The Worst Letter of 2014 – a review

The 13 December letter by Professors Glantz, McKee, Chapman and Daube published in The Lancet wins my prestigious Worst Letter of 2014 award. There now follows a detailed review…

The Worst Letter of 2014: the body of the letter

We were surprised to read in The Lancet (Nov 1, p 1576),1 Lorien Jollye’s criticisms of the public health community for, as she alleges, insulting and ignoring the supporters of electronic cigarettes (e-cigarettes).

Why so surprised? Vapers have frequently been insulted and ignored by many in the public health community, including by these letter-writers and, ironically, in this very letter.  I’d like to highlight four types of common insult:

1. To dismiss vapers as ‘industry shills’ or ‘astroturf’, which they are not, and, quite reasonably, find offensive. We don’t have to look too far for an example, because it is right here in this letter: the claim that social media behaviour is ‘orchestrated’ and citation 3 provide the necessary offensive innuendo.
2. To dismiss vapers collectively as abusive trolls as if they are a single group acting together.  This is done by finding a couple of tweets from some people somewhere and then using that to smear everyone they disagree with by implying all vapers act that way. Again, there is no need to look too far: this is exactly what they’ve done in this letter, citing a particular tweet and using to make a point about vaping advocates as a whole.
3. Provocatively misstating the science and assuming vapers simply don’t know any better.  For example, in their letter, they assert there is a public health consensus based on their own stated view of the science. To most of those familiar with the subject, their view is that of one faction, not all of ‘public health’, which tends to exaggerate risks, dismiss benefits and make distracting arguments, and it is certainly not a consensus view. These tactics appear so often now that Professor Robert West was recently driven to identify six forms of misleading e-cigarette scare tactics in an editorial in the journal Addiction:  Electronic cigarettes: getting the science right and communicating it accurately. These pervade the arguments from this faction of the public health community.
4. The most serious insult is that they simply refuse to listen to or empathise with vapers’ experience, as if it is somehow worthless, preferring taunts and jeers while claiming victimhood – this letter itself being a good example of that.   I have explained with some care why vapers find this so offensive.  See: Memo to the public health grandees: vaping vapers and you.  Perhaps it is also worth considering how these behaviours match up to the professional standards of public health practice. See my blog: Bullying traits and public health values compared.

I am sure for many vapers reading The Worst Letter of 2014, it will be easy to feel insulted and ignored.  Given the letter itself packs in several insults, I don’t need a lot of examples to make the point, so I’ll just use one:

Perhaps the writer doesn’t know that quisling means: a traitor who serves as the puppet of the enemy occupying his or her country. After Vidkun Quisling, head of Norway’s government during the Nazi occupation.

I’m sure that there must be at least some vapers and harm reduction advocates who would find being compared to a Nazi collaborator, well, a bit of an insult.

Let’s now examine the claim that vapers don’t want to engage…

A recent Lancet—London School of Hygiene & Tropical Medicine Global Health Lab (held in London, on Nov 4, 2014) debating the tobacco endgame, that was widely advertised, was an opportunity to engage on this issue. Yet rather than put forward their arguments, advocates of e-cigarettes instead chose to remain silent in the lecture theatre while insulting the participants on twitter.

Only it was not a debate and not about e-cigarettes…. This event was not widely advertised (if so, where?) and was not an opportunity to engage in debate on e-cigarettes or tobacco harm reduction. This is because:

• The debate was not about e-cigarettes.  The subject was “Can the war on tobacco be won?” and its main subject was the idiosyncratic policy ideas embodied in the ‘tobacco endgame‘ and it’s quite possible that those attending do not believe they are in a “war on tobacco” at all;
• There was no parity. A debate involves giving equal prominence to opposing points of view, not having one side represented by ad hoc and moderated interventions from the audience;
• There were no contrarian views on the platform. All the panellists appear to believe roughly the same about e-cigarettes and no-one present had been invited to represent a positive view of e-cigarettes or harm reduction.

…but the event did provide a rich feedstock for sceptical tweets. A first-hand account by one of those present, The Random Vaper, explains just how feeble and offensive this argument is.  Strangely, the use of Twitter to comment on an event as it is happening is usually encouraged by event organisers. It is not the tweeters’ fault the seminar provided rich source material for satire.  For more on the reasons for critical Twitter commentary, see the first-hand accounts of Chris Snowdon and Dick Puddlecote, who were the other two vapers present – exercising their right to free speech and critical commentary.

…and there is every willingness to debate. Many vapers have suggested discussion or debate in any forum – private or public.  But this has not been reciprocated in person or in writing. Professor McKee declined to engage when offered a platform at the E-cigarette Summit in November 2013, and Professor John Ashton, President of the Faculty of Public Health, was invited in 2014 and also declined to participate.  Both events were well attended by public health experts, academics and officials, chaired by a respected academic and had transparent funding. To this day McKee continues to refuse to meet vapers who have asked him and are open to discussion on any terms. One of my six conciliatory recommendations to public health grandees after their days of disgrace over John Ashton’s ranty meltdown was even less confrontational:

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.

…but I have concluded they not interested in civil debate. I see no sign these academics are interested in an openminded pursuit of truth and insight through debate and discussion. To me, it looks more like a campaign to destroy or obstruct this rising technology through bans, regulation and reputation damage. Also, we know they don’t respond to criticisms when they are put directly to them.  Take, for example, this letter to Professor Glantz: Cease and desist: making false claims about the gateway effect, which he declined to respond to substantively, and this invitation to discussion and debate I offered to Professor McKee, which he never even replied to.

Two things are now clear. First, the advocates of e-cigarettes seem only willing to engage on their own terms.

Another baseless insult. So some members of an audience didn’t speak up at a one-sided meeting organised about something else. Is that really sufficient to conclude vapers are unwilling to engage? Again, a false and sweeping assertion is delivered as a gratuitous insult to the thousands of people who are advocates of e-cigarettes through personal or professional experience. If the authors of The Worst Letter of 2014 wanted a debate they’d have taken the trouble to invite some people with opposing views and actually held a debate about the subject.  If they want a debate, they could have one with many possible protagonists, including me, Peter Hajek, Robert West, Konstantinos Farsalinos, Jacques LeHouezec, Jean François Etter, Ann McNeill, John Britton, Riccardo Polosa, Carl Phillips, Mike Siegel, Gerry Stimson, Lynn Kozlowski, several dozen others and any number of vaper advocates. I doubt they’d take the risk – but if they want to have a debate, why not use their World Conference on Tobacco or Health, 2015, to be held in the Emirati city of Abu Dhabi in March?

Second, anyone with the temerity to suggest that e-cigarettes are anything other than the game changing solution to the problem of tobacco will be subject to grossly offensive attacks,2 with growing evidence that these are being orchestrated.3

This statement is absurd.  The authors of The Worst Letter of 2014, deploy the tiresome technique of inventing and exaggerating the extremism of their opponents and then smearing everyone involved as if they are all like their caricature. Let’s pause to look at what the people who support tobacco harm reduction, in which I include myself, generally think…

• Many scientists, public health professionals, analysts, users and businesses see the potential for non-combustible nicotine products and are positioned in a spectrum of confidence from informed enthusiasm through cautious optimism to constructive scepticism.
• We are united in our concern that ideologically motivated anti-scientific activism is trying to smother technologies that have significant public health potential and could disrupt the market for combustible tobacco, and this could have a great human cost.
• Our goals are focussed on preventing disease and premature death, improving wellbeing and respecting choices made by people, not on condemning nicotine use or vilifying users. We look at the 1 billion deaths forecast by WHO and see this as a promising useful strategy to reduce that toll, perhaps by hundreds of millions.
• We respect the dictum “nothing about us, without us“, and we believe that many important insights come from listening to and understanding people who use these products.
• We are interested in what works. We despair at the denial of the snus experience in Scandinavia, which provides a strong ‘proof of concept’ for tobacco harm reduction, and the apparent indifference to the positive experiences of thousands of vapers.
• We are not, as these writers sometimes suggest, indifferent to population effects – this is why the snus experience is so instructive.  It shows that hypothetical future population effects can be abused by prohibitionist activists to adversely affect policy, and then when the population effects actually turn out to be beneficial, the activists don’t change their negative stance. So the writers of The Worst Letter of 2014 can come back to us on population effects, when they’ve finally accepted they were wrong, and remain wrong, about snus.
• We worry that ethics, inquiry and empathy are being driven out by black propaganda and contempt for nicotine users – and the attitudes that are evident in The Worst Letter of 2014.

So that’s us, how about you?  Our challenge to the writers of The Worst Letter of 2014 does not come in the form of “grossly offensive attacks”, it is a legitimate and evidence-based public health philosophy based on science, empathy and ethics.

Academics complaining about social media are like seafarers complaining about the sea. The overwhelming majority of responses to the views expressed by these authors are restrained, if justifiably exasperated and irritated. But this is to miss the point: social media allows everyone to express a view and no-one to control it.  So if tobacco control high priests say something annoying or wrong, then yes there is the risk someone somewhere in the world will be rude to them – that is what the public in public health can be like – it is not a reason to make a fuss in The Lancet.  Get over it.

Oh, and remember who started it… In terms of grossly offensive attacks, it is the President of the Faculty of Public Health who has made the most distinguished and embarrassing contribution. His disgrace was not mentioned in The Worst Letter of 2014 and edited out of Lorien Jollye’s.  For an account of this sad episode, see here, here, here and… here:

…and even this was used to taunt vapers. This incident also offers a useful glimpse into the taunting of vapers that goes on in social media.  One example will suffice: in contrast to the contrite, if short-lived, embarrassment of the Faculty of Public Health displayed above, this is how one author of The Worst Letter of 2014 sought to build bridges.

Claiming victimhood and underdog status. There’s a hint in The Worst Letter of 2014 that this fearless foursome somehow thinks they are plucky underdogs in this debate (they apparently believe they have shown “temerity” in putting their point of view!). This cannot pass unchallenged.  They have the money, the institutional support, abundant obedient researchers, captured journals, compliant editors, press offices and easy media access, tobacco control conferences, extensive networks, secure tenure, negligible accountability, and the misplaced public trust that comes with having ‘professor’ in your job title. The vapers that these professors taunt have none of this. Is it any wonder that some of them express themselves forcefully through the media that are available to them?

I have already mentioned that the letter contained the usual insulting innuendo about Astroturfing by implying they are subject to an ‘orchestrated’ campaign. I will examine the wholly inadequate basis for that claim based on reference [3] in an analysis of the references below.

One recent example, a tweet directed at two of us, contained a picture of a noose with the caption “your days are numbered”.

So what?  Is Lorien Jollye responsible for that? Some other vaping advocate? Or is it the responsibility of a (perhaps justifiably) angry man that’s had enough, speaking on his own account making a point with his tweet in his way? [Update: he points out in the comments that he was making a point about the destruction of their key arguments by recently released ONS data]? What are the authors of The Worst Letter of 2014 actually saying: that Twitter should be regulated to stop this? That some sort of Vaper High Command should be set up to deal with the unruly vaping public? That any vaper speaks for all others? Britain’s best-known doctor rounds on them thus:

Confusion about the public and professional standards. As I have said before, the relationship between public health professional and the public is asymmetric: no member of the public has any professional obligation to be polite to public health professionals, but public health professionals do have explicit or implicit responsibilities, for example,  see the seven principles in their Code of Conduct and this advice in Good public health practice – General professional expectations of public health professionals, published by the UK Faculty of Public Health.

If they just took these common sense professional guidelines to heart, I think we could make some real progress.

The public health community has listened, but it has also systematically reviewed the evidence.4 Numerous national and international organisations have reached the conclusion that it is possible that these products might help some people who are heavily addicted to nicotine but there are many very serious concerns about their effectiveness, safety, and potential to renormalise smoking.5

Manufacturing ‘concerns’. Some of this statement is actually true: there are certainly “very serious concerns”.  But these writers are stoking them up: manufacturing, amplifying and broadcasting them, even though they are almost all baseless or nugatory. The word ‘concern’ is now ubiquitous in the public health discourse about vaping, usually designating some hypothetical risk for which there is no evidence or quantification, or worse, the claim ‘we just don’t know’ when anyone willing to do some basic work should know. A ‘concern’ is not an evidence-based assessment of material risk.

Claiming to be the voice of public health. The public health community is, thankfully, not one thing and the most credible scientists and researchers actually working in this field do not share these views. It takes a special kind of hubris to claim to speak for “the public health community”, when the writers must know they are a faction. You can see that there is not one ‘public health community’ by reading the three letters written to the WHO about tobacco harm reduction. The faction that the authors of The Worst Letter of 2014 belong to (mainly non-specialists and activists) has not listened at all. If so, when did that happen? Nor has it ‘systematically reviewed the evidence’ because the review published in Circulation [their reference 4] is not systematic in the way that term is defined formally.

No credible review of the science has found risks or fundamental problems. In reality, there is no convincing evidence of any material risks to users or bystanders or any adverse population effects, yet there is plenty of evidence that smokers are taking to these products and experiencing significant benefits. There is also no evidence of ‘renormalisation’ – and certainly not in the study they cite to support this point at reference [5].  They don’t even consider the more likely effect that vaping normalises vaping, an alternative to the harmful incumbent norm.  They just ignore surveys that don’t fit their script – for example the reviews here, here & here present a very different view and are broadly consistent with each other.

Fear-mongering is driving harm-induction. The result of the broader public health ant-e-cigarette onslaught is that only a small fraction of smokers correctly assess the risk of vapour products relative to smoking (very much less), and there is widespread confusion about risks.  As well as poorly perceived risk, there is a disturbing and worsening trend in smokers seeing no difference in risk between smoking and vaping: only 65% of American smokers believed e-cigarettes to be safer than smoking in 2013, down from 85% in 2010.  The result of all that distorted risk communication will surely be: people making badly informed and adverse choices about their health; the protection of the cigarette trade from competition from superior alternatives; and more smoking, disease and death than there otherwise would be. Front line workers, like Louise Ross in an NHS stop smoking service, are appalled by the effect the barrage of propaganda is having.

And this is a further small window how bad it has become.

I hope and expect that one day soon, we will be discussing who’s negligence has contributed to this state of affairs.

Moreover, there are real concerns that they are introducing non-smoking adolescents to nicotine addiction,6 so it is certainly premature to encourage their use. However, the very effective campaign waged by their supporters has ensured that other measures of known effectiveness have almost disappeared from the debate on tobacco control.

Playing the youth card.  In almost all surveys, vaping is rising among young people, but this is an obvious consequence of the products being new and use rising rapidly in the adult population, and adolescents tending to emulate adult behaviours. It is not a cause for a moral panic. What the authors of The Worst Letter of 2014 cannot do is show that this leads to any harm whatsoever.  Indeed it is far more likely that the rise of e-cigarettes among young people is leading to some good by displacing smoking, just as snus has done in Scandinavia. In most surveys (bar one anomaly) smoking is falling as e-cigarette use rises.  As for “introducing non-smoking adolescents to nicotine” this is yet more spin: using US data for high school age students:

1. e-cigarette use in teenagers is much lower than combustible tobacco use (4.5% compared to 20.7%);
2. most of this e-cigarette use is combined with combustible or smokeless tobacco use (3.9%) – this e-cig use is likely to be beneficial;
3. use of e-cigarettes only is very low (0.6%) and it is perfectly possible (and likely) that e-cigarette-only users would otherwise be using cigarettes or other tobacco products if there were no e-cigarettes – again this could easily be beneficial, as it may be diverting young people away from smoking
4. cigarette smoking declined from 15.8% in 2011 to 12.7% in 2013, despite all the alarmism about the rise of vaping and gateway claims – that is the important statistic, showing a welcome decline in smoking as e-cigarette use has increased. We can be sure that the rise in e-cig use caused or contributed to the decline in smoking, but it is much easier to develop a plausible rationale for this than the idea that e-cig use was increasing smoking.

A new survey of American youth: Monitoring the Future, tends to confirm this and highlights the sharp fall in smoking as e-cigarette use has risen. See: New Study Refutes Claim that Electronic Cigarettes are a Gateway to Smoking by Mike Siegel.

Quite a sense of entitlement. The authors of The Worst Letter of 2014 write as if they are owed a place in public debate as if they have a right to airtime and column inches, and so resent the intrusion of something not in their script. To claim that their preferred policies are driven out of the public debate is also obviously absurd. The tobacco control establishment has plenty of opportunities to promote its favoured tobacco control techniques – and the news is full of stuff on plain packaging, banning smoking in cars and parks, taxing the poor and mentally ill and so on.  It is plain silly to complain that vaping is obstructing any debate on these things, especially given the enormous public sector, foundation and charitable resources thrown at tobacco control and against e-cigarettes.  If the authors of The Worst Letter of 2014 really are losing public interest so catastrophically, then it might be worth asking why, and then listening carefully to the answer.

The Worst Letter of 2014: the references

Let’s now consider the citations they have drawn on…

1 Jollye L. E-cigarettes in the UK: a more inclusive debate is needed. Lancet 2014; 384: 1576. Full Text | PDF(59KB)| CrossRef| PubMed

2 Mills D. Opponents of e-cigarettes bombarded with abusive ‘four-letter emails starting with C and F’ in bitter row with online cult groups. http://www.dailymail.co.uk/news/article-2656160/Health-campaigners-receiving-incredibly-abusive-emails-bitter-row-alternative-smoking.html. (accessed Nov 27, 2014).

3 Harris JK, Moreland-Russell S, Choucair B, et al. Tweeting for and against public health policy: response to the Chicago Department of Public Health’s electronic cigarette twitter campaign. J Med Internet Res 2014; 16: e238. CrossRef | PubMed

4 Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation 2014; 129: 1972-1986. CrossRef | PubMed

• Polosa & Farsalinos (2014), Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review

• Hajek et al (2014) Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit

• Burstyn (2014) Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks

• West & Brown (2014) Electronic cigarettes: fact and faction

5 de Andrade M, Hastings G, Angus K. Promotion of electronic cigarettes: tobacco marketing reinvented?. BMJ 2013; 347: f7473.PubMed

 6 Dutra LM, Glantz SA. High international electronic cigarette use among never smoker adolescents. J Adolesc Health 2014; 55:595-597. CrossRef | PubMed

Conclusion