by Carl V Phillips

Most of what gets published in newspapers about tobacco products is complete garbage, written by someone whose research and critical thinking abilities seem to be at about the level of a middle-school report. Thus, this article about e-cigarettes in the New York Times by Sabrina Tavernise was extremely refreshing. By virtue of that, it is a great opportunity to explore some of the common misconceptions, oversimplifications, and narrow thinking that appear in the intelligent discussion of the topic. Dissecting the usual drivel gets pretty useless after a while, but this is different.

After introducing Stanton Glantz and his protegé and reluctant antagonist, Michael Siegel, the Tavernise continues:

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

Reporters like to turn slow-moving, complicated, and broad political fights into movie scripts. Perhaps this paragraph is just an example of that. But there does seem to be a genuine misconception that the fight about THR is new, and that there is something unique here. In reality, that fight has been going on a long time, and the “public health” political movement has jumped the shark on this and numerous other issues (“Big Food”, 20 ounce sodas, smoking in cars, helmet laws, you name it) and has lost the support of many who are genuine public health advocates and researchers. This is important context for understanding this fight. There is, in fact, nothing unique going on here.

Also, it is not entirely fair to the anti-THR faction to claim they are represented by their court jester, Glantz. Many of them are just as dishonest and evil as he is, but are not cartoon villains who spout easily verifiable lies. It probably is reasonable to use Siegel as a representative voice in the narrow fights about e-cigarettes, but he is not a supporter of harm reduction more generally, or of individual freedom. This may make him the “public health” faction’s pro-ecig guy, but missing from this entire movie script are the many voices from outside that faction.

The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year. Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

The exaggerated toll from smoking and the “preventable” trope, in this context, matter little, so I will not dwell on them. The notion that anti-ecig activism is motivated by vaping looking like smoking is far too narrow, and falls into the movie script simplification: That seems to be what Glantz is motivated by, but it does not generalize. The main motivation seems to be that THR stands in the way of “tobacco-free world” goals, as I have discussed at length, and is bad for business (it hurts the revenues of institutions and individuals who depend on concerns about smoking, and to a lesser extent those who sell anti-smoking products).

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population. “The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

The first bit of that seems like a simple statement of fact, but it is not. Following on the issue of whether e-cigarettes reduce smoking, the incorrect implication is that research on current behavior could tell us much about that. But then notice the unacknowledged switching from the question of smoking cessation to the question of exactly how hazardous e-cigarettes are in themselves (which, incidentally, we also will know very little more about “in another year or two”). This conflation and changing of topic is a common tactic by anti-THR activists and a common error by non-activist commentators. These are very different questions.

Equally interesting is the “horse out of the barn” metaphor, which seems to represent a common view. First, it illustrates the ruling class attitude of “public health”, suggesting that their job is to control dumb animals, rather than to advise free and rational people. Second, is patently wrong. THR products can and will be improved upon over time. And have been: worry about nitrosamines in smokeless tobacco (probably overblown, but leave that aside) has resulted in a huge reduction in their concentration over the last few decades. E-cigarettes will be improved and the current technology will probably be mostly displaced by others. In the extremely unlikely event that something very hazardous is found, many people will rationally choose to switch products, as happens all the time with other goods. There is nothing irreversible here other than the embrace of THR and the rejection of the abstinence-only orthodoxy. That, of course, is the main motivation of anti-THR.

After a couple of paragraphs about FDA regulation:

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

Activists who trust only themselves and believe they should control people do say that (though I would not suggest they should be described as either many or scientists). But is it even a little bit plausible? THR will replace smoking because it lowers the risk and keeps a lot of the benefits. It is certainly true that high taxes on cigarettes (having nothing to do with “the right kind of federal regulation”) make e-cigarettes more appealing (just as high taxes on smokeless tobacco make that approach to THR less appealing). But in most jurisdictions, the starter e-cigarette products are not cheaper than smoking, but people are still making a rational choice to switch.

What is more interesting to people who look beyond rich countries, is the issue of offering affordable THR products to the rest of the world. Even if there were not cigarette taxes that made them price competitive, e-cigarettes would be affordable to Westerners. But their real resource cost is so much higher than cigarettes that they are prohibitively expensive for most of the world’s population. Since the article is exclusively focused on the USA, it is understandable that this is not mentioned, but it is still bothersome to make such general statements about tactics when they are only relevant to a small fraction of the world’s tobacco product users.

As for reducing the nicotine in cigarettes, this madness has been a pet fantasy of a few dozen people who now have a lot of influence. But unless the goal is to actualize Glantz’s fantasy world where e-cigarettes are used primarily as a supplement to smoking rather than a substitute, it is insane. Smokers who just want nicotine will switch products anyway. With less nicotine in cigarettes, some people who want to smoke will smoke more, while others will supplement (and that does not require e-cigarettes, by the way: enroll in a stop-smoking program and get free nicotine patches, slap one on, keep smoking). And, of course, the black market will benefit nicely from being able to offer not just a cheaper product than is available legally, but one that is higher quality — that is, assuming there is not an easy DIY recipe (“I have a bottle of inexpensive e-cigarette liquid in this hand and a cigarette without enough nicotine in my other hand. Hmm….”; possible added bonus: flavored cigarettes!).

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Despite being a card-carrying tobacco controller, Abrams has emerged as one of the most cogent voices on the topic. It is not entirely clear whether he is responsible for the unfortunate preceding paragraph, about trying to lower the quality of cigarettes. The quote seems to endorse it, so perhaps. But maybe he is just pointing out that these particular products are not for everyone. Somehow lost in the fanaticism on both sides is the simple fact that like the THR products that predated them, e-cigarettes appeal to some people but not everyone. As noted above, we are missing a lot of useful data, but we do know that most smokers who have tried e-cigarettes are still smokers. People who find them appealing — and those who breathlessly call them a miracle or the greatest health technology breakthrough since penicillin — seem to overlook this.

I will skip over the standard background paragraph on e-cigarettes and uncritical reporting of the breathless predictions about the market from the usual stock flogger (who seems to exemplify the unawareness cited in the previous paragraph). In the interests of length, I will also break here and resume this in my next post, picking up with:

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.