How should we understand the widespread hostility to tobacco harm reduction in the mainstream tobacco control community and much of the public health community?
I don’t think we can ignore it any more… the symmetries and parallels with the worst excesses of “Big Tobacco” of the 1970s can no longer be ignored. The methods, ethics and consequences are all too similar, and becoming increasingly common.
Let us consider ten examples of parallels and symmetries:
1. Misinformation about risks
Big Tobacco misled people about the risks of smoking and denied the benefits of quitting. Tobacco control activists mislead people about the risks of vaping and deny the benefits of switching. These are logically equivalent abuses of the public with similar consequences.
Examples: claiming or implying that vaping and smoking have similar risks, asserting or implying nicotine vaping causes EVALI, popcorn lung, or serious diseases. Using claims about the presence of chemicals (“contains heavy metals”) without reference to exposures. Over-interpreting animal or cell studies as proving harm. Demonising nicotine and implying it is the main harmful agent in smoking or vaping (or refusing to correct misperceptions). Attributing statements of reduced risks to untrusted sources – for example, asserting that claims of reduced risk are merely marketing claims of Big Tobacco when there is a vast body of independent evidence showing greatly reduced risk.
2. Opposing smoking cessation
Big Tobacco preferred smokers to smoke than to quit by going abstinent. Tobacco control activists prefer smokers to smoke than to quit by switching to smoke-free products.
Examples: one poll found that tobacco control experts “disagreed”(27%) or “strongly disagreed” (35%) with the following proposition: “The long-term use of non-combustible nicotine (such as e-cigarettes) is an acceptable, if not ideal alternative to cigarette smoking.” [blog]. Also, numerous smoking cessation guidelines dissuade people from quitting smoking by switching to vaping or deny users information about this opportunity. Tobacco control activists campaign for bans on vaping and heated tobacco products while cigarettes remain widely available. Many support the EU ban on snus despite substantial evidence that it has reduced smoking and disease in Sweden and Norway.
3. Buying influence
Big Tobacco used dark money to buy influence in science and politics. Tobacco control activism is opaquely funded by unaccountable billionaires buying influence and access to politics, media, science and institutions such as WHO. Tobacco control money has far more reach than Big Tobacco ever had.
Examples: Bloomberg Philanthropies funds a vast network of activists, academics, agencies, and media that dance to Michael Bloomberg’s tune. Mr. Bloomberg is often wrong, but unaccountable and closed to challenge. The private foundations of Bloomberg and Gates were major funders of the World Bank and WHO, and Bloomberg funds the WHO’s biannual flagship report on the Global Tobacco Epidemic. The flows of funds from unaccountable foundations to major NGOs and then onward to fake civil society organisations or “citizen initiatives” is exploitative, opaque and expedient.
4. Merchants of doubt
Big Tobacco misused science and experts to manufacture doubt among smokers about the benefits of quitting. Tobacco control activism misuses science and experts to manufacture doubt among smokers about the benefits of switching. Tobacco control activists are the new ‘merchants of doubt’ – both play cynically into the insecurities and dissonance of the people most at risk from smoking. Both have the effect of keeping people using cigarettes.
Examples: the position statements of WHO, medical societies and health organisations (often with strong pharma conflicts or foundation funding) taking abstinence-only positions, often at variance with their approach to other forms of harm reduction. The obvious biases in the editorial practice of journals like Tobacco Control. The use of posters at academic conferences to make preposterous claims made for media uptake. The practice of journals to allow almost any anti-industry claim, however wrong or ludicrous. The refusal to retract obviously false and misleading academic articles. The use of press releases by academics to go well beyond their findings and make causal inferences or policy proposals for which there is no basis. Tobacco control experts tend to be asymmetrically certain about the harms but doubtful about the benefits.
5. Overplaying uncertainty
Big Tobacco exploited residual uncertainty to claim that we had insufficient knowledge to act on smoking. Tobacco control activists exploit residual uncertainty to claim that we have insufficient knowledge to recommend switching from cigarettes to smoke-free products.
Examples: claiming that little is known or can be known about the risks of smoke-free products because we don’t have ‘long-term data’. Arguing that it took years to discover the health risks of smoking (even though today we would know smoking was harmful immediately and we know a lot about smoke-free products). Misusing the precautionary principle to ignore evidence and overplay uncertainty (that’s not how it works). Claiming every product is different, and data from one tells us nothing about another. Setting evidential standards for the impact of tobacco harm reduction policies and products that could not be met by standard tobacco control policies or smoking cessation treatments. Claiming we have insufficient evidence that vaping helps with smoking cessation and population smoking reductions, even though we have plenty.
6. Aggressive economic actors
Big Tobacco was an economic interest group threatened by evidence of the dangers of smoking tobacco. Tobacco control activism is an economic interest group threatened by evidence of the safety of smoke-free nicotine use.
Examples: If the harms of nicotine use become negligible, there is no longer a point to the ‘tobacco control’ profession. All the careers, grants, NGOs, conferences, university departments etc. would go – tobacco control would become as pointless as coffee control. So three survival strategies are evident: (1) claiming the harms of smoke-free nicotine are far greater than they are; (2) shifting the goal of tobacco control towards attaining the ‘nicotine-free society’ combined with drug war rhetoric; (3) defining its role as a fight to the death with the industry, even if what the industry does is appropriate for the protection of public health – something that tobacco control interests define as impossible as a matter of principle.
7. False claims based on misleading measurements
Big Tobacco used misleading machine measurements of cigarettes to make false safety claims about a highly dangerous product. Tobacco control activists use misleading machine measurements of vapes to make false risk claims about much safer products.
Examples. Tobacco companies used misleading tar and nicotine yields from smoking mahines to make ‘light and mild claims’. The vaping equivalent is overheating liquids and measuring vape products in dry puff conditions, then claiming high cancer risks from formaldehyde. Using unrealistic exposures or puffing regimes on tests of animals or cells and then overhyping the results. In both cases the control feedback between human user and device is ignored and replaced by an unresponsive machine used in unrealistic conditions. In both cases, the user is misled in a way that favours continued smoking.
8. Misunderstanding nicotine
Big Tobacco offered false harm reduction based on a wilful or negligent misunderstanding of nicotine-seeking behaviour (light and mild, cutting down). Tobacco control activists deny true harm reduction based on a wilful or negligent misunderstanding of nicotine-seeking behaviour.
Examples: using the quantity of nicotine in a pod or device as a proxy for its harmfulness and comparing this to the quantity of nicotine in a pack of cigarettes, even though it is not nicotine that does the harm. Some activists claim that vaping is likely to be the same kind of scam as light and mild cigarettes, but this is a misrepresentation of the way nicotine-seeking works in both cases.
9. Misattributing harms
Big Tobacco embraced unlikely confounding to deny causal claims about the harmful effects of smoking by attributing cancer (etc.) caused by smoking to other things. Tobacco control activists ignore likely confounding to make false causal claims about the harmful effects of vaping by attributing cancer (etc.) caused by other things to vaping.
Examples: endless studies find associations between vaping and some form of harm. In many cases, the maxim that “correlation ≠ causation” is brushed aside, and causal claims are made or implied by the authors. Studies of e-cigarettes can never take full account of smoking history, reverse causation or the deeper underlying causes of smoking and nicotine-using behaviours – yet these risk factors likely explain most of the adverse findings about health risk of e-cigarettes. In the case of snus, tobacco control activists have invented ludicrous explanations for the undeniable public health benefits of snus in Sweden and Norway, including paternity leave. Gateway claims are an attempt to attribute the harms of smoking to vaping by ignoring obvious “common liabilities” (common risk factors or confounders).
10. Backing bad policies
Big Tobacco favoured tobacco control policies that did not work and had the effect of keeping people smoking. Tobacco control activists favour tobacco harm reduction policies that do not work and have the effect of keeping people smoking.
Examples: tobacco control activists have responded to the opportunities presented by low-risk products with three main strategies to negate them: (1) outright or partial prohibition; (2) medicalisation and prescription models; (3) treating smoke-free products the same as smoked products. In each case, the value of the low-risk product as an alternative to smoking is degraded, and a competitive advantage is handed to the cigarette trade or black marketeers.
However…
There is one big difference … no one ever trusted Big Tobacco. Tobacco control advocates approach the public with an endowment of trust. The abuse of trust makes the mainstream of tobacco control worse than Big Tobacco ever was.
Who am I talking about?
Some care is needed. I am trying to capture the awful attitudes and behaviours of what I see gripping the global tobacco control mainstream – the WHO and its regional offices, the FCTC secretariat and its hand-picked observer NGOs, the giant network of Bloomberg-funded groups, hundreds of attention-seeking academics, the paternalist medical societies, the Brussels-based activist groups, the Australian fanatics etc. It would take too long to list them all.
But equally, there are many people sincerely committed to the end of smoking-related death, disease and misery, approaching their work with rigour and care for facts, evidence and analysis. I want to salute the people trying to negotiate the painful trade-offs, deadly unintended consequences, and gruesome politics with pragmatism, humility and empathy – this blog is not about you.
Have I missed anything? Please add further or improved parallels in the comments.
Great article. Says just what many of us think. The thing is, how do you get this across to law makers and health professionals – and the general public – to counter the stream of misinformation generated by tobacco control and the WHO? We, who read your blog, are already converted in the main.
Great post Clive!
I don’t know why the “tobacco control mainstream” are still referred to as “tobacco control” ; Like many smokers they’ve quit tobacco and switched to vaping, using whatever credibility they may have had from Tobacco Control to interfere .
Unfortunately much of “mainstream tobacco control” have spent thier careers studying old school Big Tobacco, so they’re acting the only way they know how.
Clive,
Brilliant as usual. Not sure how we change things to be honest. Scientific evidence appears to be irrelevant which is truly sad since scientific evidence was the foundation of what tobacco control was built upon. I still hope FDA-CTP will speak up, politics appear a deterrent.
Clive’s analysis that Tobacco Control today is the New Big Tobacco is, unfortunately, very fair and very accurate in my opinion. But often analysis is just the easy part. The hard part is trying to figure out how to extricate ourselves from a present very unsatisfactory situation. And another hard but important question is how to avoid to avoid getting into this sort of situation again in the future.
I don’t see the pro and anti tobacco harm reduction factions sorting out their differences in any other way than slugging it out until one or the other side achieves a victory. Harm reduction wins most of its battles. And tobacco harm reduction also has an advantage that the debate is also about the victory or defeat of a disruptive innovation. Again, disruptive innovations win most of their battles. So I am very confident that tobacco harm reduction will eventually be accepted and adopted. This decision will be made by politicians around the world.
The battle between pro and anti tobacco harm reduction suggests to me that public health has got to get much better at ensuring that debates over controversial questions have to always be accompanied by polite and respectful debates in private and in public. Opponents of tobacco harm reduction have generally ensured that debates or discussions about tobacco harm reduction could not take place.
I wish we could clone you Clive Bates! You described this backwards and forwards. I have the utmost respect for your tireless contributions to ending the suffering of those still smoking and the preservation of those of us that advocate, are users of saf_er alternatives such as vaping and snus instead of deadly smoking.
“But equally, there are many people sincerely committed to the end of smoking-related death, disease and misery, approaching their work with rigour and care for facts, evidence and analysis. I want to salute the people trying to negotiate the painful trade-offs, deadly unintended consequences, and gruesome politics with pragmatism, humility and empathy” Clive Bates a trail blazer and most importantly a truth sayer. Thank you.