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s2smodern

Joe Gitchell | 24 April 2014

The place of “tobacco harm reduction” in the panoply of public health responses to the cigarette smoking epidemic has a long and generally discouraging history (e.g., filters, “low-tar”, “heat not burn”), but given the substantial and increasing toll from cigarette smoking, and the apparent inability of established policies and programs to arrest these trends, the debate about harm reduction will continue. Below I attempt to inventory, in my mind, the primary foundations of why many in the tobacco control community are so skeptical and concerned about the increasing adoption of electronic cigarettes. I claim no monopoly on insight in to this question and certainly welcome the input and comments from others.

This blog entry originated as an e-mail response to questions from Dr. Gil Ross of the American Council on Science and Health regarding my personal views on the rationale and reasoning behind many public health professionals’ opposition to electronic cigarettes/vaping. I have expanded it and added a few links. These views are solely my own and do not necessarily represent those of my employer or anyone else.

A very important place to start when approaching this question is analyzing and processing the fundamental framing which scientists, advocates and policy makers view the world and their role in improving the human condition therein. [1] I would commend to anyone who wants to grapple seriously with these issues to read the Alderman et al analysis from 2010. I go on to list other contributors to these positions, but I believe that this article is the best starting place to attempt to bridge gaps. A related issue that can contribute to division is judgment on the role of profit-seeking and free enterprise, especially in the health arena.

Next, even though the comparison is far from perfect, I do not think one can overestimate the salience of the “low-tar scars” that many tobacco control leaders either bear themselves or have had branded on them from others who bear them. The history of the low-tar deception and debacle is a cautionary one that started with a very reasonable premise (“the dose makes the poison”) that foundered on the scandalous actions of the cigarette companies to engineer products that tested lower on a machine but when smoked by a human could still deliver an adequate dose of nicotine (and all of the toxins that went with it). This history is well reported in many places (I recommend NCI Monograph No. 13 for more detail). I believe that tobacco control leaders have adopted the mindset of “fool me once, shame on you; fool me twice, shame on me” and they do not want shame. A concerted “compare and contrast” exercise that provides context for how low-tar is alike and dissimilar from the current situation with noncombusted inhaled products is beyond this blog post, but I firmly believe that this is a critical lens through which many view electronic cigarettes warily.

From a communications and “advocacy” standpoint, and given the current unregulated status of electronic cigarettes in many parts of the globe (and particularly in the US where proposed regulations from FDA are expected at any day), taking unambiguous positions that highlight concerns and feature the most troublesome examples can be judged as sound strategy and tactics. It stokes fear (and thus can provide a basis for support for strong regulation) and paints the situation in a Manichean light (with clear “good guys” and “bad guys”). There are many examples of legislative and regulatory efforts where complexity and nuance fare badly (e.g., health care reform and climate change legislation in the US) and these advocates are more than sufficiently savvy to understand these realities.

Before we all decide that hope is lost, it is worthwhile to note that while the preponderance of “mainstream” tobacco control voices have been wary and negative about electronic cigarettes, this position is not monolithic and some are seeking to provide balance (see here, here, and here) that even makes its way in to the lay media. For example, the Washington Post’s editorial from 9 April, while not perfect, does at least achieve considerable balance. And I continue to derive true optimism from the progress that the UK has made over the past fifteen years (see here for details). That should not be discounted, in my mind. And while I certainly have a favorable bias towards FDA Center for Tobacco Products Director Mitch Zeller (based on having the pleasure of working side-by-side with him for 10 years) which may influence my judgment, I would submit that his statements on these topics have been at the very moderate and “balanced” end of this spectrum.

Disclosure:

I provide consulting services through my employer, PinneyAssociates, to GlaxoSmithKline Consumer Healthcare on their stop-smoking medications and to NJOY, Inc., on their electronic nicotine delivery systems. I also have an interest in a venture to develop a new nicotine medication for the treatment of tobacco dependence.



[1] It should go without saying that I do not construe malice or evil intent as motivations driving positions opposing electronic cigarettes, nor do I question the commitment and sincere desire of those expressing those positions to improve the health of those who use tobacco products and to protect those who do not.