Tobacco harm reduction, anti-THR lies, and related topics

Tobacco control’s violations of human subjects ethics, and other implications of the RSPH “sting” of ecig vendors

by Carl V Phillips

So apparently there is a UK organization known as the Royal Society of Public Health which presumably had some importance back when the East India Company was not just a retail brand. And apparently they did some secret shopper research of vape stores for purposes of generating publicity for themselves (like a retail brand would). The main payload was the breathless observation that half the shops did not interrogate the customer about their smoking status before selling e-cigarette products to them, and that most of the rest did not refuse to sell upon learning the faux-customer was playing the role of a nonsmoker. The RSPH then portrayed this as a violation of a largely-nonexistent “code of conduct” and managed to get this non-story all over the press in the UK.

I write that so dismissively — about the organization and the research — for a reason. This was much ado about nothing (as Paul Barnes entitled his post about it, which you can read for more of the basic details; see also Clive Bates’s post in which he dismisses it as a “cheap publicity stunt”). But despite this just being a blast of silly throwaway junk — what we observers of the public health industry simply call “Friday” — blogs and Twitter just lit up about it.

Part of the heightened reaction, as compared to all the other bullshit press releases, can be explained by the strange British obsession with anything containing the word “Royal”. Partially it is because the core failure — the notion that legal retailers of a consumer good should be policing their adult customers to see if they were “the right kind of people” — is something everyone can spot the flaws in; it is not some arcane matter of sample selection bias or confounding. So, for example, we can observe that no retailer ever checks to make sure an adult customer is a smoker before selling her cigarettes. This also makes it particularly easy and fun to satirize. (Incidentally, if a retailer in the USA discriminated in the way RSPH demands, refusing to sell to a potential customer because of his nonsmoker status, there is a good chance it could be successfully sued.)

But I also think the widespread reaction to this silliness, even among those who recognized it was just a publicity stunt, reflects a gut-level feeling that there is something more nefarious here than the surface level reaction implies. Since I try to point out the forest that is hidden among the trees (or should I use the royal “amongst” today), I will point out three deeper issues here. As I often do, I am trying to make a case that just responding to attacks like this at the level of their specific merits, even when the response is that they have no merits at all, is a fail. It is a terrible strategy to treat research like this as if it were fundamentally legitimate but merely flawed, as if it exists in isolation, and as if it were the work of decent ethical people who merely erred. That remains true no matter how effectively you eviscerate it on the surface.

The first forest-level observation was covered very nicely by Dick Puddlecote, so I will mostly direct you to his post, which is summed up in its title, “Today’s Lesson In Who Not To Trust“. It seems that RSPH is among those tobacco controllers who the dominant faction of UK e-cigarette advocates thought were their friends. The tale that DP offers about that is akin to my cautionary tale of tobacco control coming to own the vaping mindspace.

There might be a rare instance where common cause can be found with an entity whose raison d’etre is to destroy exactly what you are fighting for, but it takes strategic genius to recognize it and tactical acumen to play it right. In the real world, any appeasement or compromise with tobacco control is just a gift to them. For example, that “code of conduct” bit refers to a clause in the voluntary rules for members of one vape industry association. That document does indeed say that member retailers should only sell to smokers or former smokers, and by implication that they should demand personal information from their adult customers in order to make that decision. You can read more details about that in any of the above-linked posts — e.g., that only a tiny minority of the study subjects, if that, were even members of this organization.

The big-picture issue is that this rule is purely an attempt to appease tobacco controllers; there is obviously no legitimate reason to deny one’s low-risk product to the rare nonsmoker adults who want to try it, and no competitive advantage to be gained by agreeing to do so (this is the type of “rule” that can sometimes be to help cement a cartel, but it was not going to have any such effect in this case). And look where appeasement gets you: The “public health” types use the “compromise” — which they offered nothing in exchange for — as a bludgeon to demonstrate the legitimacy of their absurd demand, and as a launching point for demanding even more. In this case they implied that every retailer agrees to abide by this stupid rule, and then further stretched it into demanding that e-cigarettes be sold only as proper smoking cessation therapy. Well done, guys.

As I have repeatedly pointed out, if you want to preserve the right to use e-cigarettes or any other tobacco products (or for that matter to eat snack food, etc.), the “public health” menace must be resisted everywhere, all the time. Their strategy — and it works brilliantly — is to impose any limitation they can whenever they can, and take any concession offered, and then lock in that progress as the new battlefront and never slow their push forward. They portray the most extreme policies found anywhere as the minimum standard that everyone else is remiss for not meeting. They can be confident their progress will ratchet because there are basically immune from counterattacks: Consumers are fully focused on fighting the next holding action (even as they are losing ground somewhere else) and have limited resources in any case. Industry adjusts to the new regime, optimizing their practices to profit under the rules, and so has little interest in changing the status quo, even in a direction that could benefit them in the long run. Even efforts like FOREST’s strongly-supported campaign to roll back the ban on smoking rooms in pubs make little headway; most of the businesses that lost a lot as a result of the ban are already gone, and those that survived have already adjusted.

Moving on, the second deep issue afoot here is the patently unethical nature of this research. Tobacco control research is so replete with unethical behavior — misrepresenting study results, torturing the data, etc. — that it is easy to stop noticing just how truly evil it really is. As in, “You say the POTUS broadcast four more blatant lies today? *shrug* What else is new?” But in this case, it is a violation of human subjects research ethics, where there actually are binding codes of conduct in terms of national laws and international treaties.

The political behavior of “public health” is so unethical that it is easy to overlook what might seem like a minor technicality. But we should not let this pass. RSPH makes clear that they considered this as formal systematic research, not just a quick little “Channel 4 On Your Side” hidden camera investigation of a local news story. It was conducted on human subjects without their consent and with an element of deception. These observations alone are enough to demand that it be subject to serious outside ethical review, which it pretty clearly was not. That review would need to conclude that the knowledge being generated justified these dubious actions, which it clearly does not. But most importantly, the research was conducted with the intent to harm the subjects who were being studied. It is not like this “violating a code of conduct” attack was an afterthought, let alone the general goal of using the results to demand rules that harm the subjects. Even without the intent, the near-inevitability of resulting harm to the subjects makes this per se unethical research, a blatant violation of all accepted rules of human subjects research. The intent makes it worse still.

Perhaps some observers were distracted by the fact that this looks like a legitimate secret shopper sting operations where underage shoppers try to buy tobacco products. But whatever you might think of those operations, they are primarily police actions (even if statistics are later reported), designed to catch and punish people who are violating the law. They intend to harm the people being investigated because that is what police do. But social science researchers are not allowed to do that, even if what they are researching is a crime or similar bad act (which in this case it is obviously not).

To put this in perspective, consider a scale of human subjects violations:

  1. No problems at all.
  2. Mere technical violation of the rules with no risk of harm to subjects (e.g., a voluntary survey of non-sensitive information from fully-informed anonymous adults, conducted without ethics review)
  3. Accidentally and harmlessly collecting more information than you claim to be collecting (e.g., discovering you have inadvertently collected identifying information in the study in 2. and then deleting it.
  4. Secretly entering a special space where people think they are free of prying eyes and observing them as part of a project that is ultimately intended to harm them, even if the research itself is not harmful (e.g., spying on services at a mosque or the FDA-funded vape convention research conducted by Virginia Commonwealth that I documented here)
  5. Giving subjects misleading and harmful health advice and never briefing them that it was false, plus promising them compensation and then refusing to provide it, admonishing the subjects for even asking for it (the disturbing combination of ethical violations committed by the NIH- and FDA-funded researchers and Glantz satellites, Popova and Ling, that I documented here and here, and in this guest post by Brian Carter)
  6. Tuskegee (i.e., intentionally harming subjects as part of the research, secretly and without their consent)
  7. Mengele (i.e., carrying out obviously harmful research on involuntary captive subjects)

I include the examples in 2 and 3 as a confession that I have done that. No one is perfect (though there is a serious campaign afoot to eliminate the pointless rules that make the harmless social science research in 2 a technical violation). I left gaps because I am not one of those silly people who thinks it is possible to completely order complicated multi-factored lists; this is meant to be rough. In the 3,4,5 range is lots of somewhat ugly but sometimes ethically-defensible research that involves some harm to subjects who grant informed consent (e.g., medical RCTs give half the patients a therapy that we believe is inferior), or some deception (e.g., most psych lab research) or involuntariness (e.g., use of data collected for other purposes). By the time you get to 6, you are definitely in the realm of researchers who think “petty rules do not apply to great minds like me!” or at least the similar “my work is so important to the world I will not let procedural rules get in my way.” By 7 or 8 you have layered onto that a belief that you are sufficiently superior that you get to unilaterally decide what is right and wrong to do to people. At 9 and 10 you have reached the point where harming the subjects matters not at all to the researcher, and indeed is probably considered a feature rather than a bug — the backwater black people in 9 and Jews in 10 were “those people”, after all.

In the present case, the those people are e-cigarette merchants or vapers, who are similarly despised by tobacco controllers who do research on them. The RSPH research is in the 9 range, maybe a bit below Tuskegee but not much. Obviously I am not suggesting the consequences of what RSPH or Popova-Ling did to their subjects are of similar magnitude to letting them die of syphilis. This is not a consequentialist scale, but rather is about rules of conduct that govern whether any nontrival harm to subjects, deception, involuntariness, bad intent, etc. are allowed. There is a consequentialist overlay, as I suggested about the 3,4,5 range: Sometimes the potential benefits of the research justify some dubiousness regarding these considerations, as with a potentially informative medical experiment. However, basically nothing in the 8,9,10 range could ever pass that test, short of research to defend against an extinction-level threat. But the thing is that, like Tuskegee, the RSPH research, along with the Virginia and Popova-Ling studies, had zero potential to produce any useful scientific information. Thus no imposition on subjects could be justified, even down in the 2 or 3 range. At least Mengele’s work actually produced scientific knowledge (which created a whole other set of ethical questions: because the work itself was so evil, should scientists have just pretended they did not have the fruit of the poison tree?).

I cannot overstate this: The RSPH and similar research is horrifying, in terms of its disregard for the rules of human subjects ethics. This, in turn, says something about the commentators who ignore that. I am not talking about the average consumer who makes valid criticisms of the specific junk claims. But everyone who fancies himself a researcher, professor, or expert on research should scream about this. The fact that they — including a lot of supposed friends of vaping — do not is an equally horrifying commentary on the ethics of public health more generally. People in that field exhibit none of the sense of care-demanding responsibility a researcher or teacher should feel toward his subjects or students, and none of the humility required to be a genuine scientist. It seems that they are blind to just how outlandish this flouting of ethics is because they are personally not so far removed from the behavior of RSPH or Glantz et co.

This brings us to the third big-picture issue, which I will discuss only briefly because I am in the process of writing something more comprehensive about it: The RSPH attack research is a perfect example of the tendency toward fascism in public health. There were quite a few amusing tweets about RSPH’s demand to restrict e-cigarettes to smokers, along the lines of suggesting that grocers should demand to know that someone already drinks sugary soda before allowing them to buy diet soda. One that I did not see was the suggestion that workers be allowed to take the weekend off, or take a vacation, only if they can demonstrate that they are too tired or burned out to just keep working. Resting up for next week is, after all, the reason we have weekends, right? This analogy gets to the fascist essence of the mindset of tobacco control and more generally “public health”: Force should be used to prevent people from engaging in consumption that merely makes them happy; consumption should be limited to those for whom it improves their productivity (including bettering their health).

This mindset — that everyone owes all their possible time and energy to The State / The People / the proper worship of God / Her Royal(!) Highness’s Feudal Lords — is the essence of fascism/communism, or even out-and-out feudalism. It is also the only possible justification for denying people an e-cigarette or a soda, or for that matter cigarettes or an in-control heroin habit. Oh, they try to gin up claims that these cost other people money, but those are so obviously wrong that they cannot actually believe them. No, the only possible cost to society is analogous to people taking Saturday off — i.e., not using all their available energy to produce for The State et al. This is about not letting the serfs damage the tools, which happen to be their own bodies. Anyone with the slightest inclination toward individual freedom believes people have sovereignty over their own bodies. The “public health” special interest group, along with religious extremists and latter-day feudalists, do not.

To tie this back, consider again the unforced error in that “code of conduct”. Denying custom to nonsmokers is not merely the tactical error of conceding anything to tobacco controllers, such as agreeing to some restriction on advertising. It actually concedes that their worldview about people’s (lack of) rights to control their own bodies has merit.

Responding to each bit of public health junk science on its technical merits, implicitly conceding the problem is not their fundamental lack of ethics or vile view of humanity, is like criticizing U.S. military attacks only for their tactical errors, implicitly conceding that unauthorized killing of civilians we are not at war with is just fine so long as it is technically well executed.