September 16th, 2014

Memo to public health grandees: vaping, vapers and you

Dear Public Health Grandees (you know who you are)

I consider myself a public health advocate and, though I’m not a vaper and have never smoked, I support vaping as a tobacco harm reduction strategy, with enormous potential to reduce death and disease globally. It’s a good approach for public health as it doesn’t require prohibitions, coercion, punitive taxes or rely on fear and it goes with the grain of behaviour and what people want. I thought it might help you if I explained what I have learned about vaping and vapers, and why your relationship with them is so poor. You can also read very articulate views from vapers about your attitude to them at the links below.

1. What are vapers doing? A simple explanation was left by one of them, Mark Cowell, on my web site. “I vape because I like it, it harms no one, and I’ll live longer.” Let’s unpack that:

I vape because I like it . Vaping is a recreational activity – the use of the legal mildly psychoactive drug nicotine, currently used by about 10 million adults in the UK, mainly through its most dangerous delivery system – cigarettes. The drug itself is not very harmful to health and does not cause intoxication (violence or accidents). It is often compared to caffeine in terms of its risk profile. It isn’t even as addictive as you might think, and less addictive when vaped rather than smoked. Vapers are making a choice to use it without combustion of tobacco (hence the enormous health dividend), but with lots of technology, flavours, and personalisation instead – it’s more than just nicotine self-administration. For many it is fun and geeky, and it is has a thriving sub-culture. Remember no one ever says “I like Champix” or “NRT is fun” and there are no “Patch-meets” to distract vapers from Vape-meets. Vapour products are not medicines. Vapers are not to be considered patients, in treatment, undergoing smoking cessation or in any way to be incorporated into any medicalised model of public health.

. Vaping is a recreational activity – the use of the legal mildly psychoactive drug nicotine, currently used by about 10 million adults in the UK, mainly through its most dangerous delivery system – cigarettes. The drug itself is not very harmful to health and does not cause intoxication (violence or accidents). It is often compared to caffeine in terms of its risk profile. It isn’t even as addictive as you might think, and less addictive when vaped rather than smoked. Vapers are making a choice to use it without combustion of tobacco (hence the enormous health dividend), but with lots of technology, flavours, and personalisation instead – it’s more than just nicotine self-administration. For many it is fun and geeky, and it is has a thriving sub-culture. Remember no one ever says “I like Champix” or “NRT is fun” and there are no “Patch-meets” to distract vapers from Vape-meets. Vapour products are not medicines. Vapers are not to be considered patients, in treatment, undergoing smoking cessation or in any way to be incorporated into any medicalised model of public health. It harms no one . Despite efforts by many in public health to mine the literature for signs of the faintest risks to others, there really isn’t any material risk to others – if you read the most authoritative assessments of risk (here, here & here) rather than cherry picking studies that detect tiny traces of toxins this would be clear. As you know, the dose makes the poison and exposure makes the risk. That doesn’t mean it should just be allowed everywhere, but it does mean that use of the coercive force the law to ban it is inappropriate. Your obtuse theories for how introduction of a much safer product can somehow lead to greater harm are baseless and contrived: there is no evidence for gateway effects (other than exits), for renormalisation of smoking or that vaping is somehow ‘undermining tobacco control’ rather than supporting it. The opposite effects are more likely to be true and more consistent with the evidence there is.

. Despite efforts by many in public health to mine the literature for signs of the faintest risks to others, there really isn’t any material risk to others – if you read the most authoritative assessments of risk (here, here & here) rather than cherry picking studies that detect tiny traces of toxins this would be clear. As you know, the dose makes the poison and exposure makes the risk. That doesn’t mean it should just be allowed everywhere, but it does mean that use of the coercive force the law to ban it is inappropriate. Your obtuse theories for how introduction of a much safer product can somehow lead to greater harm are baseless and contrived: there is no evidence for gateway effects (other than exits), for renormalisation of smoking or that vaping is somehow ‘undermining tobacco control’ rather than supporting it. The opposite effects are more likely to be true and more consistent with the evidence there is. I’ll live longer. Note he’s not saying he’ll live forever, or even live as long as possible. He is implicitly recognising ‘relative risk’ – that is that it will be much better for him than smoking. This is beyond doubt – the expert debate is where in the range 95-100% better. The benefits go beyond life expectancy: many experience immediate gains in fitness, wellbeing, relief of chronic conditions, and improved self-esteem – feeling more socially at ease. It is never appropriate to label them ‘pathetic addicts’ or to instruct them to ‘grow a backbone’ and just quit smoking. Though many argue that nicotine users should ideally quit nicotine entirely, this may not in fact be the welfare maximising option for some if they are left with persistent craving or a sense of loss. If they are taking the step of reducing risk by >95%, your professional public health concern should stop there. The next step to zero nicotine is purely their concern and choice.

2. Vapers think you don’t understand this model – and you don’t care what the evidence says. You have shown no sign of understanding how this works – and keep seeing it as a tobacco industry plot (they were late to the party) or some sort of rogue medical product. Neither is true. But vapers rightly suspect you are careless with the truth: most public health organisations united to support a ban on snus in the European Union in 1992, again in 2001, and once again in the 2014 Tobacco Products Directive. This is despite indisputable evidence that snus, a very low risk way of taking recreational nicotine, has been highly positive for public health where it is permitted and used in Scandinavia – displacing smoking, diverting smoking onset, and supporting user-driven quitting. There is no scientific, ethical or legal case for banning it – but you supported it anyway. This is the same public health model as vaping, so it is no wonder they don’t trust you. Until you face up to the lethal error you have made on snus, you have not earned the right to a hearing on vaping. To the extent that smokers believe what you say, you are likely to be protecting cigarette sales by creating unfounded fear about a much safer alternative and causing damage to health that would otherwise be avoidable.

3. Activism explained. You seem surprised to find there are people who get up and do something, and do it for nothing – you seem to assume someone must be paying if vapers do anything. I can see why you might think this: it rarely happens in your world or it is a distant memory from your more idealistic youth. There are no grass roots or unpaid individuals campaigning for the things you want in this field. You should think of these people more like the activist campaigners you know in drugs or HIV/AIDS. Many vapers are passionate about their experience: they have escaped the death trap of smoking – or are heading that way – and having feelings of pride, empowerment, agency and control, as well as immediate welfare and economic benefits, and a much better long term health prognosis. They want others to benefit from the experience and they really don’t want you to take it all away through clumsy or excessive regulation based on poor science, comprehensive misunderstanding or for ideological reasons. And they don’t want to be collateral damage in your war on Big Tobacco, which is of little relevance to them.

4. Coordination and conspiracy. You notice and sound the alarm that many vapers seem to act together and say similar things. Behind this you see a conspiracy, probably under the control of your nemesis, Big Tobacco. This is because you don’t really understand the bottom-up organising power of social media. What you are witnessing has a technical name: ’emergent behaviour’. This is what you get from complex adaptive systems like social media. People with diverse knowledge share and aggregate thousands of ideas and a kind of natural selection process sorts out who people listen to, how people think and what they do. It never creates homogeneity and has no ‘command and control’ mechanism, but on some issues it can take on the appearance of a well organised campaign offensive. But it isn’t well organised or ‘top-down’ co-ordinated – it is emergent behaviour. If you engaged more interactively in social media, rather than using it to make announcements, pronouncements and denouncements you’d see this more clearly.

5. The relationship between vapers and public health people. Your relationship with vapers is asymmetric – and you really do need to understand this. They are the ‘public’ in public health. They should be a matter of professional interest to you. In your profession, you need to understand them and why they do what they do, in order to make professional public health judgements. You need to do this with high standards of professional conduct and to approach them with humility and empathy. You might start by following the seven principles your own code of conduct. You probably have something to learn and you might even get to understand what inspires them. But they have no similar obligation to you. They have other jobs, other lives and no professional need to understand you or engage with you. If you think “there is a lot of mistrust & misunderstanding on both sides” that is your problem, not their problem. Their interest in you, if any, is that you might spoil what they are doing, that you are making provocative or unfounded remarks about them or what they do, or you are dismissing their experience as mere anecdote.

6. Vapers are not one thing. You should never talk about them as if they are an organisation, a movement or as if they somehow act collectively – they are highly heterogeneous and atomised. If one vaper is rude to you it doesn’t mean all vapers can be damned as rude. Even if there is an emerging vapers’ organisation, you can’t blame them for how vapers behave any more than you can blame the AA for bad driving, nor can you ask them to stop it any more than the AA can stop someone speeding on the M1. They are responsible for themselves but not for each other.

7. Should you be blaming vapers for being rude to you? No, under no circumstances. This is the ‘public’ in public health again. The public is highly diverse – including elements that are raucous, bawdy, profane, satirical, sarcastic, insulting and so on. To complain about them as a public health professional is like sailors complaining about the weather, or politicians complaining about the electorate. They are the subject of your profession – get used to them, and learn to engage without becoming pompous and aggressive. If you think you can defend your professional failings by finding examples of people being rude to you or about you, then you misunderstand your role. So please don’t try this as a defence, it will only bring you more shame and further opprobrium The real public is not like the bland smiley types you see in NRT adverts or the dumb animations of Change-4-Life. Public health is a gritty business, not about the provision of happy-clappy advice to a peasantry grateful for your wisdom and awed by your status. If that is how you think, you’re in the wrong job.

8. Are you a victim? Senior public health people are tending to cast themselves as ‘victims’ – fearless truth-tellers cowed into silence by aggressive on-line challenge. No, you are not a victim under any lawful circumstances. As explained above, it is a matter of professional competence to deal with the public as you find it, not as the compliant supplicants that you would wish them to be. But there are other reasons why you aren’t a victim.

There is an asymmetry in the power relationship. You have academic prestige and institutional support that lends weight to your views (however ill-informed they are). You have access to media and can write tendentious editorials in the BMJ apparently at will. You have networks and allies who will defend you. You appear to have secure tenure and very little accountability for what you say if it is wrong or ultimately harmful. You can advance your weird theories in paywalled and heavily moderated journals which protect you from symmetric criticism and are closed to most of your critics.

You have academic prestige and institutional support that lends weight to your views (however ill-informed they are). You have access to media and can write tendentious editorials in the BMJ apparently at will. You have networks and allies who will defend you. You appear to have secure tenure and very little accountability for what you say if it is wrong or ultimately harmful. You can advance your weird theories in paywalled and heavily moderated journals which protect you from symmetric criticism and are closed to most of your critics. You have contributory negligence. You have not approached the tobacco harm reduction issue with objectivity and rigour – you have not engaged with the evidence except to cherry pick it for obscure studies that support your pre-determined theories. The academics with the least published research and study experience in the field have been the most aggressively opposed and outspoken, even dismissing other academics who are leaders in the field as ‘tobacco industry apologists’. The inverse correlation between experienced knowledge and opinionated criticism is striking. You make gratuitously provocative remarks about vapers and wildly accuse innocent ordinary people of being stooges for the tobacco industry without evidence. You take an abusive approach to scientific discourse: in one instance claiming the uncertainties with vaping were equivalent to those of Thalidomide. The way you behave and carry on your professional responsibilities contributes to the hostile reaction you receive – much of it is your fault.

What should happen next at the Faculty of Public Health? I don’t want to discuss individuals, but a change is needed in public health leadership. This can happen in two ways: either by the people involved changing their approach, or by changing the people. Bad language is a merely a surface manifestation of a deeper problem: it is the sneering, arrogant, boorish, contemptuous attitude; the disregard for evidence and analysis; the thuggish provocations and crass risk communication; and the ad hominem smears that are the issue. What is needed is a new professional ethos based on objectivity, rigour, humility and empathy. What would not help would be to dismiss this as an unfortunate, regrettable outburst that should just be forgiven and forgotten. Nor should there be blame shifting to vapers or shirking of professional responsibility. So, here’s what I think should happen to serve everyone’s interests…

1. Own up and apologise properly, do not try to reallocate blame or plea mitigation because you had a rough encounter with the public. That’s your job… suck it up.

2. Recognise that the issue is deeper than just a bit of abuse – it is about the professional ethos in public health.

3. Instil the Presidency of the FPH with the following values or traits: objectivity; rigour; humility; and empathy. Listen a bit more and lecture a lot less.

4. Commence a series of private dialogues – with vapers, with other academics and advocates who see the issues differently to you – ask a trusted intermediary to hold the ring.

5. Start to approach the tobacco harm reduction issue with the same passion you have approached harm reduction in other areas of public health – it is the same concept but with many more lives at stake.

6. Allow your position on vapers and vaping to evolve as the evidence and understanding accumulates – above all, approach the issue with an open and curious mind.

Update. Other people have written very well in the last week on similar themes:

Are there others?

Lettre ouverte à Mes Seigneurs de la Santé Publique – Traduction Français de la lettre ouverte de Clive Bates – a French translation of his blog.