Why is tobacco harm reduction such a controversial issue?
And how to solve this problem
I have been working in the field of smoking prevention / cessation for over 30 years, and until a few years ago, the field was pretty consensual. Then, with the arrival of e-cigarettes and later with heated tobacco, the field increasigly became a battlefield with 2 tribes: the pros and the anti-vaping or anti tobacco harm reduction (THR). I want to believe that all the actors in this field want primarily to decrease smoking-related mortality / morbidity and to protect the young from nicotine addiction, but opinions differ sharply on whether and how the new nicotine and tobacco products can achieve these goals. So why is this issue so controversial?
One reason is obviously the presence of contradictory results in the scientific literature. When some studies say black and others say white, how can the reader choose the best ones if he is not equipped with the necessary scientific knowledge or does not have the time to read and critically assess each study ? And there are lots of contradictory results in this literature. The science in this field is heavily biased, with many partisan authors, and if you are familiar with this field, you do not need to read more than the name of some authors to know what their study will conclude.
Also, there are conflicts of interest on both sides of the debate. On the side of the “pros”, some authors are employed by the tobacco / e-cigarette industry or accept payments from it. But there are also serious conflicts of interest on the side of the anti-THR : if you are employed by some government agencies or some academic institutions, it may be difficult for you to progress in you career or to obtain competitive grants if you are openly pro-THR. In this case, it is much safer to side with the anti-THR. There are also non-material conflicts of interest, such as being a reknowned expert in the field, being called by journalists and invited an TV shows, all of which may depend on which tribe you side with. It may be difficult to change sides if your reputation depends on you being identified as either a pro- or an anti-THR.
Indeed, this division can be interpreted as tribal behavior: you are either with “us” of with “them”, and if you are with “them” I will not listen to you, not read your articles or dismiss them, not invite you or talk to you. If you are with “us”, I will forgive the flaws that I see in your research, and I will support you.
These divisions are also fueld by very strong feelings and emotions, e.g. feelings of disgust and anger. Lynn Kozlowski explains this very well. Also, we use 2 systems to think: fast thinking that enables us to make very quick decisions in front of a new situation (system 1), and slow thinking that enables us to rationalize our decisions and to plan strategically (system 2). If your gut feeling tells you that object A is bad, then you will later use system 2 to rationalize your decision to reject A and prefer B. Once you have elaborated a rationalization to justify your decision to prefer A, it will be costly for you to switch to B. This is explained in the famous book Thinking, Fast and Slow by Daniel Kahneman. This model perfectly fits the field of THR.
Understanding these mechanisms may make it easier to produce better science, to design better policies, and to reach a compromise between stakeholders. But producing more and better science will not solve the problem, if the problem is caused by conflicts of interests, strong emotions, and tribal behavior.
I welcome comments and ideas about all these points.
"But producing more and better science will not solve the problem, if the problem is caused by conflicts of interests, strong emotions, and tribal behavior."
As far as I am aware Tobacco Control is a global billion dollar industry funded by taxpayers and billionaires like Michael Bloomberg. People working in TC are the same as the rest of us, they pursue the incentives built into their environment. Those incentives are to find and promote harm, as that is what keeps them relevant and in funding, jobs, careers and reason to exist. It does not seem to matter how trivial, speculative, misleading or as we have seen at times, how fraudulent such claims are they continue to be made because without harm they lose relevance, hence funding, jobs etc.
I do not suppose most of those working in TC are dishonest, they are to my mind simply being pulled towards the incentives built into their environment like to the rest of us.
I cannot see that changing until such time as the mainstream media decides to do their job and question and challenge them on the many misleading claims they make as a matter of course. But then the media has its own in built incentives that incline it towards easy scare stories etc. Challenging the TC narrative would difficult and troublesome and so far they don't seem to have any inclination towards it.
As a former smoker and now vaper I don't have any real suggestions on how to change this unfortunately. Luckily I am old and happy enough to use the black market until my time passes.
Thank you for your reflections on this important topic. I have been working in government administration on tobacco control for many years, although I do not have a scientific background in public health. Still, my impression is that the controversy is not so much about contradictory findings in the scientific literature. As far as I understand, there is broad consensus that tobacco-free nicotine products are less harmful than traditional cigarettes. We may not know exactly how much less harmful they are, and the long-term effects remain unclear. Nevertheless, most of the available evidence suggests that using these products is less harmful than smoking.
The real controversy seems to stem from the potential trade-off between individual health benefits and the normalization of nicotine use in society. Again, the extent of this effect is debatable, but it seems plausible that making these products widely available—which helps encourage smokers to switch—could also increase overall nicotine use in the population. This is an undesirable outcome, since nicotine addiction is considered a mental disorder and poses a problem for many users who would actually prefer to quit.
So, there is undeniably a potential conflict of objectives. But this conflict is not black and white. Rather than debating the health effects of these products in a polarizing way, we should focus on regulatory questions and ask: How can we ensure that smokers who cannot or do not want to quit switch en masse to tobacco-free nicotine products, while also preventing access for non-smokers—especially young people?
We already have a strong example of how this can work: in Switzerland, anyone in need of medical treatment has access to prescription drugs, while those same products are not available to the general public. I’m not suggesting that nicotine products should be regulated under medical law, but we should apply similar principles: some form of prescription or controlled distribution system, professional guidance, advertising bans, quality control, and regulation of pricing and profit.
The last point—profit regulation—seems particularly important to me. As long as the profits of tobacco and nicotine companies depend on the number of addicted users, they will remain fundamentally opposed to public health goals, regardless of their claims that they want to be part of the solution.