This session from a California tobacco control conference was circulated on Twitter and caught my eye. To me, it summarises a lot that is wrong with the anti-nicotine crusade and also with the behaviour of public servants and public health professionals in this field. Here was my reaction on twitter, but I decided to go further…

Rather than just get annoyed on Twitter, I decided to take action in the real world and set this argument out properly, found their email addresses on the internet and wrote to the people involved in person. The memo is framed using the three themes in the tweet:

Here’s the memo as sent Tuesday 3rd May 2016.

TO:

Derek Smith

Julie Lautsch

Tess Boley Cruz

Beth Olagues

I write as a former director of a well-known tobacco control organisation, a former senior civil servant and as a current advocate for tobacco harm reduction as a public health strategy. I have no competing interests with respect to any tobacco, nicotine or pharmaceutical business.

I note with some concern the theme of a seminar held during the conference: Tobacco Control, Research, and Education: Joining Forces to Address New Challenges on October 27-29, 2015 at the Sheraton Grand Sacramento Hotel.

7B: Fighting the Vape Militia Online and Off

What happens when you produce an excellent educational campaign on e-cigarettes in your community only to have pro-vapers stampede right through the middle of it, creating a storm of negative attention and calling you names along the way? Learn from people who experienced it first-hand as we explore who the vape militia is, the tactics we use, and what you can expect from them in response to your campaign. Leave with smart strategies for planning ahead, talking points for a coordinated response, and knowing how to better prepare for negative encounters – online and off.

Speaking as someone who may even be part of this ‘militia’, I think you would be better served by understanding a little more and mocking the public a little less. Have you really understood why the “Curbit” campaign attracted the hostility it did? And have you figured why those involved feel strongly enough to ‘stampede‘ through your campaign?

I’d like to make three suggestions for a better approach in future.

1. Treat the public with respect

Maybe the public is right and you are wrong? Three of you are public servants and all of you rely on public funding for your own livelihoods. You all work in public health. The key word here is “public”. When the public, or a subset of it, dislikes what you are doing, you should not react by dismissing them and indulging in name-calling. This is a matter of professional ethos – your responsibility, not theirs. Something bad happened to you and your campaign, but maybe the fault was with you. You should reflect on it more carefully before you go any further with coaching others on how to fend off public criticism or, worse, to ‘fight’ them.

If you think any sort of industry is behind this, you are mistaken. Obviously, I don’t know what you believe lies behind the ‘storm of negative attention‘ you earned from the public, but if you have even the slightest suspicion that it has been orchestrated by the tobacco or vaping industry, then should abandon that idea immediately – it is completely incorrect. If this is the case, you need to spend some time understanding social media more deeply. The effect you experienced – no doubt unpleasant – of many vape activists swarming on your campaign is known as an ’emergent behaviour’. It arises from thousands of people sharing, liking and retweeting ideas, arguments and links that they find interesting, or, in your case, they find annoying. The best ideas, arguments and links emerge through a process of natural selection and arrive on your screens looking like a concerted onslaught. But they are not – the behaviour is emergent not co-ordinated.

You’ve been called names – get over it. If you spend much time in a frontline role with the general public, you will find the public is highly diverse but mainly includes people who are mostly polite most of the time when they criticise others. But there will always be some who will find the asymmetry in the power relations between your well-funded mass campaign and their actual lived insights so frustrating that they will be blunt with you. You must not whine about this. You should get over it. They are the ‘public’ in ‘public health’ and you are professionally obliged to engage with them on their terms as long as they are lawful. If you would like to explore the vapers’ perspective on this conflict more deeply, I would like to recommend starting with my memo to public health: Vaping, vapers and you

2. Spend public money wisely

Did you do any due diligence on your campaign? Your dismissive approach to critics would be a little more bearable if the campaign itself had been built on proper evidential foundations, a realistic understanding of the behaviours involved, a clear justification for the desired outcomes, and a worldly assessment of the risks of unintended consequences that might be caused by your campaign – eventually leading to others dying in agony. If you are going to spend public money, these are the things you need to do.

There is no sign that you have done any of the above.

The upfront falsehood in your campaign is fatal to your credibility. Your campaign leads with a blatantly untruthful statement, which can only have been designed to mislead.

“E-cigarettes are harmful, like cigarettes”

That is just not true, is it? E-cigarettes are very much less harmful than cigarettes, and that is their most relevant characteristic for consumers. The legitimate scientific arguments focus on where in the range 95% less to 99.9% less harmful. As the UK Royal College of Physicians puts it, in its report Nicotine without smoke: tobacco harm reduction

Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure. (5.5)

Can you see the difference between in the messages conveyed by these two statements? You may disagree with this expert assessment, but it is evidence-based and you certainly cannot point to any evidence that suggests the risks are remotely equivalent.

The campaign is founded on multiple misrepresentations of risk. Your campaign literature is full of highly misleading statements about nicotine toxicity, second-hand vaping and the presence of contaminants or products of thermal decomposition in vapour. If it would help, I will give you a line-by-line assessment (you just have to ask), but the criticism boils down to the most basic idea in toxicology:

the dose makes the poison

The only reason I can think of to mention chemical names without quantifying exposure is to scare people. But in reality, there is no reason to be scared. What matters is the exposures relative to smoking and relative to what we normally tolerate in society. This is very well set out in several reviews, which you should digest before communicating risk with the public:

Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks, BMC Public Health 2014; 14 :18 . doi:10.1186/1471-2458-14-18 [Link]

Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks, 2014; :18 doi:10.1186/1471-2458-14-18 [Link] Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf 2014; 5 :67–86. [Link ]

2014; :67–86. [Link Hajek P, Etter J-F, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction. 2014 Aug 31 [ link

Your legitimate role is to use public money to inform, not to manipulate. If you were trying to inform Californians so they could make their own decisions in their own interests then you would not have implied smoking and vaping have equivalent harm. The effect of this is to imply to smokers that there are no health benefits from switching to vaping. So if any smokers have acted on your information and continued to smoke, you may well be ultimately responsible for their death from cancer, cardiovascular disease or emphysema. No wonder vapers reacted so forcefully to this misinformation from you – lives are at stake. Maybe you thought this message formulation would trick people into rejecting e-cigarettes? As public servants and public health professionals, it is not your job to deceive anyone. People make their own decisions and your role, if any, is to assist with that with high integrity communications.

Do you really know what you are doing? You should consider the following carefully, and what they might mean for your work.

What if vaping is an alternative to smoking?

What if users – young and older – are overwhelmingly smokers or would otherwise smoke in the absence of vaping?

What if the record declines in US adult smoking since 2012 are due to adults switching to vaping?

What if the rapid declines in youth cigarette smoking since 2012 are due to adolescent switching to vaping or never initiating smoking?

What if all your policies like vilifying vaping and vapers, banning vaping in public places, taxing e-liquids, banning flavours etc all just make vaping less attractive relative to smoking?

What if the FDA regulation you favour is so onerous that would simply wipe out most American businesses involved, protecting the cigarette trade from competition and favouring the tobacco industry in the vaping market? Do you want to be doing the dirty work for Big Tobacco?

Have you thought through any of this? Because if not, you should not be spending a cent of public money on this campaign. And if you have, then you would not be spending a cent of public money on this campaign, because you would have concluded it was ill-advised.

I can walk you through the evidence on all of this if would help, but it is really your job as public servants to do that. To get you started, I’ll just offer you this evidence-based rejoinder to the arguments of the e-cigarette crypto-prohibitionist Matthew L. Myers of the Campaign for Tobacco Free Kids.

Your critics say you are deliberately trying to promote smoking for fiscal reasons. Your critics point to (YouTube) California’s dire public finances, the Master Settlement Agreement funds, and irresponsible securitisation and draw an obvious conclusion: the state is trying to protect cigarette-related revenues by putting people off the alternative. I don’t believe this theory myself. I think that ordinary ill-conceived policy and poor science is the more likely explanation. But what have you done to respond to their challenge?

3. Learn from your mistakes

Complaints are learning opportunities not a reason to mock your critics. You call them ‘negative encounters‘, I call them ‘feedback’. Just as modern governments and businesses increasingly value public complaints as an input into their improvement and innovation culture, you had a learning opportunity here. But you don’t seem to have taken it. Here are some things to consider that might help you in future:

Did you make contact with any of your “vape militia” critics?

Did you invite them to share their insights and concerns – for example by meeting with them or asking them to write to you?

When they raised challenges to your campaign, did you engage to address their concerns or even to accept they had a point?

Did you defend the things you were saying or was the social media interaction one-way only – you hectoring and haranguing them, and then ignoring their reactions?

With such a hostile reaction, did you reflect on whether you had misunderstood the area you are working in (see above) and need to rethink?

Are you sitting in an anti-vaping echo-chamber suffering from group-think?

In public health offices, university departments, tobacco control conferences and the closed and introverted world of tobacco control it is quite easy to acquire a profound misunderstanding of the real world and believe everyone else shares your view. Maybe your views about vaping just didn’t survive their first contact with reality. That’s something to learn from and not a reason to sneer at the people who took you down.

I would very much like to see sound public health thinking return to California, and I would be delighted to follow up this memo with a Skype call at your convenience. Please let me know if you would like to proceed with that.

This matter is of interest more broadly, so I have made this memo publicly available. I look forward to hearing from you, and will, of course, respect any request for confidentiality.

Yours sincerely

Clive Bates

Counterfactual

London