by Carl V Phillips
I have seen several year-end posts about the state of e-cigarettes, most from cheerleaders who naturally made optimistic predictions. Overly optimistic, I would say.
Yes, it is possible that President Trump will lift FDA’s jackboots off of e-cigarettes, but the man is so random that it is possible he will do most anything. After all, he might initiate a massive mission to create a Moon colony, or might even save Medicare, Planned Parenthood funding, and the Affordable Care Act from congressional right-wingers and his VP (he is certainly more likely to save them than his more reliably Hobbesian opponents in the primary). He might even make life better for his core voters, though that seems rather far-fetched.
But there is no particularly good reason to believe he will rescue e-cigarettes. His past life and actions as PEOTUS show he is no particular friend of recreational drugs, the man on the street, small businesses, or anyone who cannot do something for him. If there is relief from FDA, it will probably be in the form of changes at CTP designed to please the major tobacco companies (he is a friend of crony capitalism, and it could offer payoffs sufficient to be worth touching the “soft on tobacco” third rail). Those could spill over positively to the e-cigarette sector. On the other hand, the most effective cronyism would consist of handing the e-cigarette category over to the majors more effectively than FDA has already done, so that is another reasonable possibility.
More generally, it seems like e-cigarettes will continue to be squeezed in the USA and most other populations. It would really not surprise me if, in a couple of decades, e-cigarettes had a hookah-like niche: a few old timers swearing by them, hanging out in vaper bars; members of each generation that come of age “discovering” them, using them until they no longer seem trendy; and regulators calling them a “novel product” even though they have been around forever. This is not a full-on prediction in the sense of “I would be surprised if that did not occur”, but it does seem very plausible. They might end up being thought of as an England thing (as in, “I quite like HP brown sauce and drinking ESB, and always have them when I am over there, but I seldom think to have them at home even though I can easily buy them locally”).
Despite the miraculous survival of the present iteration of e-cigarettes, after other iterations were abandoned or quashed numerous times before, and the impressive growth in sales and public opinion for years, e-cigarettes seem to have stalled or even lost ground by most measures of policy, momentum, and mindshare.
This is largely thanks to relentless campaigns against them by “public health” liars. The pre-existing product most similar to e-cigarettes is smokeless tobacco, and given how effectively the latter has been demonized and the public disinformed about it, it should not be all that surprising that tobacco controllers have had success doing the same to e-cigarettes. See, most recently, the Kafkaesque response to the Swedish Match MRTP application (link is an outsource to Rodu; he covered it definitively and I never got time to add anything).
In addition to the much-discussed trend in overestimating the risks of e-cigarettes, there is also the less quantifiable failure of e-cigarettes to really normalize (a fact that is easy to overlook if you are immersed in pro-ecig social media or “libertarians against ‘public health'” type blogs). To most Americans, whatever they think about smoking, vaping is a step or two more suspect than smoking. That seems to be the case in most of the world. The likes of homeopathy and Scientology are much better positioned politically. Every week or so, some essay or recording gets touted as a game-changing great piece about how wonderful e-cigarettes are. From my current vantage — of seeing a lot of the chatter about e-cigarettes but no longer immersed in it — it is pretty clear that those have basically no impact beyond the echo chamber.
Meanwhile, what we currently call e-cigarettes are probably about to get squeezed from the other side, by new heat-not-burn cigarettes (which actually fit the term “electronic cigarette” better, and “vapor product” as well or better; next year should see some good unintentional comedy from the terminology-obsessed in the space). The iQos became instantly popular when released in Japan, and if the category does half as well elsewhere, it will be huge. HnB products are more similar to smoking than e-cigarettes, which increases their immediate appeal to people who like smoking, or are just used to it. They are not as flexible (i.e., complicated), but that is probably a feature rather than limitation for most consumers. In addition, they can be designated as low-risk cigarettes, rather than a low-risk substitute for cigarettes. While at a practical level this is a distinction without a difference, it has huge implications for making regulatory options much easier in many jurisdictions. (There is obviously a lot more to say about the growing importance of HnB. I will write about it when I can.)
One additional factor that looks like it will squeeze the niche of e-cigarettes is the extent to which “public health” people have become its main champions. While that might seem like a plus for the category on a day-to-day basis, it probably is not in the medium- and long-run. Consider how Oxy has been losing market share to heroin, now that “health” people have started asserting more control of it. Or how few people have used NRT products as lifestyle drugs. Or how many yummy foods are less popular as a result of being primarily known as healthful choices. “Consume this! it will make the public health industry happy” is simply not a great marketing slogan.
In addition, it does not really work out so well for consumers when their champions medicalize them. E.g.: “We need [sic] these flavor options because they aid in smoking cessation.” “But the new research [sic] says that the availability of these flavors makes no difference for smoking cessation.” “Oh, ok, then there is no reason not to ban them.” See also: “Sure, it is fine for you to have sex, as long as it is done in a way that has a chance to conceive a new adherent for the church/fatherland. Just don’t do anything improper (i.e., for pleasure).”
But my point here is not to explore the ramifications of the transition, but to note that it has happened. Tobacco controllers, rather than harm reductionists, now dominate the e-cigarette discourse and policy space — on both sides. Obviously tobacco controllers lead the anti-ecig efforts, but other tobacco controllers now dominate the pro-ecig mindspace. The first generation of consumer activists have mostly burned out and the current generation have largely subordinated themselves to tobacco control, apparently often without really realizing it. There are still genuine harm reductionists in the mix (notably including everyone I cite in this post), but they are increasingly overwhelmed by the tobacco controllers and their antisocial plans for the future of e-cigarettes.
(Recall that the term “harm reduction” is commonly misused by people who wish to misappropriate it to mean something like “medicalized health risk reduction”. A simple test is that if someone favors increasing or maintaining caused-harms for some consumer choices, like punitive taxes and campaigns of personal stigmatization of smokers, then they are opposed to harm reduction, whatever their position on product substitution. Put another way, if their position is that smokers should be pushed to switch to vaping, rather than just offered the truth and the option, they are probably opposed to harm reduction.)
Obviously there is no bright line in this transition, but it just feels like the last year saw the trend become the dominant reality. Also obviously, the “officially” in the title is tongue-in-cheek. On the other hand, there really are not any other macro-level social scientists who have paid much attention to this space, so I suppose I am as official as it comes.
A survey of handful of this year’s events should serve to illustrate the point:
Consider the reactions to the recent anti-ecig junk report published by the U.S. Surgeon General’s office (really the work of the CDC). I cannot recall seeing any rebuttal to it that did not lean heavily on the contrary opinion offered in the Public Health England report on e-cigarettes (sometimes along with the similar Royal College of Physicians report). But who wrote those reports? All were written by tobacco controllers. The political goals each was trying to advance were obviously in some(!) conflict, but they were still all written by political actors of the tobacco control variety.
An underlying irony here is that the reason anyone would take seriously the PHE report is exactly a reason to take seriously the SG report: It was an official government publication written by government appointees. In reality, such reports almost always fall somewhere in the range from “out-and-out political fiction” to “mediocre student-level reviews of the science”. There are almost always better reviews of the science available. There are almost always patent errors in the reports.
Most important, they are always written in support of some predetermined political conclusion. This is true for most government reports, and always true for topics like tobacco. The authors are constrained in what they can write and are chosen because they have already demonstrated they support the position the agency wants to take. These are not papers by disinterested independent experts on reviewing scientific evidence. So the tobacco policy people at PHE chose to endorse generally positive and mostly scientifically defensible statements about e-cigarettes, and commissioned that report. But they could just as easily have chosen (and sometime in the future might still choose) to endorse nonsense, as they recently did about alcohol, as chronicled by Snowdon. [Update: It occurs to me that the subtext to that is perhaps too subtle: Ask yourself why they made those choices? Perhaps because they consider one of those products to be theirs and the other to be the enemy’s.] All such reports get treated as authoritative in spite of being of quite poor quality on average because most people, despite all protests to the contrary, slavishly believe whatever governments say.
(Aside: I really wanted to write a post on the ironies of many of the criticisms of the SG report. There were oh so many cases of someone complaining about flaws they are notoriously guilty of themselves. But no time. At least I was able to mention this, the most important example.)
Anyway, the point is that the battle for perceptions about e-cigarettes has become largely about official reports, making it is mostly a duel between tobacco controllers. There are no harm reductionists or consumer advocates in positions of influence in government health agencies or big non-governmental health organizations. On tobacco issues, these operations have been completely captured by tobacco controllers. The UK is no exception to that; the difference is merely that the capturing tobacco controllers have plans for controlling e-cigarettes do not include obliteration (yet).
Continuing this theme, discussions of great moments in e-cigarette history are increasingly dominated by news of some government unit, usually in the UK, taking some favorable action. Ultimately these are the actions of tobacco controllers who want to adopt e-cigarettes as anti-smoking tools, but are not really o.k. about people using e-cigarettes, if you see what I mean. This is made more stark by the fact that these same actors seldom accord smokeless tobacco the same consideration, and I am betting most will not accord it to HnB products despite them being the same as e-cigarettes for all practical purposes. (Next year should see more unintentional comedy from those who try to defend their “ecigs are a public health tool, but HnB is an evil plot by Big Tobacco” position. Stay tuned.)
Meanwhile, many of those very same tobacco controllers in positions of power have taken vile anti-smoker and anti-vaper — definitely anti-harm-reduction — actions. Clark and Puddlecote, among others, documented many of these over the course of the year. Those leading the cheers about the favorable actions do not seem bothered by this, further suggesting dominance of the tobacco controller mindset in the pro-ecig space.
Then there was the campaign to get the UN’s FCTC to go easy on e-cigarettes, one of this year’s biggest pushes by e-cigarette advocates. This is an effort that only a tobacco controller (or perhaps Neville Chamberlain) could love. The FCTC are the scum de la scum of the tobacco control world. Treating them as responsible actors and implicitly granting them further authority and influence, rather than trying to condemn their many harmful actions, is an effort only a tobacco controller who wanted to return to their embrace could love. (To continue the analogy from the previous parenthetical: a Sudeten resident who wanted to be annexed back into the empire.)
At a more grassroots level there is the tendency illustrated by the “A Billion Lives” movie. The movie itself turned out to be a non-event but is worth mentioning because it got so much positive chatter from advocates. Much of the content of the movie, including the title, was straight out of tobacco control propaganda, including about half of the points I identified as impossible things tobacco controllers believe. It is my impression that the author lacked the expertise for this to have been a deliberate choice. Rather, it was an example of how effectively tobacco controllers have come to dominate the thinking of the current generation of e-cigarette advocates, even those who do not see themselves as tobacco control supporters. (The implications and irony of this were discussed extensively on several posts on Clark’s blog, though nowhere else I am aware of.)
And then there are those weekly “game-changing” statements about e-cigarettes that I mentioned. A large and increasing portion of them are the words of tobacco controllers. Those that are not still often ape the tobacco control approach. Also, a large portion of them are actually absolute dreck, despite the paeans, but that is another story. I have been documenting, for longer than this year, the descent of e-cigarette advocacy toward the quality of analysis of tobacco controllers: rife with junk science claims and undefended (and often indefensible) normative premises. Frankly, given various other observations in this post, I cannot say I think that really matters much practically. This space seems to have entered a “post-truth” phase. But whether or not it matters, it does make clear the increasing dominance of tobacco controllers.
This tendency toward capture should not surprise anyone who understands political science. Despite the overzealously celebrated passing attention from a handful of people with generic power (think: legislators or celebrity-level opinion leaders), it is concerted focus that ultimately influences the politics and mindspace. Tobacco controllers think about this every day and have secured tax funding that lets them work on it every day too. They have the natural advantage. Of course, it is still kind of sad that almost everyone else with a voice in the matter seems intent on amplifying their advantage rather than pushing back against it.
There are, of course, still the other major players who also think about this every day and get paid to work on it: industry. Several influential pro-ecig advocates who do not sound like tobacco controllers work for industry or are funded by them. Manufacturers are not always consumers’ best friends, to say the least, but they are reliable friends. Because they have clear concrete goals, their actions do not blow with the political winds, so at least we can usually predict what they will do that is bad for consumers. And, of course, industry is made up of human beings, and most human beings are decent people and thus favor harm reduction and increasing consumer welfare (in contrast with authoritarian, puritanical “public health” types). So that is all good.
Industry has always been the most important, if rather inconsistent, supporter of harm reduction. The individuals and organizations who advocate for consumers (i.e., really support harm reduction) who have managed to persist in this sector have depended on industry funding (I can think of only a single exception). But at the boardroom level, the big players in industry are just fine with the machinations “public health”. Tobacco controllers — not being particularly smart or wise about how the world works[*] — live in a fantasy where they think “Big Tobacco” considers them a mortal enemy.
[*Don’t worry. No one who would be insulted by that is going to read that and the similar observations here. I should add that they are also not very well read.]
But capitalism is not some state of nature; it consists of some people making rules and some people playing by them (sometimes the same people — see above references to crony capitalism). Those who thrive in the game, like the major tobacco companies, are not inclined to complain about the rules they have adapted to. Compare professional athletes: They did not make up the rules of their game, and they may push for particular little tweaks to them occasionally, but they certainly would not want to see a major change that might undermine their primacy. The reality is that big industry works hand-in-glove with big tobacco control. They need each other, but neither one of them really needs consumers to be happy. Thus the consistent presence of industry in the space is not really a counterweight to the machinations of institutionalized public health.
Still, as I said, industry is mostly a friend of consumers and harm reduction. What is sad is how much 2016 has come back around to looking like 2006, in terms of the players. It seemed, for a while, that things might change.
The main difference seems to be that in 2006, the handful of card-carrying public health people who supported low-risk tobacco products were mostly genuine harm reductionists who cared about consumer welfare. We were never a part of the core political system of “public health”, of course, and as a result of what we experienced, I suspect few if any of us would still self-identify as being part of the Public Health Industry. The public health dissidents in 2016, however, are generally politically-committed apparatchiks who are not actually bothered by what is fundamentally wrong with “public health”, notably including both the junk science and that the field does not actually care about what people want. This suggests that when push comes to shove, they are much more likely to fall back into line with the FCTC types rather than becoming real dissidents. I can identify only a couple such individuals who I think will refuse to go quietly when the wind shifts. Such is the way of political actors, as opposed to those motivated by humanitarianism or doing good science.
But that is a retrospective for another year’s end. Remind me to say “I told you so” — I always forget to do that.