by Carl V Phillips
In response to a couple of recent requests and my schooling of FDA in a recent Twitter thread, it seems time for me to again write a primer on the meaning of tobacco harm reduction (THR). Rather than return to a previous version I have written, I am doing this from scratch. This seems best given the evolution of my thinking and changing circumstances.
The key phrase, of course, is “harm reduction”, with “tobacco” denoting the particular area it is applied to. This is important: THR is not a concept that stands apart from HR. It means “the principles of harm reduction, applied to the use of tobacco and nicotine products, and other products that tend to get lumped in with them” (see my previous post for an explanation of that last bit and some other useful background about the current politics). Indeed, when my university research and education group was trying to decide on a name and URL in 2005, it was far from obvious that this was the right term, and we considered others (e.g., “nicotine harm reduction”). While the first prominent use of “THR” appeared in 2001, it was far from established as a common term. (There is probably some endogeneity here, of course — if we had chosen a different term, that might have ascended instead.) In any case, the key to answering “what is THR” is asking “what is HR” rather than thinking it is something different.
[Note: what follows includes a more organized and streamlined version of material that appeared in this more animated post, as well as this one.]
Harm reduction refers to trying to help people who choose to engage in a potentially harmful behavior improve their welfare. As with most terms that are constructed from multiple words, those words point you in the direction of the meaning but are not sufficient (a hammer is not a screwdriver, even though you can drive a screw in with it). This has created some confusion, though most often the “confusion” is not honest mistakes, but intentionally engineered (only an intentionally obnoxious child responds to a request for a screwdriver with a hammer and the above observation). Most important, anyone who reads the word “harm” like a “public health” person, to mean only disease risk, rather than seeing its broader meaning like an economist or, frankly, any normal person, is not understanding the concept (so please read on).
Harm reduction does not refer to just any policy or practice that reduces harm like, say, pollution standards or consumer protection laws. It is specific to behaviors that people choose to engage in. (I trust you know that I understand there are factors largely beyond people’s control can cause them to engage in risky behaviors. The point is that — unlike with an actual disease or environmental threat — people could, at least theoretically, choose to stop engaging in the behavior as an act of volition.) Moreover, the term tends to be reserved for risky behaviors where there is strong advocacy for abstinence as the “proper” “solution”. There is no bright line there, but we tend to speak of drug use harm reduction or sexual behavior harm reduction, but not transport or sport harm reduction. Indeed it should be clear from what follows that what we practice in transport (e.g., auto safety) is exactly what harm reduction principles call for. Indeed, the phrase “harm reduction” is basically reserved for behaviors where there is not already general agreement that harm reduction is the right approach.
In the 2000s, a cabal that was apparently led by Mitch Zeller tried to hijack the term “tobacco harm reduction” to basically refer to abstinence and prohibition (“hey, what reduces harm better than abstinence!”). That proved to be a nonstarter. Now Zeller’s FDA division is again trying to hijack the term: They are attempting to claim that they support harm reduction merely because their rhetoric does not exhibit the most extreme possible hostility toward the use of low-risk tobacco products as an alternative to smoking, even as they pursue backdoor prohibition. Despite being as much of a perversion of the ethic of harm reduction as the first attempt, this has gained more traction because THR has become widely misused to merely refer to anything having to do with low-risk products. But as Clive Bates put it when amplifying my Twitter thread, “harm reduction is not a product set”. It is an ethic of humanitarianism and human rights. Indeed, it is just a special case of the most widely-accepted health ethics.
The three key elements of a harm reduction approach, in order of litmus test status, are:
- Reduction (ideally elimination) of caused-harms. These are generally harms caused by government directly (e.g. imprisonment, punitive taxes) or indirectly (e.g., criminalization preventing sex workers from seeking police protection when they are abused). However, sometimes they are caused by other social forces or institutions (e.g., gay men who engage in risky sex not seeking medical care because of stigma).
- Empowerment of the individuals who choose to engage in, or want to stop engaging in, the behavior.
- Offering (developing, providing, encouraging, decriminalizing, destigmatizing) technical tools for reducing the harm from the behavior, or lower-risk versions of the behavior that are sufficiently attractive to the consumers.
The order is important. Most of what gets talked about under the rubric “tobacco harm reduction” falls under point 3. But when it is done without embracing point 2, this does not represent support for harm reduction. It is merely medicalized social engineering, trying to impose a “fix” on people as if they were malfunctioning equipment.
But it is important to step further back and start with point 1. Anyone who supports inflicting harm upon tobacco (etc.) users, including specifically upon smokers, does not support harm reduction. In most wealthy jurisdictions (i.e., where approximately all of my readers live and deal with public policy) the caused-harms inflicted on smokers are greater than the harms from smoking itself (and more so for low-risk products). Converting among different types of harms is necessarily a little fuzzy, of course, but there is a good case to be made that decades of paying high punitive taxes inflicts more harm on the average smoker’s lifecycle well-being than dying a few years early. Then there is the loss of social options and the stigmatization, both of which are engineered.
Naturally, it is possible to make a case that certain limitations on behavior are justified to reduce externalities, such as by forbidding smoking and even vaping in particular places. This includes some ostensibly private places that function as public places (it should really be common knowledge, since the time of Coase, that free markets are often terrible at dealing with externalities like this). But intentionally preventing people from setting aside any social “safe space” where they can gather and smoke (or whatever) is clearly intended to cause harm to smokers. Tobacco controllers admit as much.
Similarly, it is possible to make an argument that high taxes serve the arguably legitimate purpose of discouraging use by hapless children, even though the harm inflicted on the inframarginal user (i.e., those who choose to use the product in spite of the elevated cost) is unfortunate. (Please spare me the claim that the health impacts of smoking impose net costs on the rest of society and smokers need to pay for that; the opposite is true, overwhelmingly.) But the argument that “the costs are unfortunate, but the benefits are positive on net” is, of course, is never made. The supposed benefits on one side are not quantified and balanced against the obvious harm on the other. Rather, the harm inflicted on the inframarginal users is intentional and celebrated. Indeed, it seems to be the primary goal; it is supposed to “help” them to quit. Inflicting harm on people “for their own good” is antithetical to harm reduction, as well as most enlightened codes of ethics more generally.
And then there are even more radical ideas for causing harm, like the FDA’s proposal to reduce the quality of cigarettes by reducing the nicotine content. There are, of course, many ways to intentionally reduce the quality of a product, ranging from making it uglier (e.g., disease porn on the packaging) to making it toxic (e.g., poisoning alcohol during Prohibition; doing nothing to stop deadly adulteration of street drugs and preventing pill testing services). Like any of these, FDA’s effort, which motivated me to rant at them about their bullshit claims of supporting harm reduction, is antithetical to harm reduction. Their current signature policy consists of intentionally harming product users.
This really is a litmus test. The “moderate” tobacco controllers who are positive about point 3 and low-risk alternatives to smoking (or, more often, their one pet low-risk alternative to smoking), but who think this pairs nicely with continuing to punish smokers, are not supporters of harm reduction. They still advocate causing harm. At best they can be credited with wanting to empower tobacco product users to have low-risk alternatives, though even this is not true for many of them. A few even support freedom to choose to use those products, though most favor restricting use of the low-risk products to “curing” smoking to the extent possible.
Perhaps that most important thing to realize is that point 2 is basically an application of the primary rule of health ethics: Individuals have a right to informed autonomy over their own bodies. Like all overarching principles, this is not perfectly precise. In particular, there is the question of how much and what type of communication is sufficient to inform people. But obviously disinforming them (e.g., the common practice of exaggerating the harms from all the products in question) violates the fundamental ethical rules and disempowers people.
(Some might also be inclined to argue that point 1 is just a special case of what is often mistakenly believed to be a primary rule of health ethics, “do no harm.” But since simple economics tells us this is not really a meaningful rule — and really was coined as a nice way of saying “stop doing random things to people when you have no clue about whether it hurts them or helps them” — I would not choose to do so. Rather, I would go with the more general point that intentionally inflicting harm is a decent definition of evil. A better encompassing “special case” observation is that this is all just a just a special case of the benefits of idealized free markets (not to be confused with the political rhetoric about “free markets”); I basically approached it from that angle in this paper.)
For some areas of harm reduction, empowerment is an operational and ethical challenge. How, for example, do you empower a person who uses drugs and has become dysfunctional or has given up on herself? At some point, even the strongest harm reduction supporter will see paternalism as the only answer. Real empowerment and freedom often requires affirmative provision of resources (e.g., syringe exchange facilities), especially when caused-harms remain great (e.g., buying a clean syringe is criminalized).
But this is moot in the case of tobacco because tobacco use does not make people dysfunctional nor — despite the best efforts of tobacco control — does it remove people from mainstream society or force them into the criminal economy. So it really is quite simple. For tobacco harm reduction, point 2 is exactly the same as that preeminent health ethics rule. People need only be given informed autonomy. Tobacco harm reduction means helping smokers understand about low-risk alternatives and making sure they have the opportunity to switch to them if they want. But it also means letting them choose to keep doing what they are doing if that is what they want. Ideally the latter would also include reducing the harm from the behavior (e.g., technical tweaks that make cigarettes produce less carbon monoxide; improving early diagnosis of lung cancer). Needless to say, no matter how much it is dressed up in Orwellian rhetoric about making the product less risky, taking the nicotine out of cigarettes is antithetical to this.
It is worth noticing that the quintessential example of harm reduction, syringe exchanges, is an example of letting people continue the same behavior, using their drug of choice in a particular way, while making it less risky. Low-risk tobacco products are more analogous to offering methadone, an alternative consumption choice that some consumers will find to be a better alternative, all things considered. Moreover, switching to methadone is often inflicted upon people involuntarily, an example of using a reduced-harm alternative in a manner incompatible with the harm reduction ethic.
As for point 3, there is really not much to say. Even though it all that some people mean when they refer to tobacco harm reduction, it is the most trivial aspect of it. A low-risk alternative to cigarettes existed for centuries before cigarettes became popular. Extracted nicotine products — whether oral or inhaled — are a trivial technology. Dozens, if not hundreds, of potential entrepreneurs independently redeveloped or rediscovered the technology for e-cigarettes over the course of many decades. The story of them finally becoming established is a fascinating story of sociology and commerce, to be sure (it turns out the trick was setting up shop in a regulation-free jurisdiction and simply ignoring legalities). But that is ultimately a story of how THR had failed, or more precisely that active opposition to it had succeeded.
If inhaling smoke had stopped being the only “normal way” to consume tobacco in the 1970s (as happened in Sweden), when the harms from smoking had become generally understood, there might be little demand for an alternative inhalation system. This observation applies even more so to the new heat-not-burn products that are poised to overtake e-cigarettes in popularity. Sort-of-smoking is the most promising alternative because smoking never stopped being the “normal way”. Or, going down a different thread of alternative history, e-cigarettes could have been produced, and allowed and encouraged, three and perhaps even four decades ago.
But those who worked on anti-smoking efforts ignored these options at first, letting their vision of the perfect (“everyone is going to realize they should just quit any day now”) become the enemy of the good. But that “perfect … enemy … good” story ceased to describe what was happening three decades ago, and was grossly inaccurate by two decades ago. Even as it became obvious that “everyone will quit any day now” was fantasy, the response to THR ceased to be “nah, we don’t need that” and became brutal suppression of the idea and those who supported it. Those who still suggest that tobacco controllers’ anti-THR efforts are motivated by a childlike quest for the perfect are the ones who are naive.
What actually happened is that anti-smoking advocacy morphed into a typical drug war. Harm reduction is anathema to drug warriors, who are all about creating more caused-harm and disempowering people. They are tribalist hawks who see sworn enemies who must be beaten. To tribalist hawks, beneficial compromise, showing respect for the differences among people, and granting others self-determination makes you a cuck. It is worse than losing the war.
One of the great ironies of the war on tobacco harm reduction is that the people fighting it tend to come from political factions and social strata that despise other (largely identical) wars on drugs. They despise hawkish tribalist foreign policy. They despise the sort of people who would use the word “cuck” non-ironically. And yet they are everything they despise. I suppose it is an example of atavistic tribalism being all too common a human trait; those inclined toward it will find a way to act on it, even if they are acculturated to despise its more traditional manifestations.
There was a point to this digression: A lot of the confusion that makes it easy to dismiss or hijack the real meaning of harm reduction — the misuse of “tobacco harm reduction” to merely refer to low-risk alternatives — has been caused by the tactics of those of us who fought for THR. It is the common dilemma of making bad arguments to try to convince bad people to do good things.
When fighting for, say, free school breakfasts and lunches, the good argument is that it is evil that a rich society would let little kids go through the day hungry rather than spend the trivial sum it takes to stop that. But everyone who is persuaded by that obvious point is already on the same side. So instead the political rhetoric focuses on how feeding kids improves test scores and lets people grow up to produce more. Or when fighting against deporting DACA kids, the good argument is that ripping law-abiding people, guilty of nothing, from the only home they have ever known, to send them to a country they do not even remember, is a cruel violation of human rights. But to try to convince people who inexplicably do not get that, we say “they pay lots of taxes, are more productive than natives on average, and cannot even collect most government entitlements if they want to.”
Similarly, we could focus on the self-evident truth that people should be able to put whatever they want into their own bodies — the harmful stuff, the not so harmful stuff, or nothing. They have a right to do that, they should not be punished for it, and we should make sure they know which stuff is which. As an added bonus, we can work on making the all the stuff safer, though this remains tertiary. But instead we craft arguments intended to persuade the ethically and morally challenged people who deny that:
We don’t want injection drug users spreading HIV and hepatitis in the community, so we should encourage syringe exchanges. (subtext: I know you really don’t care if people who inject drugs get sick and die, but maybe you will act to protect “decent” people.)
If people think that low-risk tobacco products actually pose high risk, consumers will switch from them to smoking and dramatically increase their risk. (subtext: I know you do not hesitate to blatantly lie to people to manipulate their behavior and further your social engineering agenda, but perhaps you really do care enough about health outcomes to see this as an unfortunate effect of particular lies.)
We can’t stop people from being non-monogamous, so we should push them to at least use condoms. (subtext: I realize you want to impose 17th century puritanical rules on everyone because you can’t stand the thought that your daughter has sex, but maybe your thoughts will drift somewhere near reality if I point out the disease risk.)
Since we are not achieving the goal tobacco abstinence, isn’t it better if people are encouraged to switch to something less harmful? (subtext: Even though I know you probably do not really care about people’s health, I am going to pretend that your goals are what you say they are and try to persuade you to adhere to them.)
Every time we indulge these facile and deprecating arguments — “yeah, gee, it sure would be great if everybody just did the right thing, but for some reason they don’t, so maybe was should at least….” — we concede there is some ethical validity to the prohibitionists’ vision of what everyone should be doing. Moreover, every time we refer to one of these arguments as “the harm reduction approach”, it implies that harm reduction is merely an unfortunate choice, a necessary evil that must be pursued only because prohibition is not working.
This has sometimes been an effective, albeit distasteful, tactic in some areas. However, it turns out that tobacco is not one of them. Other drug wars involve not just extremists and those they hate — the consumers and anyone who stands up for them — but pragmatic and persuadable “moderate” politicians and opinion leaders who are seriously interested. The tobacco wars do not. There are only the extremists, the consumers and those who stand up for them, and people who do not really care. The attempts at appeasement have had no effect on the anti-tobacco extremists, who are as anti-THR as ever. A few tobacco controllers claim to be pro-THR but (per they above) they are not, and moreover most remain authoritarian extremists, just with a slightly different set of authoritarian rules. The number of “moderate” opinion leaders who have bought into the appeasement rhetoric and who are not true believers in harm reduction (i.e., human rights) — the target audience of that rhetoric — is so small you can basically name them all.
What the attempts at appeasement have done is dilute the concept of tobacco harm reduction to the point that the phrase is probably used inaccurately more often than accurately. They have allowed it to be hijacked by anti-THR activists. They have created a divide, wherein many smokers’ rights advocates are hostile to the concept of harm reduction because they mistakenly think it is hostile to them. The more sophisticated among them understand what THR really is, of course. But probably a majority of them who have heard the term (along with most vaping advocates who have heard the term) have such a perverted notion of what it means that they consider it yet another antagonist.
A harm reduction approach embodies basic human rights, concern for people’s welfare, an enlightened view of individual freedom and dignity, and an effort to resist egocentrism and appreciate others’ perspective and preferences. Oh, and it also involves some tools and behavior changes that can lower risk. For tobacco controllers, the first of the previous two sentences might as well have been written in Sanskrit, and so they misconstrue tobacco harm reduction as being about a product set. Clearly a few of their puppet masters do this knowingly, to try to undermine advocacy for human rights and consumer welfare. But given the moral blindness that characterizes drug warriors, it is safe to say that most of tobacco controllers would genuinely not understand the first sentence of this paragraph.
You’ve nailed it once again Carl. If you were head of the FDA (the tobacco portion thereof) we would all be better off and in more ways than one.
Thanks. Though you have to balance that against how much worse off I would be. :-)
I have a solution!
We’ll just have to clone you (or create similar, but varying versions of you to populate the board and its surrounding bureaucracies)!
There is an extensive literature on the creation of clones to do ugly tasks. It is not pleasant
(Damn, I am trying to think of the story where instant perfect replication chambers are sent by necessarily slow space travel to extra-solar planets to work on terraforming for future colonists. Once it is there, someone steps into the transmitter chamber on Earth and creates a clone of himself there who is basically on a suicide mission. Sure the original person is happily still himself, but the crux is that a person who thinks of himself as that person opens the door of the chamber to step out and 50% of the time he finds himself doomed to labor and die young on a distant planet. Anyone else recall that one?)
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Well thought out post. Sorry for my long reply but my story can really show how THR (specifically #3 saves lives).
It wasn’t until about 3 years ago when I quit smoking did I start to follow the politics of the anti-smoking movement, I smoked for 22 years, for 15 of those years I tried figuratively everything to quit. at first my doctor (a never smoker) recommended cold turkey, I tried it several times but it was literally torture the only way to really describe it is it was like I had a nail through my skull and when I’d get a craving it was like someone was slowly pulling out that nail for hours on end(it was at some points more painful than when I shattered my wrist).
After failing several times I went back to my doctor and discussed other options and he gave me a prescription for what is now known as Chantix I believe, it did work and I was smoke free for 1 week after a bit of dual use, however I was experiencing severe side effects of irritability and aggression, it got so bad my wife and family asked me to stop use and I went back to smoking.
Then came years of doing 2 to 3 serious quit attempts with NRT’s, Patch, Gum, Inhaler etc joining support groups every year, I wanted to quit smoking so bad but nothing was working, I tied up 1000’s of dollars and hours into it yet I still failed, after 15 years of trying to quit I gave up became depressed every time I had a smoke, my life down spiraled for a bit and I started drinking more alcohol and was smoking between 40-60 cigarettes a day (to put that into perspective that’s one smoke every 16-24 waking minutes).
That is until one day I found vapor products, a friend bought me a cheap device and it kind of worked, I went out and bought a better more expensive device and on that day about 3 years ago was the last day I had a cigarette and it was the first day of the rest of my life, within weeks I could breathe better, I became more productive and got a raise, in about a month I got my taste buds back and could taste my food again, I started eating healthier because I had more money (it costs me 40$ a month to vape 460$ a month to smoke), I spend more time with my family, I no longer need my cpap at night and so so much more than just that.
Some people will never understand this but THR, vaping gave me my life back, it freed me from the grips of big tobacco and continues to allow me to live free, I’ve helped dozens of others become free of tobacco as well all in my free time most of which eventually ended their use of nicotine (I do not work in the industry I’m just an ex smoker).
If I continued to smoke the way I was I probably would have been on Oxygen if not now it would have been soon based on my lung function before I quit.
Vaping did save my life, THR works gracefully, I wish I could scream it at the top of lungs especially now that I won’t keel over coughing to all those that don’t support THR.
It is good to hear that you succeeded and are happy with your choice. However, in keeping with the theme of this post, it is not entirely clear that you were affected by THR rather than merely a product set. Your story sounds like that of someone who credits a miraculous medicine with saving their health, with just a few different words. That is still good news, of course, but not necessarily THR. Perhaps your friend was an empowered and informed tobacco user, which would make this a story of THR’s success. But insofar as you were “cured” by this “medicine”, it is really only a story about the success of THR because e-cigarettes existed (and even that is, in itself, mostly not due to THR efforts).
Also I might caution that some of what you say strays rather close to the bashing of smoking, and by extension smokers, that Walt Cody notes in his comment here. I am not say you meant to imply this, but your words stray close to an attitude that vaping is clearly the only sensible way to consume tobacco!!! and every smoker should be pushed to switch. That would be an anti-THR attitude.
When you say “I tried and tried to quit smoking and nothing worked,” what you really mean is “I preferred smoking to not smoking.” That you you use this sort of phraseology is emblematic of the fact that you’ve allowed militant tobacco control lunatics to take over your mind.
You didn’t really “quit smoking,” you just found an alternate way of smoking that you found sufficiently enjoyable to switch to. The fact that you’ve radically reduced your disease risk is just a nice side benefit.
If your inclination right now is to angrily retort that “vaping is not smoking,” that is also emblematic of the fact that you’ve allowed militant tobacco control lunatics to take over your mind.
Thanks for that comment, Nate. It made me realize something that has been gnawing at me for years but I could not put my finger on: I have always found it deeply bothersome when vaping advocates push hard on “nicotine is not tobacco!!!” or even “vaping is not smoking” as you note. Obviously these are accurate at the simplest non-judgmental factual level, but that is not the intended meaning of the statements. Rather, they are inherently judgments of “what I am doing is fine, unlike what Those People do.” I have tended to respond to these objectionable statements at a surface level: it is perfectly natural to categorize e-cigarettes as a tobacco products, and in any case if lawmakers declare that then it is so for purposes of law; these statements are divisive, needlessly splitting what should be an alliance of consumers and thus playing into the prohibitionists’ hands; products that no one argues “is not tobacco!!!” about range from cigarettes to products that are far less risky than is commonly claimed about e-cigarettes, so it is absurd to imply “not tobacco” means somehow “better for you”.
But you have make clear the anti-THR nature of such messages. By effectively saying “I’m ok; ~they~ are not”, these statements condemn and implicitly endorse caused harm for users of other products. You are probably right that this is usually caused by militant antis having taken over the mindspace, and thus the thinking of such individuals. But whatever the reason, the implications are that this approach to defending e-cigarettes is inherently anti-THR. That is why it has been so readily embraced by the “moderate” tobacco controllers. It lets them embrace low-risk products (well, again, actually only one pet low-risk product usually) without having to concede any ground to human rights and health ethics.
As a smoker, I appreciate your enlightened and expanded definition of harm reduction to include an end to purposely and increasingly harming me (through bans and taxes and propaganda) because of my choice. Till now, I’ve only heard the more limited definition. But I’d add that smokers are also led to see THR as “antagonistic” (to use your term) by the public attitudes of converts to vaping who pile onto smokers in exactly the same terms as Tobacco Control does–evangelists who see themselves as suddenly Saved and smokers as rightly-persecuted sinners.
I agree that is a problem, but I actually think it is this same problem, not a different one. The subset of vapers who become anti-smoker only indict harm reduction if they (inaccurately) portray their attitude of criticizing smokers who choose not to switch as THR. If they are not committing that crime against the concept of harm reduction then they might be sending the (still unfortunate) message that vapers or vaping are antagonistic to smokers, but not that HR is.
THR means something entirely different when it comes to smoking. This deserves something well-thought-out, sadly I can’t do that right now.
The perceived harm anti-smokers claim to be protecting people against is smokers themselves. Remember – this whole thing got started because smokers are murderers. ETS kills! Third-hand smoke is even worse! – and we’re so addicted (whatever that means) to tobacco that we don’t care who else we kill as we merrily kill ourselves.
How much mercy do you show to killers? It’s okay to take away their (our) rights.
Am I reading this wrong? I think this is how anti-tobacco came to the conclusion that an all-out war against smokers is a moral thing – or at least presented it that way.
That they knew from the start it was all bollocks – well, that’s another story. One that fits both your and my definition of evil.
Can we have true THR when everything they’re doing is based on lies?
Yes, definitely. It is an opposing force to them, just like it is an opposing force to the other drug warriors who abuse users of other drugs.
If you are asking can tobacco controllers actually be THR supporters. Then, no.
Very good post, thanks. It provides a needed context to what we call “Tobacco Harm Reduction”. It also fills a conceptual vacuum in understanding its anchor in the Harm Reduction notion, and as a variant of the “drug wars”.
As you say, it is very important to understand that mere “substitution” to less risk products without the ethical side (considering also social aspects of harm and empowerment of users) is not really harm reduction but a softening of a prohibitionist approach (taking point 3 while dismissing 1 and 2).
While a reduced risk product like smokeless tobacco was dismissed by the medical establishments and by PH bureaucracies, a vocal minority of PH is currently willing to argue openly the “substitution product” case for the e-cigarette. Yes, this is hesitant and often contradictory, and it comes with all the attached strings that you mention (continuing the denormalisation of smokers, etc).
However, I would argue that in spite of all these limitations, it is still a positive development, which has the potential to evolve (at least in some of its proponents) into a future acceptance of points 1 and 2. To support this hypothesis I would mention that a shift in attitudes within PH cannot occur abruptly. The fact that part of PH is actively promoting e-cigs as a product substitution approach can be just the beginning of a process whose outcome is uncertain. So far it has produced a genuine rift in PH (of course, so far only within the product substitution parameters).
Still, the fact that researchers within the PH establishment are openly challenging the junk science and pronouncements of Glantz, Chapman and the like is definitely encouraging. It has the potential to open a Pandora box that could expose science frauds in other areas of tobacco and nicotine research. If Glantz (to mention a known example) is forced to concede that evidence favours PH researchers criticising his assurances on gateway effects, or his meta-analysis on the utility of e-cigs in smoking cessation, there is good likelihood that PH research criticising his Helena miracle fraud could become more newsworthy. This could open a cascade of criticism that could go into a direction not desired nor controlled by its proponents. Of course, this could also backfire and fail precisely because this Pandora box could harm the whole of tobacco control edifice.
My guess is that old cunning ideologues like Glantz and Chapman know that once they concede on e-cigs and accept the product substitution approach, they become open to question on other issues. Since they know that they have a lot of skeletons in their intellectual closets, they fear this process (even if only involving product substitution). Their expected response is to present a completely rejectionist front in which any minimal concession is seen as a threat to the whole of FTCT tobacco regulation. They do so, probably, because they are well aware that the FTCT bureaucratic edifice is not resistant to rational criticism. Other bureaucracies, such as the WHO, are bound to react in this manner, since the e-cigs are a disruptive consumer product, and thus accepting them (even within the purely product substitution approach) is a threat to vested Pharma interests and Bloomberg donations that feed them.
Another development that could influence future tendencies in product substitution that could (in some way) involve user empowerment in the entrance of low risk HnB products manufactured by the big tobacco industries. Empowerment of consumers could occur if these products become price accessible, available and attractive. Obviously, this will be opposed by the powers that be in tobacco control, regardless of how safe they are. So far, it is not clear how the part of PH promoting e-cig product substitution will react to this. It seems that part of the product substitution rebellion within PH is to adopt a more pragmatic approach to the tobacco industry.
In short, those in PH promoting merely product substitution through the e-cig (point 3 without points 1 and 2) should be given “the benefit of the doubt”. Perhaps their rebellion within PH will collapse, simply because a majority of those promoting it may come to realise that they would not be able to control the consequences of the process they have unleashed. Also, the entrance of the tobacco industry into product substitution may bring interesting developments that are hard to foresee.
Thanks for the feedback.
I do quite enjoy the sideshow of the pro-ecig junk scientists (for 95% of people doing public health research are junk scientists) squaring off against the tobacco control extremist junk scientists. They both score solid hits (more in favor of the former, but not overwhelmingly so) because both factions are mostly doing crap work. So, yeah, it would be great to see that have the beneficial effect of exposing just how bad the entire field is.
I am not so optimistic about authoritarian pro-product-substitution attitudes morphing into people really accepting human rights (harm reduction). It is possible, of course. I understand your point that the closer someone gets to acting like a decent person, the more likely they will actually become a decent person. But the authoritarian pro-ecig cliche is now solid and self-reinforcing enough that they may not feel much influence from human rights advocates. If there were a few oppressed voices in the wilderness, as their might be in the USA, India, or Mexico, they might come to identify with the real rights advocates who are the only other ones saying what they are saying. But that cliche is almost completely UK and Commonwealth (who think of themselves as part of Mother England despite geography), they focus on one another and have achieved critical mass to not care what either the extremists or the human rights advocates think.
The science around e-cigs and vapor is not some sophisticated complex “rocket science”. It is rather plain bottom line science that could have been undertaken 50 years ago: it involves simple toxicological analysis that can be done (with some adaptations) in any minimally decent chemistry lab, plus (for gateway & smoking cessation studies) some undergraduate level population statistics that reveal basic trends without trying to obtain fine predictions. In this context, any researcher will do “good science” by simply following the protocols and by not deliberately distorting the experiment design and the data. I believe that a lot of the pro-ecig crowd have done this reasonably well. The pro-ecig crowd would have fared much better against the dogmatons if they have kept this simple science simple, instead of going into the risky business of assessing complicated lifestyle risks and concocting the “95% figure” by obscure and discretionary methods.
It seems to be clear that the battle for the e-cig and snus, even within the substitution parameters, is no longer a science debate but a political fight. The quest for introducing the ethical side of THR is part of this political struggle, but perhaps the order of events is important, perhaps a victory of the product substitution approach (even if authoritarian) is a necessary condition for this political struggle to open up (and not the opposite order nor simultaneity). In concrete terms: a key element for the product substitution approach to win a political victory is to succeed in eliminating the “harms from second hand vapor” argument as a political argument. Once this is done and product substitution becomes part of the PH establishment, then vaping can be defended as a basic human right that does not affect third parties (an argument that cannot be used today with smoking). Yes, the ‘no harm to third parties’ argument was not useful for smokeless tobacco, but these were other times. It does not mean it would not work today.
In short, to pursue a strategy of “only product substitution” without later incorporating social and political elements is unstable and will bring (in the end) many contradictions that could force change. The dogmatons know it, so they oppose product substitution like hell. I think that at least some in the pro-ecig camp also know and would welcome the changes, others may back down and do a U turn. We will see who is who.
Finally: what is your take on the entrance of the tobacco industry into product substitution? Probably this could be the theme of another post.
Taking your points in order:
It is a bit too strong to say that we could have done all this 50 years ago. The analytic chemistry was not even that good. More important, the accumulated knowledge from occupational epidemiology, that lets us estimate the impacts (or lack thereof) from the various chemical exposures did not exist. But you are totally right that doing this correctly now is a matter of workaday methods, the tech/engineering side of science. That is why the bit companies do by far the best work in the field — that is what they do well. Those who try to do something “creative” are most likely to be doing junk. Too many people in public health and medicine think science is mostly about creativity, because they only studied science in grade school where we learn about great breakthroughs and not the day-to-day of doing science. They never actually studied doing science.
The 95% absurdity is an extreme example of this, trying to come up with some cutesy way to get a number when there is a perfectly good workaday way to tot up risks. CDC does it for cigarettes (whatever you might say about the liberties they take with cherrypicking and exaggerating). I did it for smokeless tobacco. Burstyn sketched it for ecigs. But instead of putting the effort into doing it right, the tobacco controllers just make stuff up. They simply don’t understand science.
This is definitely a political fight that sometimes pretends to be about science. I will publish, in the next few days, an article for Daily Vaper about the current kerfuffle about formaldehyde. The main point of that will be that the fight that is playing out in journals is really pure politics and the journals are just playing the role that you described in your guest post here.
Returning to the main thread of our conversation: I totally agree there is a case to be made for the “drag them by the balls and their hearts and minds will follow” approach. It could work. But I am not all that sanguine about it. Just consider what happened in injection drug use harm reduction, where the harm reduction ethic anchors the resistance much more completely than it does with tobacco. Recall this post: https://antithrlies.com/2016/08/05/what-harm-reduction-really-means/ It is possible that it will all work out, but I doubt it. Rather, anti-HR attitudes could be reinforced. See the thread here with the comment from natepikcering.
At the very least, I am certain the human rights based outcome will not occur without some of us constantly pushing it, including keeping up a steady rain of criticism of the pro-substitution anti-HR people.
As for the role of the majors in product substitution, that is what got me into this field in the first place and what I spent much of my career on. This is not new. They have been trying to promote product substitution for two decades and faced (fanatical, successful) pushback from “public health”. It is completely a good thing. It is far better than tobacco controllers pushing substitution. The reason for that is that the industry mostly endorses the full HR agenda.. Perhaps not for all the “right” reasons, but your arguments about hearts and minds following make the case for why that does not matter. Companies that sell multiple products have reasons to oppose caused-harms that are directed at any of their customers (setting aside that they actually profit more when already high taxes increase further). Since they cannot arm-twist, medicalize, or propagandize, their only avenue to encourage substitution is consumer empowerment (education).
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I am a smoker that chose to vape instead of using cigarettes 1 year ago today. I didn’t want to quit smoking but had attempted to, halfheartedly, several times, either cold-turkey or using various NRT, due to societal pressure. That pressure came from friends, family, doctors, media, anti-smoking messages and most often my son (due to anti-smoking media images that made him upset that I was going to die).
I didn’t want to quit smoking so the biggest motivator for me was the economic benefits of vaping. The health benefits I have experienced have been an added bonus. I have made it clear to my son that I am still a smoker, I have just chosen (in my opinion) a better product to smoke. It is certainly cheaper than tobacco here in NZ as the government, in it’s goal to be smoke-free by 2020, is in its 2nd year of 10% annual tax increases on tobacco to “encourage” people to quit.
I had never considered the points you have made about THR being about human rights but I knew the overt judgement of smokers in general was wrong.
After complaining that vapers were tarred (pun intended) with the same brush as smokers, in our restrictions to various areas and condemnation by those morally superior people who never smoked or have quit, I will instead continue to support all my smoking colleagues in their choices whatever they are. I will still share what I think are the benefits of smoking my chosen replacement to tobacco.
NIcely said. Thanks.
Perhaps the solution to the navigation of the complexities in the creation of a meaningful definition to harm reduction have nothing to do with the semantics of the term itself: Maybe everything to do with the semantics… Let’s just call it, “Personal Harm Reduction.” and we can take the fight from there.