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.