobacco controllers currently describe smokers as sick addicted folks requiring medical cure. Homophobes who agreed with this (now discredited) medical opinion described homosexuals as desperately crying for help in order to “quit” (ie become heterosexual or “normal”). Tobacco controllers follow the same line of thought regarding smokers: sick nicotine addicts desperately trying to quit.

    The shame, stigmatization and marginalization of smokers that follow from tobacco control policies resembles the shame, stigmatization and marginalization of homosexuals 50 years ago in the west (even today in many countries). Coming from a homophobic culture (Latin America) I am familiar with the arguments of homophobes, and can testify that they are very similar to the arguments of tobacco controllers. For example, the obsessive issue of “protecting children and teenagers”. Homophobes declare that children must be be protected from homosexuals, who are always trying to “induce” the young or weak minded into homosexual practices, a sort of “second hand smoke” type of argument that resembles the arguments of tobacco controllers justifying bans. Witness the pathetic obsessive efforts by Herr Professor Quackton Glantz and other TC fauna to remove smoking from films that minors can watch. Homosexuality was also removed from general audience films 50 years ago (or ridiculed when portrayed in other films). Another argument common to homophobes and tobacco controllers is the obsession with “cleanliness”: homophobes obsessively describe homosexuals and their sexuality as “dirty”, just as anti-smokers obsessively describe smoking as “a dirty habit”. Homophobia and ideological anti-smoking will certainly provide a lot of material for future psychologists and social scientists to analyze.

    Finally, perhaps we need to learn a few lessons on how homosexuals challenged institutional and popular (widespread) prejudice against them. Besides the debunking of the junk science describing them as mental deviants, Gays and Lesbians engaged in the 70’s in an aggressive political activism based on demanding fulfilment of their human rights (which include the right of any adult to define his/her sexuality). Fortunately, they succeeded. Smokers and vapers need to engage in similar activism and become more assertive in demanding fulfilment of their human rights. Promoting THR and goes hand in hand with challenging the strictures and excesses of tobacco control. These are clearly issues of human rights. The action taken by CLASH is a promising first step in this direction.

    • Carl V Phillips

      Homophobia has always been my go-to comparison for the hatred exhibited by tobacco control. I have alluded to the similarities scores of times in various writings. As you nicely summarize, the parallels are uncanny. It is also convenient that the people who abuse smokers are almost all of the political leaning that decries homophobia.

      My analogy here to religious/cultural discrimination is not quite so perfect a parallel, but it is not so far off. I actually think the comparison to miscegenation is the closest parallel in terms of the behavior, and I do not recall having used that before. Unlike being gay, choosing a mate is 100% a choice and someone can be actively or passively pushed into make a dispreferred choice due to the social pressure. Obviously choosing to engage in gay coupling is a choice, so the difference is limited. Anyway, I am not sure I can really run with it because at least among people who read in the USA, the UK, and Canada where most of my audience is, as well as Australia and the EU where most of the rest of my audience is, it seems like such an ancient bit of discrimination that it does not resonate. Whereas, the discrimination against LBGT people is still a huge fight in the USA and elsewhere. Perhaps more important, it does not have quite the “evil”, “dirty”, and self-identity issues that LBGT and tobacco use share (people do not think it is part of their identity “I married outside my race” except in the rare moments when someone brings it up). Still, I might play with it some and see if it takes.

      As for tactics, they obviously cannot be quite the same. The culture is different. The fights are different. The deployed technology is different (we have everyone’s-a-broadcaster mass communication; today the Stonewall rioters would be shot, not just beaten, and anyone taking over an FDA meeting would be at risk of a life sentence for some Bush-era “terrorism” charge). But the mobilization and willingness to do *something* that is the first step is certainly very similar.

    • natepickering

      “Herr Professor Quackton Glantz”

      I think one has to be an actual medical doctor in order to be classified as a quack. But who knows, maybe the same rule exists for airplane mechanics and I just wasn’t aware of it.

      • Roberto Sussman

        LOL, I thought that “quack” applied to crackpots of any discipline, not just medics. So, I should have said “Herr Professor Krankton Glantz”.

  10. Does a pro-vaping organisation’s aim of ‘reducing cigarette smoking’ invalidate any claims it may have with regard to THR?
    Does including this aim set up multiple psychological and group conflicts per se?
    For example:
    Group:
    People who smoke vs people who do not (vapers, snus users, non-smokers)
    Full on tobacco control vs pro-vaping Tobacco control.

    Psychological:
    Additional pressure on people who smoke to switch or stop. (With or without the advocated method)
    Pressure on the organisation’s members to use increasingly coercive methods to achieve the aim.

    While agreeing with a lot of the spiked article, it would seem that the smoking cessation side completely neglects the simple fact that vaping is not an alternative for some. There are people who will never switch and these should be respected. Nicotine is only one aspect of smoking hence the need by tobacco control to institute bans, airbrush pictures, censor books and stifle advertising. Is smoking cessation a required aim for the vaper? Why shouldn’t non-smokers have the opportunity to vape?

    My view, FWIW, is that THR is about laying out factual information and giving people choices. It is about promoting the lowest risk yet still giving people the option of the highest risk, spirits alongside wine, beer or water. Is the aim of a non-alcoholic beer manufacturer to reduce drinking alcohol? Should it be the aim? Will it eventually be made the aim when synthahol comes along? (It has been suggested, in the UK, that more non-alcoholic beers be made available, just to increase choice of course)

    On seat belts: In the UK a seat belt law was introduced which took away choice. It is trotted out as a good way to remove choice for other activities e.g cycle helmets). It was successful in getting people to wear seat belts, longer term it has set a precedent for government intervention and the removal of personal choice.

    • Carl V Phillips

      Yes, good points/questions. I think it is quite clear that merely educating about and encouraging the choice of a lower risk alternative behavior as an informed option is real harm reduction. (Of course — obvious COI — that is what I have been doing for most of my career, so there is very little chance I would say otherwise.) Merely doing that comes in at the level of simply educating about the risks from smoking — something that I characterized as prompting no objection, and that is very hard to object to on any ethical grounds, even though it might indeed cause some distress. Fomenting conflict of any kind starts to have some anti-harm-reduction elements. But I would not include in that the mere act of playing up the advantages of the alternative, though it undoubtedly does put further pressure on those who do not choose the alternative, and so inevitably introduces some additional conflict and recrimination.

      It gets more complicated when we get close to your point about seatbelts. Notice that I invoked the existence (option) of seatbelts and said nothing about mandates. I find it difficult to say that mandating a driver wear a seatbelt is anti-harm-reduction, since I can conceive of literally no apparent practical material reason for someone to prefer the other choice — the seatbelt is there, it is free to use, it merely constrains you in the spot where you need to be anyway. (If applied without exception to passengers, such that you are not allowed to unbuckled to get something from the back or help your child, then there are material costs. Set that aside for the moment.) This is not to say that there is not a purely libertarian argument against the driver seatbelt requirement: that it creates a slipperly slope, that people should be able to make informed choices to do something that hurts only himself, and that just because even a personal-choice libertarian like I cannot conceive of a good reason does not mean someone does not have one.

      Compare something closer to the questions at hand: Imagine that it were absolutely costless for an injection drug user to obtain as many clean syringes as he wanted and have one whenever he wanted one. (Obviously this is a hypothetical — it is impossible to imagine how this could be accomplished.) Would it then be anti-harm-reduction to impose some punishment for using a dirty syringe, apart from whatever rules governed the drug itself. I don’t see that it would, though I can certainly see how it would be dangerous precedent: If it is fine to punish for that, then why not go a bit further and punish for…[fill in the blank]. On the other hand, now we are talking about increasing the prevalence of infectious disease, so it could be seen as similar mandatory vaccination. In any case, since it is difficult to imagine that anyone who is capable of taking advantage of the magical clean syringe supply and it is capable of really responding to the threat of punishment, it seems rather pointless.

      Now consider harm reduction via decriminalizing prostitution, but then making it punishable to not use condoms when engaging in it. That gets more complicated. There are the real public health implications of transmitting infectious disease again. But also there is a power issue, wherein a prostitute might want to use a condom but is under pressure to not do so; the prohibition might actually help her. Notice that tobacco controllers and their ilk try to gin up something analogous to justify their prohibition of private choices, with no opposing power and no public health implications: They claim that they are “helping” people to make a different choice, as if somehow they were being forced to act. This is one of the foundational myths that they use to justify their actions.

      Anyway, bringing that back to promoting a low-risk alternative, anytime that advocacy starts to tread close to justifying prohibiting the high-risk alternative, it is turning anti-THR. Unlike my assessment of seatbelts, as you note, there are lots of people who genuinely prefer smoking. Anything that demonizes or punishes them for making that choice is anti-harm-reduction. So — as happens way too often — ecig advocates say “yes, smoking bans are justified by the (massively overblown) claims about environmental health risks, but our shit doesn’t stink” or “you want everyone to quit smoking, and here is a way to make them do it” or the like, then it is getting quite close to being tobacco control, not THR. Many ecig advocates are quite overtly anti-THR. Of course, mere success at getting people to switch will make life harder on smokers, but that is just life — legitimate creative destruction.

      Oh, and of course I agree that low-risk options are not just for those who would use the high-risk option if it were the only choice. (Should only people who would have taken the risk of air travel in 1920 be allowed on commercial airlines?) Anyone who pushes for that, in this realm, is definitely tobacco control and not THR.

  11. Dear Carl,
    Quick question since your grasp of infinitely small but often crucial details in the use of the English language, is at the level it is:

    (d) “tobacco control” means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke;

    The choice of wording after a population has interested me for a few years. If the drafters of the FCTC really wanted to make it clear that population trumps individuals, in terms of preferred end goals, wouldn’t they then have chosen “it’s” when referring to the population not as it is written “their”? Since the English “sounds” funny to me the way it is written, I have always been of the opinion that it may have been a smart way for the drafters to signal that aggregate effects are reached through individual choices?

    Tangential to your excellent post and the very smart comments on it, but I would value your thoughts on it anyway. Cheers, Erik Atakan Befrits

    • Carl V Phillips

      I suspect that is just the difference between the most common British construction and the most common American. The rules are a bit fuzzy, but American English almost always refers to a collection of people with the singular “its” (no apostrophe, btw). British English generally uses a plural like they did (perhaps someone over there could tell me an exact rule). So I suspect it is nothing more than WHO being euro-centric (even though we pay for them!).

      Even more tangentially, I have a habit of adopting the British rules that I like better and this is one of them. I usually refer to groups of people with the plural. I do it in particular for governments and agencies to emphasize that it is a group of people and not some unitary actor. No one that I can recall has ever tried to “correct” that in an American English context, so clearly everyone feels the rules are a bit flexible.

      Non-tangentially, their use of “harm reduction” there is in patent violation of what I explained in the post.

      • I totally agree with you on the violation, and am grateful for a little better knowledge of how to handle the tricky its/it’s bit:) I do however see the other issue as a potential point to try and successfully argue whenever someone makes it to a court room somewhere. The aggregate should not and may not be reached, through deliberately or by default, leaving them without perfectly satisfactory harm reduction/risk reduction products, should they want to use them. The point does come right in the very beginning of the treaty (Article 1, Use of terms) and could therefore be of paramount importance to us, in legal terms. FCTC is not ratified in the US, so you can always dodge it, but if we could find legal expertise who think it is an arguable point, then I would be happy. Keep it in mind please, even if you don’t think it is a court-room winner.

        BTW: Sweden has removed Harm Reduction entirely from its (it’s?) official documentation explaining the FCTC. Only supply and demand remain. Funnily enough, when you read the full text translation of the entire FCTC text as it was presented and voted on by Parliament in Sweden the point d) actually reads more like this:

        Supply reduction+Demand reduction=Harm reduction

        instead of

        Supply reduction+Demand reduction+Harm reduction=Harm reduction

        A not insignificant difference
        Cheerio, Atakan

      • natepickering

        I couldn’t help but chuckle when I read this, because it’s an argument in which I’ve been engaged with certain of my English and Scottish friends for about 20 years. From the British perspective, a singular noun describing a group of people should be paired with a verb that would normally be used with a plural noun (e.g. “the team are,” “the army are,” “the band are,” etc.), whereas we in the US and Canada have opted to only pair singular nouns with singular verbs, since this is obviously correct and sounds much better (insert brazenly jingoistic grin here).

        • @natepickering. Thanks for the comment and insights. Question is if it could be effectively used in a “litigative” style courtroom situation in the future? I am Swedish and am fully confident that THR will end up in national courts and/or in front of the UN in the shape of an “Human right to best attainable standard of health” issue. When that happens every shred of useful argumentation will be useful, that point to 180 nations agreeing that only through individual health choices will a positive aggregate be achieved. Denying us those choices must not be used to protect children or non smokers – as we have the same rights as they do. The unborn generations to the best of my knowledge are not endowed with human rights yet. Cheers

  12. I think you are being rather hard on tobacco control given how feeble it was for many years and given the tragedy unfolding in China now. Substitute ‘cancer’ for ‘tobacco’ – and many other diseases of course – and the wider context of harm reduction you mention becomes apparent. I’d also say that in the West, surveys do seem to say that a majority of smokers want to quit, so maybe many actually welcome their ‘marginalization’ as part of their quit attempts. (Disclosure – I’m a retired oncologist, so I guess you would expect nothing else from me.)

    Oh and I am completely supportive of a barely regulated e-cigarettes market But how can we get Chinese men to switch? Or in your language, move somehow (how if no one does anything) to “freedom of choice, empowerment, and minimization of needless created harm”?

    Of course if you are making a purely libertarian/objectivist/Randian case then anything or nothing goes – but then I’m unsure why you need a blog of more than a few words!

    • natepickering

      “I think you are being rather hard on tobacco control given how feeble it was for many years”

      What do you mean by “feeble?” When I grew up, I lived in a world where some people smoked and some people didn’t. When smokers wanted to smoke, there were plenty of places they could. When nonsmokers didn’t want to smell smoke, there were plenty of places they could go. If a smoker’s smoking was bothering a nonsmoker, and the nonsmoker politely asked the smoker to go elsewhere, the request was usually honored without question. Society seemed to function perfectly fine. There was no need for hatred or revulsion to exist between the two population groups. So, getting back to the original question, how is today’s world (shaped in no small part by what you presumably regard as non-feeble tobacco control) preferable to that one?

      “and given the tragedy unfolding in China now.”

      What tragedy would that be? People buying and using a legal consumer product from which they derive pleasure?

      “I’d also say that in the West, surveys do seem to say that a majority of smokers want to quit, so maybe many actually welcome their ‘marginalization’ as part of their quit attempts.”

      Surely you must understand that these survey results are shaped largely by 30 years of smoker-shaming and social marginalization. People say they want to quit smoking because they think it’s what they’re supposed to say. They live in a world where they’ve been browbeaten into believing they’re detestable, weak-willed drug junkies with no agency over their own behavioral choices, who can only be welcomed back into the auspices of polite society one they’ve ceased all tobacco/nicotine intake.

      “so maybe many actually welcome their ‘marginalization’ as part of their quit attempts.”

      This is, on a host of different levels, a profoundly disturbing statement.

    • “…so maybe many actually welcome their ‘marginalization’ as part of their quit attempts.”

      I don’t know how people who can be so book smart (e.g. able to become a doctor) can be so people stupid.

      Putting aside those flawed stats (no one follows up the survey question with “why?” — most of whom would likely answer is due to outside forces rather than their true personal pure desire), just because it might be some people’s wish doesn’t justify that sort of indecent remedy now that they’ve also validated YOUR wish.

    • Carl V Phillips

      Well, given that tobacco control hurt a lot of people (usually intentionally), lie to the public, undermine the credibility of the sciences they abuse, threaten the credibility of real public health, and erode modern values, I don’t think it is actually possible to be too hard on them without committing a felony (oh, and they frequently do that too). Appealing to the humble origins myth is kind of like saying the USA was long a ragtag small country at the edge of a wilderness, so quit complaining that we are bombing civilians and are considered the world’s greatest threat to peace. It is not quite the same — there are still a few people active in tobacco control who spent their lives struggling at the edge of wilderness. But not very many and they need to stop pretending they are still there. Tobacco control has been the dominant force in the space, by far, for a generation.

      As others have noted, much of those survey results are people simply saying what they know they are supposed to. A lot of it is second-order preferences expressed as if they were first-order. It is *obviously* not their actual preference because quitting is always an option and they have not chosen it. Nothing in those responses can be interpreted as people wanting to be tortured into making a different choice. I have written extensively about all of those points.

      Getting the Chinese to switch would involved: (a) giving them the option, something to switch to, which they do not now have — in part because of the efforts of tobacco control, and (b) giving them access to credibility information and personal empowerment. A few of those conditions seem a ways off for the Chinese, I’m afraid, and rather beyond the influence of Westerners. But some of the problem of information is the same as in the West and is affected by those in the West. That is, the same tobacco control lies that convince Westerners that it is not a good idea to switch to a low risk alternative also reach China. The barrier to people switching is tobacco control.

      Finally, please do not conflate libertarianism with Rand talk. The latter gets couched in terms of liberty but is really about the distribution of wealth. This is an almost orthogonal concept to the liberty-authority axis, as I pointed out a couple of posts ago. Trying to understand libertarianism by reading Rand is kind of like trying to understand American values by reading DC comic books. Try J.S. Mill.

      • natepickering

        “Trying to understand libertarianism by reading Rand is kind of like trying to understand American values by reading DC comic books.”

        Carl Phillips, you may now circle the bases.

    • Roberto Sussman

      As an oncologist (even if retired) you should be very “hard” on Tobacco Control for the sake of your own profession. As an oncologist you should worry on the damage that the continuous abuse of science by TC is causing to the credibility of medical science itself. Currently TC has total control and veto power on the peer-review process in medical journals on anything related to tobacco. So, there is no accountability and any study that produces the “desired” outcome gets published, even if it is utter methodological garbage (such as meta-analysis in of many unrelated studies and many other examples). However, this lying to the public cannot last forever. Sooner or later the bubble will burst and will affect the credibility of medical science.

      As an oncologist, are you not worried that actual research (biochemical, physiological and genetic research, not epidemiology) on lung cancer has less funds than the massive anti-tobacco advocacy lobby recommending punitive taxation and coercive measures against smokers?

      As an oncologist, can you really testify (say in a federal court) that medical science has hard data (not epidemiological statistics) confirming that “second hand smoke causes lung cancer”. Can you testify (under oath) that the statement “there is no safe level of exposure to ETS” has sound scientific basis? Sooner or later oncologists and other medics will have to answer these questions to the public.

      • Carl V Phillips

        Well, in fairness, any data that lets you make estimates about an exposure causing a disease is epidemiologic statistics, by definition. I am not sure what you mean by hard data. The problem is not the type of evidence, but what the evidence shows. If not cherrypicked and interpreted with proper scientific epistemic modesty, it shows that any risk from ETS is so small that it cannot be measured and that zero risk cannot be ruled out.

        Also that is the reason for the “no safe level” trope, which is actually a willful misinterpretation of the statement “we not managed to estimate how low the exposure has to go before there is zero risk from it”, as if that were the same as saying “we know that there is no level that is low enough to pose zero risk”. It is a proper statement of ignorance that people (i.e., liars) use to imply knowledge. Of course, since we (the honest among us) cannot even figure out whether realistic levels of ETS even cause disease at all, we obviously do not know where to draw the line.

        • natepickering

          This is a rhetorical game at which tobacco controllers have grown remarkably adept, and which large portions of the public are regrettably still gullible and credulous enough to fall for. It’s the same thing they do with their (newer, just as asinine, but equally effective) trope of “We found detectable levels of [insert scary-sounding thing] in e-cig vapor.” The casual reader tends to infer “potentially harmful” out of “detectable,” where the actual meaning is merely “not zero.”

        • Roberto Sussman

          By “hard data” I mean strictly experimental and direct observational biological and physiological data at the cellular and molecular level. I do not dismiss epidemiological research, I just point out that it is insufficient to establish causation. Epidemiological statistics merely suggests correlations that should provide a direction for experiments in more fundamental levels, it does not (by itself) determines causation. A simple example (already known): statistics may show that prevalence of dysentery is correlated with usage of certain water fountains, which suggests looking at the contents of the water (an experiment). The experiment reveals bacteria and parasites and known research on how the latter affect the intestinal tract leads to establish causation. As far as I am aware (correct me if I’m wrong) current research on the relation between smoking and lung cancer has not gone beyond the stage of “detecting a correlation between dysentery and people drinking from certain water fountains” (ie epidemiology). l

        • Carl V Phillips

          The real epidemiology (including experimental epidemiology — e.g., clinical trials — when that is actually possible) always trumps those kinds of biological observations. It measure the actual endpoint, while the looking at cells, pathways, etc. make you guess about how the result translates into real outcomes. Finding a microbe in a water source does not tell you it causes a disease unless you have epidemiology about actual diseases being caused by exposure to that microbe. Once you have that, testing the water is a very good shortcut for predicting what will cause disease, but you only have that shortcut because of the epidemiology.

          Science **never** establishes causation. All beliefs about causation are inferred from subjective human observations about associations among phenomena. Some inferences are better than others (we think — again, it all comes back to human inference), but there are no bright lines. I have written extensively about this, as have quite a few others in the epidemiology context (and if you really want to spend some time on it, check out what the philosophy guys have written about it).

        • Roberto Sussman

          Perhaps we have a misunderstanding on the term “Causation”. I admit ignorance on the methodology specific to medical science.

          What I meant for “Causation” in the context of our discussion is the knowledge of the connection between tobacco smoke and lung cancer at the cellular (tissues), and molecular level (biochemistry & genes). Yes, epidemiology reveals a statistical cause-effect connection (which has some faults and contradictions and too many unexplained “confounders”), but the main question is: how much do we know beyond epidemiology?

          I know that experiments have failed to produce lung cancer in laboratory animals exposed to tobacco smoke. I know of some research showing that some genes facilitate the processing of nicotine. As far as I am aware (I may be wrong), we still don’t know the deeper and more intimate biological mechanisms in which tobacco smoke may produce lung cancer at a cellular and molecular level. If we did, we would be able to fit the epidemiological and clinical data (ie empiric data) to a more fundamental level. In other words, we would have a deeper understanding that could be called “knowing the cause”.

          I have asked several oncologists and (as we have seen in this forum) most of them conduct a purely clinical activity disconnected from the type of research I described. Given the fact that “tobacco causes cancer” is screamed from rooftops all the time, I find it very surprising (and puzzling) how little we seem to know on the relation between tobacco smoke and lung cancer beyond epidemiology. Perhaps I am mistaken, so any reference on this issue is most welcome.

        • Carl V Phillips

          Well, without delving into metaphysics debates, I will just assert that epidemiologists mean the counterfactual definition when they say “cause”: If D happened and condition E existed, but counterfactually D would not have happened then if E had not existed, then E caused D. Since you can never observe that directly (you can either observe the factual or the counterfactual world, but not both) you can only infer it. That goes for epidemiology and for physics experiments — it is all inference from statistics.

          If you are hunting for causes of cancer, biology and epidemiology studies tell you different things. As you note, the former can help you sort out the details of how E might cause Ca in ways that are difficult or impossible with epidemiology. But that should be described as knowing the pathway from which the cause, E, leads to the disease, Ca. (Yes, you can legitimately call each step on the causal pathway a cause in itself, per the definition, but you start to get into serious communication confusion if you do.) But the biology experiments can never tell you that E causes Ca (i.e., actual cancer in actual people) because they do not observe that. Only epidemiology can tell you that.

          Science is only just sorting out the impacts of many complicated exposures like smoking at the molecular level. Perhaps that can lead to prophylactics. But it does not really matter at the human decision level. If action E causes P% risk of disease D, then that is all you need to know to make an informed decision about whether to do E. If we think that is true then it will remain unchanged by finding the molecular engines (which might make us a little more confident that P>0, but if we already figured that then that is no information; they cannot possibly quantify P; they cannot convince sensible people that P>0 if the epidemiology shows it is not).

    • Enter the God complex, so ingrained into the medical profession as the priesthood of compulsory peak fitness that they are collectively blind to their own hubris.

      Doctors are trained technicians – arguably collectively no more “smart” than an average roomful of plumbers or electricians. What they have is social cachet and institutional power born of Victorian era notions of social engineering and middle-class respectability. They should be servants of society not block wardens of social control or cops of group mores.

      Science is a collective and social endeavour aimed at understanding the world as objectively as currently possible by mastering it; experimenting to see how far we can reproduce phenomena to reach ever closer approximations in our descriptions of reality and our practice.

      When treating diseases or illness, naturally we want trained observers and skilled technicians. When researching disease we want accurately collated and accurately reported studies – and we want them subjected to the widest possible critique and re-assessment.

      What we get instead are political campaigns by led social engineers with an agenda backed up by medical professionals who are being anything but. If one wants to discuss cancer one would be inclined to talk to an oncologist; when discussing taxation or health costs (or saving the misguided bloody poor from our own wayward natures for fucks sake) such are no more qualified to advise than any other bum on the street.

      Any hospital cleaner, let alone nurse, could probably capture what I’m getting at in plainer, and more robust, English – but then hospital cleaners have saved more lives than than the entire Congregation of Doctors and Misters (collectively crippled with narcissistic personality disorder as they are) combined.

      If I’m feeling poorly I’ll call you: if you pick my pocket (for my own good or otherwise) I’ll stub me fag out in your eyeball.

      As for the Chinese – I think they’re aware well enough of their own history to beware of Jesuits on holy missions and other peddlars of noxious goods in gunboats: and make no mistake that the WHO is anything but a bought and paid for.arena of world politics – unfortunately it’s a case of the piper’s tune being played as an outcome of some the wierder dystopian manifestations of (frequently US) social conflicts. Hence, for example, the restrictions on contraceptives to an Africa beset by an AIDS epidemic.

      Apologies for length of this – my only excuse is that down here in the land of the misanthrope Dr (not) Chapman we have both opposition parties campaigning to double the price of a packet of cigarettes to over $40 a pack by the end of the year. Naturally, being Australians, they have already inflicted this misery on whole communities of outback indigenous citizens by banning the use of welfare payments.to buy cigarettes at all (they’re not allowed to buy alcohol or look at.dirty pictures either). Mrs Grundy and her daughters are saving the lower orders from all manner of sin. Again.

      • Carl V Phillips

        Note to John R: I realize you might bristle at the aggressiveness of this comment, but it is a good complement to my most recent one (that appears right after it): This is the feeling that is created by the behavior of tobacco control and their enablers in a large portion of the population. An enterprise that is creating such feelings is clearly not so benign and popular as you see it. Note also that the physicians unions in the UK (and apparently Australia — I have less expertise about that) are full-in on policies like tobacco control even though, as noted in this comment, they really have no business taking such political stands. I too already noted that the perspective of physicians has no particular authority here — on average they are no better at the relevant natural science than the average educated person, probably less in tune with the sociology than the average well-read person, and have such a skewed perspective (based on seeing sick people) that they tend to forget other concerns. That obviously does not mean that each individual is not entitled to his own educated opinion. But when medics start using the authority and prestige that is granted to them by virtue of the important job they do to influence politics, it is not unlike the military intervening in domestic politics.

      • I have found that physicians who are well-trained technicians are NOT all that great at treating my family members. Good doctors combine art, science, experience, intuition, and go light-years beyond being a technician. But they also keep up with their fields, which means they read medical journals, which are almost 100% finance by ads from pharmaceutical companies. And the doctors’ ‘unions’ like the AMA, and most “health” advocacy organizations, have a physician as a frontman but are composed of lawyers and publicity specialists and project coordinators trained more in business than medicine. Until the last couple of decades, doctors DID have enough god-like powers to take individual stands when they disagreed with these organizations, but over the last few years, that appears to have reversed. Now the doctors I talk to are terrified to be truthful with their patients on matters of personal choice because there are Big Brothers looking over their shoulders, ready to pull their licenses or reputations or positions, or even their freedom, if they disagree with the Pharma/Puritan machine. There is an oncologist in Florida in prison for prescribing more too many more painkillers than the average doctor — no consideration exists in the law to differentiated between what a pediatrician should average vs. an oncologist. The doctors are not the problem. Big Pharma is.

  13. Chinese men won’t switch until 2 things happen: 1. China saturates the foreign market and starts making devices at Chinese prices, and 2. Chinese women add “non-smoker” the the famous “4 C’s” of the requirements for a husband (since girls are very underpopulated, they have a huge choice.) Cash, Car, Condo, and…I can’t remember the other one. Needs to be Cash Car Condo, Clean breath, and the one I can’t remember. Back in the days of cartos, it looked to me like about a third of the young men switching to vaping did so in order to get back into someone’s arms.

  14. Strange how we as physicians see things very differently! I guess if you’ve not seen many people die of lung cancer (and also other diseases such as COPD) you may not appreciate how desperate I and my colleagues have been for measures that cut smoking. I can honestly say that for most years of my practice, working in the US and England, we could only watch small efforts to promote antismoking greatly outweighed and slowed down by the tobacco industry, and we often had few options to help people quit as even people with cancer continue to smoke despite compromising their treatment. On returning to the UK, it was only fairly recently that the NHS set up smoking cessation services.

    I’m puzzled by a few things:

    – Attack on epidemiology – it was the work of epidemiologists such as Richard Doll and Harold Dorn that gave us the smoking-cancer link. It has been the tobacco industry that has long tried to debunk epidemiology as ‘not causative’ – but it is one of the essential disciplines in medicine.
    – This ‘dominant’ tobacco control movement has done what damage exactly? I can’t see any public appetite for reintroducing smoking on public transport or in workplaces, or for tobacco companies sponsoring sports, or advertising in the media, or smoking in cars with children (as a recent measure). And if it is so dominant, why has it managed to cut smoking by only about half over 40 or so years in the US? And why isn’t this cut to be welcomed! If anything, what I’ve observed are poorly funded and fragmented public health efforts, and lawmakers pushed into action by public opinion, not the other way around.
    – The data on people wanting to quit (and also those who have quit attempts over a year) – I’m not up to speed on this but surely the difficulty of quitting is a factor (ref: “because quitting is always an option and they have not chosen it”).

    I said I support e-cigarettes and certainly oppose extending hardline tobacco style regulation to them. If any country could enact wholesale change it’s China but that surely does mean better conventional tobacco control.

    Oh and didn’t Mill say something about not being truly free if one’s ability to be free is constrained?

    • Carl V Phillips

      “Strange how we as physicians see things very differently! I guess if you’ve not seen many people die of lung cancer….”
      Yes, well, we usually (quite wisely) try not to let people with an extremely unusual view of the world have too much influence over broad public policy decisions. Doing so gets us into a lot of wars, lavishly funds special interests, etc.

      “we could only watch small efforts to promote antismoking greatly outweighed and slowed down by the tobacco industry,”
      You said you are retired, so I assume you are recalling your life from the 1970s. Because this certainly has not been the case more recently. What exactly did the industry do that had such a magical effect? Slowing the draconian punishment of smokers for a decade? Putting their logos on race cars?

      “we often had few options to help people quit as even people with cancer continue to smoke despite compromising their treatment.”
      Well, you can thank your UK tobacco controllers for the fact that you did not have harm reduction as an option before ecigs. It was their doing that snus was banned in the EU.

      Re epidemiology: I am with you there. Epidemiology (properly defined) includes any research about causes of actual disease in actual people, so everything in sight is epidemiology. Even if the term is being misused to mean “observational epidemiology”, as it often is, it is still most of what we know. However, you have a verb tense problem with “the tobacco industry that has long tried to debunk epidemiology as ‘not causative’”: That is kind of like saying the USA has long tried to bomb Vietnam into oblivion, since those events were basically concurrent and similarly historical.

      “This ‘dominant’ tobacco control movement has done what damage exactly?”
      It has demonized smokers and tried (often successfully) to make them feel miserable about themselves, to take just the theme of this post, as well as compounding the harm from smoking with the harm from punitive taxes. It has aggressively blocked harm reduction efforts. It has actively promoted scientific innumeracy. It has turned large subsets of epidemiology and other sciences into utter junk. It has eroded Western values, taking us down a path where the state dictates individual choices. It has perverted the concept of public health and damaged the credibility of real public health. I could go on.

      “And if it is so dominant, why has it managed to cut smoking by only about half over 40 or so years in the US?”
      First off, it hasn’t. Not unless you are counting the legitimate version of tobacco control that existed in the 1960s (which is not who I am talking about). Approximately all of the reduction in smoking can be attributed to the initial education of people about the risks and the ripples through time as a result. The actually smoking reduction resulting from modern tobacco control is trivial. They are not dominant in the sense that they control people’s choices (they would like to, but fortunately they can’t). They are dominant in the sense of controlling all of the discourse on the topic and inflicting enormous harms (for little gain, even by their own measures).

      Re “wanting to quit”: If someone makes a particular choice, we know what they really want. You can come up with stories about what factors made them want that, and you might be right about them. But “ceasing to do it is unpleasant” is a reason for wanting to do it, not some alternative explanation for the choice. Whatever it is they are communicating with “I want to make the choice I am not making”, it is not the literal meaning of the statement.

      China can certainly do a lot of things that a free society cannot. They could force people to stop smoking. They could allow ecigs to flood on to the market and pressure people to use them. It is difficult to think they would want to either of these, given that the government of China is the world’s largest cigarette producer, but they could. If they took such steps, it would almost certainly involve actions that are even worse than those taken by Western tobacco controllers.

      I am not sure what you are quoting from Mill, but that kinda sounds like the whole point: If someone is trying to force you to take a particular action, it is reducing your freedom.

      • “Approximately all of the reduction in smoking can be attributed to the initial education of people about the risks and the ripples through time as a result.”

        Any evidence to back that claim up?

        • Carl V Phillips

          Um, kind of like asking for evidence that the sky is blue. But, sure, why not — some people don’t get outside much:

          -Most of the reduction in prevalence, and a huge portion of the actual quitting took place before there was any “tobacco control” other than basic education about the risks.
          -Most of the ensuing reduction in prevalence is due to simple cohort replacement. Combine this with the fact that the best predictor of someone starting smoking is parental smoking (and assume a fair bit of that causal — the tobacco controllers certain claim it is, and it is a plausible claim in this case) and most of the secular effect is ripples of the initial downward shock. This predicts an asymptotic decrease, just as we are seeing.
          -There has been very modest reduction in smoking cessation and prevalence reduction — setting aside the recent shock that is attributable to e-cigarettes — during the entire time that tobacco control has been ascendent.
          -Populations with similar demographics and culture to those societies where there is aggressive tobacco control have seen approximately the same trends as those with aggressive tobacco control.

          This obviously does not mean that punitive tobacco control measures have had no effect. In particular, there is decent support for the claim that high taxes have shaved a few percentage points off of prevalence. Basic economics tells us that other punitive measures must have had some effect on someone at the margin — and increase in the costs of an activity does. But it is not enough to show up in any data (if we restrict ourselves to honest interpretations), so we have to resort to theory to conclude that.

        • Roberto Sussman

          “Most of the reduction in prevalence, and a huge portion of the actual quitting took place before there was any “tobacco control” other than basic education about the risks.”

          This is true. There are no large scale open space smoking bans in Mexico and attitudes to smoking and smokers are much milder than in the USA. Yet, the proportion of smokers in Mexico has steadily decreased from (about) 37% of the adult population in the 1970’s to the current figure of (about) 16%. This is comparable to the data from USA: from (about) 44% to (about) 20%. So, smoking prevalence can diminish at the same rate from education about risks and without excessively authoritarian policies, bans and “de-normalization”.

    • Since John R. mentioned China, I looked at some articles and data. Most articles either refer to Increased smoking rates overall or refer just to Chinese men’s smoking rates. I found this all very puzzling.

      Chinese women have, it seems, always smoked less than the men. In 1980 approx 8% of Chinese women were smokers, this had declined to <5% in 2012 with some sources suggesting as low as 2%.

      With prevalence rates so low, why is the lung cancer rate in Chinese women in the top 20 (2012) country rates behind the US and UK? May I suggest that Tobacco Control has caused the focus to be so much on smoking that other factors are being ignored?

      The TC simplistic Tobacco=Cancer is not only false [not every smoker gets lung cancer], it is also a disservice to those who contract lung cancer from other causes.

  15. What harms has Tobacco Control done? 1. LYING to people about smokeless tobacco, thus preventing what could have been a 50% reduction in smoking today compared to what we have today, based on comparing Sweden to the rest of Europe. 2. Talking many employers into refusing to hire smokers, or even fire them, for smoking OFF THE JOB, causing unemployment, which is very bad for health due to stress and, sometimes, homelessness. 3. A concerted effort to assure that 40% of GED holders, LGBT, African-Americans, and other minorities AND their friends will bolt off campus the minute class is out, and return at midnight to go to bed, leaving all the on-campus life, leadership opportunities, networking, and study groups to clean-cut, clean-living, children of well educated parents. 4. Pushing for laws in rent-controlled cities that would allow landlords to evict vapers for vaping inside their own apartments. 5. Re-purposing parks and beaches paid for by taxpayers into auxiliary nicotine treatment clinics, arranging to have long stays on-site be “uncomfortable so they will quit smoking or vaping.”

  16. And the #1 harm of TC: I now hear LOTS of vapers saying “I used to respect and believe Public Health departments and authorities, but after watching them lie and lie in hearings at the state and local level, and on media, I’ll never be stupid enough to believe them again!” Oncologists might be unaware of the “herd effect” component of vaccine effectiveness, but with the migratory birds over the Americas now carrying Avian Flu since last year, I find it terrifying that Tobacco Controllers (and people they’ve bought, such as the CDC’s Tom Frieden) are destroying the credibility of the people and organizations that used to be the world’s premiere respected defenders against the very real and deadly threats that Mother Nature likes to inflict on overpopulated species…like humans.

    • I think the largest harm inflicted by the tobacco control industry, along with their “useful idiots” is the fracturing of society, and their destruction of tolerance for other human beings. This has become very obvious since the smoking bans and anti smoker laws have come in over the last decade in my country Australia.

      Its extremely noticeable in my isolated small community, (although these bans and laws have destroyed much of the community spirit). There used to be pubs and clubs, (sports clubs mostly), where people could mix freely, with others from all walks of life, wealthy, poor, blue or white collar workers, farmers, truck drivers, lawyers or doctors. Now what we see is smokers simply staying away, and the promised pubs full of grateful non-smokers never materialised (another ANTZ lie), so the pubs, clubs, and many cafes have closed. Our community has been atomised, small groups of people meet at each others homes, (smokers are not hated or vilified in the homes of most people, much to the disappointment of the ANTZ).

      There is also the consequence of smokers and vapers, (and other former smokers that still resent what was done to them as a smoker), are not interested in protecting or supporting the businesses that evicted them, they are not invested in caring for the parks and beaches they have been banned from. They are not willing to support arts or sports events that treat them like scum, and/or accept money from the tobacco control industry responsible for their vilification, discrimination, and exile.

      If all those smokers really want to quit, as some would have us believe, why aren’t they flocking to these tobacco control industry organisations, to help them, or be singing their praises for bullying them to stop smoking. Instead what we see is seething resentment, and increasing hatred for these bullies and liars.We see businesses closing down, and communities fragmenting. we see more open hatred and intolerance than I’ve ever seen in my life time.

  17. As I said I hold no brief for stifling e-cigarettes but I really don’t see this rather sneering stance on ‘tobacco controllers’ – in reality a wide number of people including doctors and counsellors who also offer support – as very productive. There are only three main control areas as I see it:

    – Bans on smoking in workplaces, transport etc. As I said I see no demand, even from many smokers, or case for going back on this. We really cannot allow people to smoke in places such as hospitals and smoking rooms just didn’t work. If you really want to smoke in bars there are plenty of countries that allow this but over time likely to be fewer owing to public consensus.
    – Taxes: tobacco has always been subject to excise duties and in many countries the price of cigarettes is actually not high. Price is a well tested public health tool and having looked around I see that in France, for example, smoking rates are actually rising, particularly among young woman, and it seems that failure to increase tax may be partly to blame. To be credible on this I would say you’d have to be confident that lowering tobacco taxes would not lead to increased consumption. There are similar arguments about alcohol in the UK.
    – Ban on marketing – again I see no sense in letting tobacco companies advertise and sponsor again. Do you?

    As for stigmatising smokers, my colleagues and I spent many years trying to help people quit or cut down, and we certainly never belittled anyone we saw as suffering from an addiction such that they couldn’t even quit with a cancer diagnosis. When your patients are wheeling out their drips to the outside to smoke you cannot but empathise. I don’t think I’ve ever met a smoker who thinks that not being able to smoke say on a bus (and I remember the top deck of London buses) is unreasonable, although they of course complain about cost.

    Having said that I’d like to see the evidence you have that counters the widely accepted research that a majority of smokers would rather not smoke (I would expect this to address addiction), and that anything other than information has minimal effect – my understanding over the years is that successful health interventions are usually multifactorial, culturally related, and the parts vary in impact but I can see only great disadvantage to lowering disease in abolishing the three I itemised above.

    The quote I was half recalling from Mill is “The principle of freedom cannot require that the person be free not to be free. It is not freedom, to be allowed to alienate his freedom” which I’ve looked up. This was used by a guest lecturer in a talk on addiction I now also recall when I worked in the US – the point is not that we are free to intervene directly – I know that is strictly against Mill when it is a personal problem – but we are allowed to recognise that someone in the grip of addiction (he was talking about hard drugs but it could be nicotine) is not able to exercise full freedom. We can intervene to protect others (no smoking on buses), and to try and stop people becoming addicted (trying to stop young people taking up smoking), which would ‘alienate’ their freedom.

    • I would have answered a survey saying I “wanted” to quit smoking, but Carl is right. I wanted to want to quit, NOT the same thing. I really enjoyed smoking, and I really enjoy vaping. But I don’t see why I should NOT sneer at people who are completely trashing the credibility of doctors and scientists with a few hundred thousand people, and, trust me, those few hundred thousand are going to KEEP spreading all those videos and news quotes of those lies to more and more people. The Tobacco Control people have been getting the heads of Public Health departments to introduce themselves as such, then spout blatant lies ON CAMERA and ON THE RECORD to city, state, and county bodies all over the country, and vapers across the world watch the URL’s to those videos.

    • John R
      Totally and utterly “stifling” e-cigs,is exactly what public health is trying to do.
      There is no doubt in my mind , by now, that they exactly know what they are doing. And there is no question either that they are utterly without ethics , scruples, honesty that they are completely, without Love.

      Their only love is for power, nothing more.

    • Roberto Sussman

      John, I cannot speak in the name of other posters, but I assume that most would agree that starkly criticising “tobacco controllers” does not mean advocating for cigarette smoking. Also, nobody denies that cigarette smoking is a health hazard for the smoker.

      I think you misunderstand what posters here mean by the term “tobacco controllers”. I have no problem in accepting most of the three items of “control” that you mention: ban on marketing, no smoking indoors in public places (offices, transport, etc), taxation on smoking (but much less punitive). I assume that you also oppose total smoking bans in large outdoor open spaces, parks, beaches, campuses. You have stated that you also support facilitating that smokers have the option of switching to much much safer e-cigs. Perhaps we have reached a common ground of agreement.

      Evidently, tobacco must be regulated, the issue is whether it is regulated along a humanist and enlightened manner or along an authoritarian ultra-paternalistic manner (authoritarian eugenics). In other words: to regulate by prioritising education and access to information based on sound science, or to regulate by prioritising an aggressive authoritarian political lobbing and advocacy based on strict bans and stigmatisation of smokers.

      Tobacco Control is the short hand name for a global network of Public Health bureaucracies that follow the Framework Convention of Tobacco Control (FTCT) treaty established by the WHO in 2003. The main purpose and priority of this bureaucracy is to engage in an aggressive anti-tobacco advocacy and political lobbying at the national and global scale. This advocacy rejects the “harm reduction” approach in favor of a non-compromising absolutist “quit or die” strategy, though recently some controllers have become more amenable to the “harm reduction” approach through e-cigs as “smoking cessation” devises. Some of the controllers may be councillors, social workers or even lawyers, but most are senior medical bureaucrats (including some crackpot figures) whose activity has little connection with clinical work among lung cancer patients or with researchers on the biological, physiological and genetic issues. Harsh critique of “Tobacco Control” is a critique of this bureaucracy. It does not mean dismissing or attacking every doctor or councillor whose work is somehow related to tobacco. Not every physician is a “tobacco controller” even if he/she strongly opposes smoking. In my modest opinion, what makes a physician a “tobacco controller” is the emphasis in militant political advocacy based on the FTCT protocol at the expense of clinical and research activity.

      The political advocacy of the controllers is allegedly based on scientific research (there is even a “Tobacco Control” journal), but most of this research is grossly biassed and methodologically dishonest: misusing epidemiological meta-analysis, lying about the statistical significance of the correlation between ETS and lung cancer, claiming that 30 minutes exposure to ETS leads to severe hardening of coronary arteries, arguing that links exist between smoking and infertility, grossly over exaggerating tobacco morbidity and mortality (the list is very long).

      This may seem to you a sort of “conspiracy theory”, so I don’t expect you to believe me, but I assure you that all this abuse of science is very well documented. The motivations are evidently unethical but not wholly irrational. The misinformation serves to create exaggerated public fear on the harm effects of ETS, which in itself serves a double purpose: (i) it facilitates the implementation of increasingly extensive smoking outdoor bans and the “de-normalisation” of smoking (which stigmatises smokers) along the “quit or die” strategy, (ii) it keeps the public money (grants, promotions, jobs) flowing into the Tobacco Control network of Public Health institutions, anti-smoking charities, regulating government agencies (EPA, FDA, etc) and (also) the money flow from the Pharmaceutical Industry (whose financial and political power dwarfs the Tobacco Industry) .

      What is wrong with the political advocacy of the controllers? a lot is wrong.

      (1) Leaving aside the obvious paternalistic cruelty of the “de-normalisation”, outdoor bans lack any scientific justification: all epidemiological studies on the relation between ETH and lung cancer involved long time (even decades) indoor exposure of spouses and children, and still the risk factors are almost statistically non-significant (the studies are publicly available). Long exposure to ETS in indoor poorly ventilated spaces can be irritant and harmful for sensitive persons, but the risk of harm from large open outdoor exposure to a few minutes of ETS is so negligible it can be reasonably termed “non-existent”. There are studies showing that in practically all open space conditions the concentration of carcinogenic components of smoke from a lit cigarette at 2-3 meters distance is in the range of pico-grams (0.000000000001 grams) per cubic metre (its detection would require very special and expensive instruments, I know this because I am a professional physicist with good training in the physic of gasses and gas mixtures). You find much higher concentrations of carcinogens in air pollution in any mid sized city. Outdoor bans have nothing to do with health protection of non-smokers (hence they violate civil liberties of smokers), they merely serve the purpose of advancing the political advocacy of the controllers.

      (2) After 10-20 years of producing misery and stigmatisation to smokers the FTCT based advocacy has failed to be a “game changer” in decreasing the prevalence of smoking. As Carl mentioned, this prevalence has slowly decreased almost everywhere in western societies even before the TC bureaucracy imposed its aggressive advocacy in the late 90’s. Tobacco controllers claim to have detected a 10-20% drop of coronary disease rates in specific locations (the so-called “Hellena” miracle) as a byproduct of the implementation of smoking bans. These are extremely dishonest and fraudulent claims, not only because they involve very small population samples (which magnify statistical instability and errors), but because they ignore the overall long time statistical pattern by “hunting” for fluctuations in specific years in which a drop was detected (but looking at following years the pattern re-emerges). If large scale bans produce a drop of smoking prevalence and if this reduces rates of coronary disease (a lot of “ifs”), it would take decades to detect a statistically significant correlation and it would occur (for example) also in San Francisco, where bans are particularly strict, so why the controller Glantz from UC at SF went looking for a “miracle” in far away Hellena, Montana? Because he dishonestly “hunted” for a statistical fluctuation that agreed with his advocacy. Glantz has never made the data of this “experiment” available for public scrutiny.

      (3) Another disaster is the blunt opposition of most controllers to the “harm reduction” approach as an alternative to the “quit or die” strategy outlined in the FTCT treaty. While some controllers have recognised the potential of e-cigs to induce smokers to switch to vaping and thus support their liberal widespread usage, the majority of controllers vigorously oppose this move and are pushing to regulate and tax e-cigs as normal cigarettes. They have launched a fear smearing campaign against e-cigs based on pure junk science (Carl can provide many examples), which has produced the very negative widespread misconception that e-cigs are just as hazardous as normal cigarettes. You have stated support for promoting that cigarette smokers switch to vaping and that e-cigs should not be subjected to heavy handed regulation. So you should be concerned by this. Don’y you think this is sufficient reason to be “hard” on the controllers majority fanatically clinging to the FTCT protocol?

      Finally, I take issue with the following statements:

      “If you really want to smoke in bars there are plenty of countries that allow this but over time likely to be fewer owing to public consensus.”

      First, in a democratic and enlightened society you should be able to argue for (or against) the right to smoke in a bar in the country where you live. Imagine a non-smoker in a heavily smoking country (say, China) being told “If you really want smoke-free bars there are plenty of countries that allow this”. You would be up in arms.

      Secondly, you claim there is public consensus (majority support) on restaurants, bars and pubs banning indoor smoking (in a ventilated smoking section) in their premises. This is not true. Several pols have surveyed this issue, and (as happens in all polling) the results strongly depend on the questioning format. If you ask a “yes or no” question such as “would you like to allow for indoor smoking in bars and restaurants”, then most of the polled (mostly non-smokers because only 20% of the population smokes) will say “NO”, assuming that saying “YES” implies going back to old times and having to eat or drink in very close proximity to tobacco smoke. However, you get very different results if you survey this issue in a more nuanced manner: allowing the polled to reply to various options, such as “would you allow for separate ventilated smoking sections in pubs and restaurants?” A poll by the IEA showed the following result:

      “Half (51%) of Britons believe owners of pubs and private members clubs should be allowed to have a private room for people to smoke in if they want to, with 35% disagreeing. Of those expressing a preference, this figure rises to 59%. UKIP voters are the most likely to agree (62%).”

      Source: http://www.iea.org.uk/in-the-media/press-release/seven-in-ten-voters-believe-sin-taxes-are-too-high

    • Carl V Phillips

      Roberto noted that when we refer to tobacco controllers it is not necessarily describing every single person who is involved in discouraging smoking. I would expand the core group wider than he did, to include academics and government agencies, among others, but same idea. Jude referred to the useful idiots that enable them, and that is the key observation here. I have written about the distinction between opinion leaders and useful idiots in my (yet unfinished) series on why there is anti-THR. As you presumably know, “useful idiot” is not a commentary on someone’s intelligence, but a reference to a Leninist concept: A core group of people with narrow (usually selfish) agenda manage to convince a large body of people to support them out of delusion about what those at the core really stand for and are doing. Generally the implication is that the useful idiots would never support the actual agenda and tactics if they really understood them, but they get tricked by “for the good of the people” rhetoric. Obvious modern examples include people who are merely worried about security and terrorism serving as useful idiots for neocon agendas and indiscriminate homicides that they would not actually support, or people worried about law and order getting sucked into supporting police brutality and abuses in the justice system that they would never support.

      Needless to say, I am telling you that you are a useful idiot for them. Please don’t take offense at the term of art, nor even the implication that you have been tricked — you had a job to do and a life to live and could not be expected to really delve into all the details of the nasty people you were implicitly endorsing. You probably did not even realize you were implicitly endorsing anyone. That is the terrible beauty of the whole useful idiot thing. The good news is that you have come to a right place to understand that. I have already recounted in these comments, a couple of times, the list of nasty things that the core tobacco controllers do, which is far beyond the list you give in this comment. Others have added observations about their wanton willingness to destroy social networks with draconian rules, without regard for the costs they are imposing on others. I will also add their active engagement in McCarthyist tactics to try to personally destroy anyone who opposes their special-interest goals. From what I can tell from our brief interaction, you do not support these things. Yet you are supporting them by effectively signing your name to the mission statement even as you disagree with some of the particulars.

      As for the specifics you note, there is not nearly as much support for private place bans (and we are mostly talking about indoor private places — businesses, not actual public places) as you imply. Consider the recent poll in Scotland, where the tobacco controllers are celebrating the tenth anniversary of the pub-closing social-life-destroying universal indoor smoking ban. When offered a choice other than a universal ban and no restrictions at all — namely, allowing well-ventilated smoking rooms in pubs — the majority of the respondents supported that. Or, consider it in the terms of this post: Even if a majority supported a ban on gay bars, as they would in much of the USA and elsewhere, would that make it a good idea?

      As noted in this post, taxes have a very dubious role. Yes, they eliminate a few marginal users for whom this punishment is enough to tip them into not smoking. But then they compound the harms suffered by the inframarginal people that you want to help, adding the harm from the regressive tax to the harm from smoking itself. Do not let them trick you into thinking this is not harm-creating. You might be of the opinion that the harm that is created is warranted by the benefits (as you measure them) but anyone who pretends there is no harm from this is basing it on a belief that smokers deserve to suffer more. They want to *hurt* smokers, not help them.

      As for advertising: *shrug*. It really does not really matter much. The tobacco controllers try to trick everyone into believing that it does, but there is no evidence of that. However, such bans do not hurt anyone materially (though they do erode freedom of speech). It is an enormous boon to the tobacco companies who do not have to spend on a zero-sum game to try to take one another’s customers (I am sure Cocacola would love to get such a ban for their industry).

      As for the evidence that smokers want to smoke, it is already in that sentence. They choose to smoke. Therefore they must want to smoke. For more on that, read Phillips-Nissen-Rodu.

  18. “-Most of the reduction in prevalence, and a huge portion of the actual quitting took place before there was any “tobacco control” other than basic education about the risks.”

    … which does not mean that control has been meaningless. The prevalence has definitely come down as a consequence of legislation and control, at least in Finland (where I’m from, BTW).

    https://helda.helsinki.fi/handle/10138/20363

    Of course, if you could quantify the expression “almost all …”, I’d be a start.

    • Carl V Phillips

      Almost all = in the general neighborhood of 90%.

      Yes, you can find countless examples of tobacco controllers claiming success for their miscellaneous actions, beyond mere basic education. Obviously. But since 90% of the reduction clearly would have come without any of that it rings pretty hollow. They can argue about how much of the other 10% might have resulted from some of their policies. They have a solid case for some of that being caused by taxes, but the claims about the impacts of all else are extremely tenuous, based on ad hoc measures designed to make the claim but which do not stand up across populations.

  19. I’ve had a think about this and can only conclude that you won’t be seeing any return to smoking in enclosed public places, lowering of tax or revival of advertising and sports sponsorship in the US and UK and in many another countries. I doubt you are really arguing that a tobacco firm sponsoring an Indian cricket team, or distributing free samples to young people in discos in China is worth while as an exercise in freedom.

    Now I’ve been back in the UK for a few years I can see that much of the opposition to the smoking ban in public places has been about unfounded fear of change.

    As a physician who has been much concerned about prevention as well as treatment I see no difference between helping smokers to quit and trialling tamoxifen to prevent breast cancer – both can result in less disease.

    I find your comparison with discrimination against gay people grossly inappropriate and offensive.

    • Carl V Phillips

      I agree there is little chance of reversing smoking bans in enclosed genuinely public places. Frankly, it does not matter that the health risks are trivial because the aesthetic impact is huge and perfectly adequate to justify bans. However, there definitely could be a relaxation in private places, such as allowing smoking rooms in pubs. The lack thereof creates enormous harms so is a particularly good candidate for relaxation. The Forest poll in Scotland found majority support for allowing that. In any case, mere place bans, when not coupled with active vilification, are beside the point of this post.

      The difference between treatment and prevention-via-force should be obvious. Forcing people to alter their behavior in a way that is costly to them is very different — both in terms of the force and the costs. (And, on the other hand, prevention results in much better outcomes than those awful treatments.)

      I wonder why you find the comparison to gay people (or black people in apartheid South Africa, which I have also written about, or any of the other examples I used) to be inapt, let alone offensive. Perhaps you are asserting that it is apt but is still offensive. Whichever of these you are asserting, can you show your work? I do not recall ever encountering an argument to that effect.

    • “Helping people to quit?” Do you actually get people to “alter their behavior for their own good” by forcing doses of tamoxifen on unwilling patients? How is that done? Threaten them with losing insurance? Slip in in their I.V.s? When did that start? Do doctors who do not force patients to use tamoxifen lose their licences to practice, like pubs do if they do not force the medical behavior change prescribed by the Powers that Be? When did that kind of practice of medicine start?

  20. What is meant by “unfounded fear of change” in the context of smoking bans? How has this manifested itself? How long will this fear continue? Does ‘fear’ itself have medical adverse consequences? Is there a difference in reactions to ‘founded’ as opposed to ‘unfounded’ fear?

  21. “Almost all = in the general neighborhood of 90%.”

    Good. Now, could you refer to studies backing up this claim?

    • Carl V Phillips

      Um, scroll up. It was already covered in this thread. Please do the reading before asking questions.

      Anyway, it is apparent to me that at best you are not really trying to understand, and alternatively you are just trolling. Your comments are not contributing anything useful to the conversation. Please stop now.

  22. Pingback: Economic innumeracy in public health, with an emphasis on tobacco harm reduction | Anti-THR Lies and related topics

  23. “Gays and Lesbians engaged in the 70’s in an aggressive political activism based on demanding fulfillment of their human rights (which include the right of any adult to define his/her sexuality). Fortunately, they succeeded.”

    Actually, there has now been some official government-level recognition of the violation of smokers’ Human Rights in Russia! I’ve been emailing with Dmitri Kossyrev of the Russian Movement for Smoker’s Rights. Dmitri has actually authored a book on smoking bans in Russian, likely the first such book, and has been actively working on such things as successfully persuading the Russian Office for Human Rights to devote a page in its Annual Report to the problem of the Antismokers’ attacks on the human rights of smokers. From the 2016 Report of the Russian Ombudsman for Human Rights to the President of Russia, ch. 2.5. here is a preliminary rough translation of a segment, translated by Dmitri:
    = === = = = =
    .”..the 2014 law “On safeguarding of public health from the effects of environmental tobacco smoke and the consequences of tobacco consumption” had from the very start leaned exclusively towards limitations of rights of the smoking citizens. According to various estimates, there are more than 30 million of such citizens in Russia, constituting a significant part of adult population. Their elementary rights have not been taken into account at the drafting of that law. As a result, the law does not contain the minimal necessary range of rights of smokers, such as would not be encroaching on the rights of non-smokers.”
    = === = = = =

    The document then goes on to call for “the reviewing of the results of implementation of the current law and passing of the necessary amendments to it.”

    Quite an achievement, particularly from a country that that the US and UK like to characterize as being LESS free than their own pseudo-democracies.

    – MJM

    • Roberto Sussman

      Very interesting news on Russian smokers raising the human rights issue. As far as I am ware the smoking bans were a sort of sudden “health whim” by super-athlete anti-smoker Putin.

      Given the total absence of a scientific or medical justification for ETS health hazard in open outdoor spaces, outdoor smoking bans are really human rights violations that go far beyond a reasonable regulation of tobacco. Sooner or later this will become a pressing issue globally, perhaps connected with opposition to other prohibitionist policies. There is a clear conceptual connection between the “war on drugs” and the “war on tobacco”. There are obvious differences as well: the “war on drugs” is conducted by the police and military and has produced thousands of casualties, while the “was on tobacco” is conducted by well funded (but unarmed) public bureaucracies. However, the prohibitionists conducting both “wars” use similar public health arguments and concepts: the notion of a overall crusading “war on a substance”. They share similar paternalistic moralizing impulses. They share the exaggeration of the health hazards of the substances. They share the coercive promotion of uncompromising and total abstinence. They share the total support of the organized medical profession. They share vested interests with the pharmaceutical industry (nicotine patches are analogous to methadone).

      Tobacco controllers have made an intense effort to compare themselves with advocates against hard drugs: smokers are “addicted” to nicotine just like heroine or cocaine consumers are addicted to these substances. While this comparison is factually flawed, it has been a very successful political stunt to get public support. Ironically, this false “addict” analogy may become a political boomerang harming the tobacco control bureaucracy in the long term. As popular opposition grows everywhere against the global disaster brought by prohibitionists waging the “war on heroine”, opposition will also grow on those waging the “war on tobacco” or the “war” on any substance (since they all quack they must all be ducks). Drug prohibition is already suffering its first blows with marijuana. As hard drugs pass from prohibited and illegal to regulated and legal, it is very unlikely that those consuming them will accept the current dictatorial regulation and “de-normalization” that tobacco smokers must endure.

      • Carl V Phillips

        The “addiction” trope is indeed somewhat harmful to their cause, at least the anti-THR bits of it: If someone is hopelessly enthralled then it is obviously a human rights violation to punish them for failing to carry out the cessation that you are claiming that cannot do.

        The militarization of anti-tobacco is obviously quite trivial compared to that of anti-drug. The horrors suffered by your wonderful country are obviously testament to that. But the use of police powers is obviously not zero: People are punished for evading restrictions sometimes and intimidated by that threat into complying the rest of the time. The fight against smuggled tobacco products does not feel militarized quite yet, but it is tending in that direction.

  24. Well I’ve certainly come across colleagues being described as ‘health fascists’ and ‘Nazis’, for example when we went smoke-free at one of the hospitals I worked at in the US so I guess you’re not quite in that camp but to compare not being able to smoke in public places with the horrors of apartheid or systematic homophobia is the kind of hyperbolic rhetoric we see in the UK from nasty right wing groups like our UK Independence Party, whose main manifesto seems to comprise being anti-Europe, anti-immigrant and pro-smoking. Quoting Forest, a longstanding right wing industry pressure group also does you no favours.

    Looking around I see that underage smoking take-up has gone down by a fifth in the UK in recent years, and according to my copy of the Economist this week there is a particular boom in e-cig shops in poorer areas of the UK. This is surely good news.

    • Carl V Phillips

      I am still not seeing any basis for your stated objection. Reading between the lines, I can only come up with “people like me are appalled by homophobia, but people like me support ‘denormalizing’ smokers, therefore they cannot be the same.” Sorry — doesn’t work that way. They both quack. The both involve Group A, a majority with greater political power, who hate / despise / are disgusted by people in Group B, and who generally sincerely believe the Bs are harming themselves and others, and want to deny the Bs the right to choose their behavior. Not seeing much difference.

      Forest is a consumer rights group, not an industry pressure group. Also, I was not quoting them, but citing the results of a study they commissioned. I really had gotten the impression that you were above the ad hominem bullshit that substitutes for scientific argument in the tobacco control community.

    • John, you say, “but to compare not being able to smoke in public places with the horrors of apartheid or systematic homophobia is the kind of hyperbolic rhetoric we see in the UK” John, you’ve accepted the mind-set laid out for you by the Antismokers here. It’s not simply a question of “being able to smoke in public places.” It’s about not having the government throw you out of your home because you dare to smoke in your HUD housing. It’s about not being denied a job simply because you are a weekend social smoker. It’s about not having your children taken away from you and handed over to an abusive spouse simply because you smoke and they don’t. It’s about not being forced to walk off campus into a dangerous neighborhood at night if you want to smoke (or, as Antismokers usually put it, when you “need” to smoke because you’re “an addict.”) It’s about being able to set up a private club for you and your friends to gather and smoke and discuss politics with no one else about. It’s about not being forced to pay a 300% tax rate. It’s about not being accosted by strangers and harassed or even physically abused, shot, or having excrement thrown in your face simply because you dared to smoke out in the open air.

      It’s also about not being able to get any financial support for your work to improve things without being labeled as a “shill” for an “industry pressure group” because the only source of support for your beliefs happens to be a different industry than the NicoGummyPatchyProduct industry. How about we pull FOREST’s funding and also ALL the $500 Million Dollars a year that the US Tobacco Control folks are getting dumped into their laps by the MSA “smokers’ tax” money used to persecute smokers, not to mention a likely equivalent amount spent by those Patchy Product People and the nice folks at “Big Charity” who spice up their fund drives with pictures of Choking Children being attacked by Evil Smokers.

      It’s about a whole heckuva a lot more than just being “able to smoke in public places” John, but I think you already know that. Btw, you are also aware I hope that “public places” is now being defined to mean even a stretch of neglected beach with no one within a hundred yards of you, right? A nice automatic segue from the original intent of INDOOR public places that bans were *intended* to address.

      – MJM, who gets no money from any “industry pressure group” and who also posts openly under his full name rather than an anonymous or semi-anonymous “handle.”

      • Carl V Phillips

        I do not use “like” buttons on this blog because I do not really care for them and because it would probably harm the conversation if I started creating a hierarchy of my opinions about posts. So I just have to reply to this one and say that it really helped clarify several points, and I love the sig.

    • John R. In my county, hospital regulations prohibit a cardiac doctor from ordering his patient to be able to vape in his private room to avoid the high blood pressure and stress of being denied his comforting, if harmful habit of smoking. The “health professionals” that made this rule, which OVERRULES the physician’s judgement for his patients, is a non-physician hospital administrator allied with “health groups.” The California Public Health Department just spent $75 million pushing commercials saying “you’re vaping poison” which have successfully convinced the parents of some vapers on the forum I’m on to “play it safe and go back to smoking” AGAINST their doctors’ orders. This will probably kill them. Calling them Nazis is a MILD overstatement, one of magnitude only, and that’s only if you do NOT consider that vaping could save a BILLION LIVES in the next century if it were promoted instead of being squashed.

      • Carl V Phillips

        The “billion lives” thing is a bit of a silly trope — pretty clearly wrong. “Nazi” is probably never a useful metaphor — rather too inexact and inevitably treated as hyperbole (even if it happens to be a spot-on analogy). But the good points about lies and draconian restrictions go to Michael’s point that it is a strawman to suggest this is about mere bans on buses and such.

        • I don’t use “Nazi” myself, I realize it’s not useful. But I feel very strongly the JUSTIFIED anger of the people who do use that term, the people they are calling “nazis” ARE causing deaths — how many, exactly, does it take before we have a right to be REALLY angry? Even without the individuals whose relatives have been affected, if you look at the drop-off in vaping uptake since these “poison ” campaigns got going, and the fact that we are constantly being told BY SMOKERS that we should return to smoking if we don’t want popcorn lung, we can probably come up with a WAG-style estimate of how many people are smoking in 2016 who would not have been. Then, even if we cut the prohibitionists’ estimate of annual deaths to smoking down to 100,000 from their oft-touted 480,000 number, we can estimate that, say, 100,000 people a year are crossing the boundary between salvageable health and doomed to die. Some subset of that, HAVE ALREADY BEEN KILLED by “health” advocates, we just don’t know their names. I’m morally sure it’s in the low thousands at the least. Anybody else causing that degree of harm would long-since have been put into a maximum-security prison for terrorism. It’s not that far off from that HIV-infected dentist who injected his blood into patients along with their novacaine shots — the patients did not die that year, but given the state of AIDS treatment at the time, it is sure that that one girl will not live her full lifespan. And, as you have pointed out, this anti-vaping campaign, and the utter callousness of considering smokers to be acceptable collateral damage, is an inevitable outcome of demonizing smokers, and getting comfortable with lying to people “for their own good.”

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