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Manufacturing Harm: A Public Health Initiative Gone Horribly Wrong

The Early Days: Smoking and Health

The harm of smoking cigarettes was, long ago, of concern to a grassroots group of medical professionals and others interested in seeing a reduction in the harms resulting from smoking cigarettes.

1962 – Royal College of Physicians

The landmark 1962 report from The Royal College of Physicians titled Smoking and Health, noted:

“The harmful effects of smoking might be reduced by efficient filters, by using modified tobaccos, by leaving longer cigarettes stubs or by changing from cigarette to pipe or cigar smoking.”

1964 – US Surgeon General

That report was soon followed by the 1964 report of US Surgeon General, Luther Terry: Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, which discussed reducing harm by what would one day become known as nicotine replacement therapies. NRTs have low or no harmful effect, but have turned out to be ineffective for many nicotine consumers.

“The administration of nicotine mimics the subjective effects of smoking. In uncontrolled experiments Johnston administered nicotine hypodermically, intravenously, or orally to smokers and non-smokers. Nonsmokers found the effects “queer,” whereas many smokers, including Johnston himself, claimed the subjective effects to be identical to those obtained by inhaling cigarette smoke and found that the urge to smoke was greatly reduced during nicotine administration.”

The report goes on to say:

“Of the methods cited above, those which deal with the psychogenic drives have been the more successful since ultimate realization of the goal involves the firm mental resolve of the individual to stop smoking.

Something the clever tobacco controller might realize is that bans, evidence of harm, restrictions and a certain amount of convincing might be required to give the cigarette smoker that ‘firm mental resolve’.

Notably, the 1964 report defined smoking as habituation rather than addiction:

“The tobacco habit should he characterized as an habituation rather than an addiction. Discontinuation of smoking, although possessing the difficulties attendant upon extinction of any conditioned reflex, is accomplished by reinforcing factors which interrupt the psychogenic drives.

Identification of smoking as habituation acknowledges the persons agency in deciding to quit, as opposed to addiction where the temptation is to assume the addict has not control or agency, will do almost anything to continue their addiction, and requires the help of others in order to stop.

1988 Report by the US Surgeon General

The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General

“The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.”

“Chapter V demonstrated the commonalities between tobacco use and use of other drugs such as heroin and cocaine.”

“The report further concludes that the processes that determine tobacco addiction are similar to those that determine addiction to other drugs such as heroin and cocaine.”

Media Stories on the Report

The article by the New York Times reported Surgeon General Asserts Smoking Is an Addiction:

The Surgeon General of the United States warned today that nicotine was as addictive as heroin and cocaine and recommended the licensing of those who sell tobacco products and tougher laws prohibiting their sale to minors.

… Asked how he would word the warning, Dr. Koop said that he would say that tobacco products were “just as addictive as heroin and cocaine.”

That seems to be Dr. Koop’s personal opinion, as it is not supported by statements in the 600+ page report he was referring to!

The Lawrence Daily Journal-World article: Nicotine is addicting, surgeon general asserts identifies one possible reason why Dr. Koop went beyond the findings of the report he published.

WASHINGTON (AP) — The surgeon general declared today that nicotine is addictive like heroin and cocaine, a finding that came as no surprise to researchers but which will provide new ammunition for anti-smoking forces.

The significance of the report by C. Everett Koop is not that it unveils new scientific evidence, but that he organized existing research into a systematic presentation lumping nicotine with heroin and cocaine as physiologically addictive substances.

See also Twitter thread in which I discuss this in more detail.

The Rise of the Machinations (of Tobacco Control)

N-gram for “Tobacco Control”: 1975-2019

The concern over the health of people who smoke gradually morphed into a desire to control both the supply and (more importantly, given that had little effect) the demand for nicotine products. While the term ‘tobacco control’ had been appearing at a low and steady rate for decades, it began to rise in the 1980s and reached a peak between 2000 & 2005. The WHO Framework Convention on Tobacco Control was established in 2003. While it paid lip-service to Harm Reduction via Article 1d, the bulk of the document was focused on limiting supply, demand and tobacco industry influence on government decisions (which has since been interpreted much more widely than the original intent of Article 5.3).

The Rise of the Smokeless, Non-Tobacco Sources of Nicotine

At the same time as the FCTC protocol was developed, a pharmacist from China was looking to find a way to implement the harm reduction alluded to in Article 1d. In 2003, Hon Lik invented the first (practical) electronic cigarette. Sans the fire inherent in smoking, it was a way for consumers to enjoy nicotine without the harmful effects inhaling of tobacco smoke. This was followed later by nicotine pouches.

Although the anti-nicotine and tobacco zealots (ANTZ) had previously treated ‘smoking’, ‘tobacco’ and ‘nicotine’ as being effectively synonyms, they recognized the need to focus on the ‘harms’ of nicotine itself.

The Nutt Paper

In response to these attacks on nicotine, Professor David Nutt et al published Estimating the Harms of Nicotine-Containing Products Using the Multiple-criteria decision analysis (MCDA) Approach. Their assessment of nicotine vapor products being likely at least 95% less harmful than smoking cigarettes sent the ANTZ into a tail-spin. Some criticized the (funding) connections (current or long passed) of some members the committee, others began saying that they did not know the long term harms of nicotine use, still others did both.

The criteria used to determine that estimate: Definitions of the evaluation criteria for the nicotine products (Table 2 of the paper).

Criterion Description
Product-specific mortality deaths directly attributed to product misuse or abuse as in the case of accidental and deliberate poisoning
Product-related mortality deaths indirectly attributed to the product, e.g. death due to cancer, respiratory illness, cardiovascular disease and fire
Product-specific morbidity damage (morbidity, chronic ill health) to physical health directly attributed to product misuse or abuse, e.g. ulcers, lung disease, heart disease
Product-related morbidity damage to physical health indirectly attributed to product misuse or abuse, e.g. bums, allergies
Dependence extent to which the product creates a propensity or urge to continue use despite adverse consequences and causes withdrawal symptoms on cessation
Loss of tangibles extent of loss of tangible things (e.g. income, housing, job)
Loss of relationships extent of loss of relationships with family and friends
Injury the extent to which the product increases chances of injuries to others both directly and indirectly, e.g. traffic accident, fetal harm, second-hand smoke, accidental poisoning, burns
Crime the extent to which the use of the product increases criminal behavior (e.g. smuggling) directly or indirectly (at the population level, not the individual)
Environmental damage the extent to which the use and production of this product causes environmental damage locally, e.g. fires, competition for arable land, cigarette stub pollution
Family adversities the extent to which the use of the product causes family adversities, e.g. economic well-being, future prospects of children
International damage the extent to which the use of the product contributes to damage at an international level, e.g. deforestation, contraband as criminal activity, counterfeiting
Economic cost the extent to which the use of the product results in effects that create direct costs to countries (e.g. health-care costs, customs) and indirect costs (e.g. loss of productivity, absenteeism)
Community the extent to which the use of the product creates decline in social cohesion and decline in the reputation of the community

This presents an entirely new view of the result that nicotine vaping was assessed as approximately 5% of the risk of smoking, in that most, if not all, of these aspects can be manipulated & amplified by the regulatory environment in which the nicotine vapor products are sold.

The interplay of harms, causes and effects

Aspect Description
Bans & Arbitrary Restrictions Prompts a black market & potentially leads to involvement with the law. Arbitrary restrictions on strength, flavor, tank size etc., prompt extra-legal, gray or black markets.
Stigma Eroding relationships & mental health, leading to isolation.
Cost High taxes force more users into poverty and spawn criminal acts e.g. ram-raids to obtain supply.
Injury To users: black-market causing drop in quality & safety.
To retailers: by ram raids and assault.
Demonizing Nicotine Translates to denomination of nicotine consumers, increasing stigma and isolation & prompting panic among voters who then demand their representatives ‘do something’ about it. (N.B. Separate from denomination of smoking, and given the relatively innocuous nature of nicotine itself, even more harmful.)
Extra-legal, Gray & Black Markets Without regulatory oversight, potential harms are amplified.
  • Electrical devices do not meet the electrical safety standards applied to other consumer products, resulting in greater risk of battery explosions and fires.
  • The e-liquid that goes into vapes have unlisted ingredients (e.g. nicotine when banned), ingredients that are poorly measured or specified (e.g. a vape containing over 50 mg/mL nicotine, under the rules of a nation that applies the Tobacco Products Directive). adulterated content (e.g. diacetyl or cinnemaldehyde – banned from Australian e-liquids).
  • No age restrictions enforced.
  • Members of the population who need the products (e.g. pensioners who smoke) either interpreting the ban to mean they are more harmful than smoking cigarettes, or being afraid to break the law. Medical professionals who might otherwise recommend switching, also seeing the ban as indicating harm.
  • … and maybe others as yet undiscovered

How the MCDA criteria feed into harmful effect, which can then amplify the criteria, in a vicious self-escalating circle.

Connections between Condiion & Effects

Clive Bates, in discussing Nicotine And The Weirdness Of Harm notes a major driver for nicotine to be demonised:

“Much safer products pose an existential threat to a powerful interest group. As a profession, tobacco control exists only because of a need to control severe harm to health. A significant part of the professional tobacco control field could ultimately be rendered irrelevant and unemployed by safer forms of nicotine. The whole edifice of careers, grants, university departments, journals, conferences, advocacy campaigns and the personal prestige of anti-tobacco warriors has harm as its foundation.”

As Billy Binion points out in Don’t Be Surprised When Stupid Laws Are Maintained With Force:

“[T]here is essentially one way the state upholds the laws they enact: through men and women with guns. Politicians, then, must be comfortable with the fact that any rules they pass will at some point be maintained via force, and, yes, violence.”

Manufacturing Fear

A key factor in the ANTZ getting what the ANTZ want, is to weaponize the public against the people who enjoy nicotine. The “Mind if I smoke? Care if I die?” campaign helping to instill fear and disgust in the general population.

"Mind if I smoke? Care if I die?" Styles from the mid to late 1950s. Meme first seen around 1992.

“Mind if I smoke? Care if I die?” Styles from the mid to late 1950s. Meme first seen around 1992.

“Mind if I smoke? Care if I die?” uses clothing and hairstyles which hark to the mid to late 1950s, while this was first used as a meme funded by the Tobacco Tax Initiative, established in 1992 via sponsorship from California’s Tobacco Tax Initiative. The anachronistic styles suggest whoever was responsible for this was trying to make a kind of ‘appeal to authority’. The naive observer might interpret the message as meaning that the harms of tobacco smoke were known and understood since the 1950s, and sans further information would assume that the profiteers of cigarettes, the tobacco companies, were funding ways to counter that knowledge for over three decades.

It also spoke to a deeper truth. The ways of tobacco control took decades to work, they wanted to speed things up. By enlisting kids to tearfully ask their parents to quit, or by causing a member of the public to scowl angrily at a person enjoying a cigarette downwind of them, they achieve that with little cost or effort. A member of the public weaponized to their cause is invaluable.

The Glantz of the ANTZ

Prominent in the creation of California’s Tobacco Tax Initiative was Stanton Glantz, then a professor of the University of California.

“… that’s the question that I have applied to my research relating to tobacco: If this comes out the way I think, will it make a difference [toward achieving the goal]. And if the answer is yes, then we do it, and if the answer is I don’t know, then we don’t bother.”

Stanton Glantz, Conference transcript, 1992

A dedicated health professional would be haunted by such doubts, designing experiments and studies aimed at discovering the reality. But Stanton Glantz seems unconcerned with the facts, preferring to take the expedient path to the desired goal.

More on Glantz

The funding of, and focus on, tobacco control was coming to the fore. Significant events and organizations around the time included:

  • 1984: American Nonsmokers’ Rights organisation is established, a project inspired by Glantz that helped weaponize the populace against people who smoke.
  • 1992: The Tobacco Tax Initiative is established in California.
  • 1995: Campaign for Tobacco-free kids is established with funds from the Robert Wood Johnson Foundation, the American Cancer Society and the American Heart Association, among others.
  • 1998: The Master Settlement Agreement is concluded, ensuring funding for tobacco control was paid for by the tobacco industry (or rather people who smoke, as the costs were passed onto them).
  • 1999: The American Legacy Foundation (later re branded as the Truth Initiative) is founded – based on an initial injection of funds from the MSA.
  • 2003: FCTC established. In contrast, the first workable e-cigarette is invented. Hon Lik’s invention should have been the darling of FCTC’s Article 1d (spoiler: it wasn’t).

Fear, Uncertainty & Doubt

Some in Tobacco Control leverage fear, uncertainty and doubt (FUD) when they have no concrete evidence of harm or when they know there is no harm but wish to imply otherwise.

I performed an analysis of submissions (and attachments) to the inquiry into the Use and marketing of electronic cigarettes (E-cigarettes) and personal vaporisers in Australia.

The documents were parsed & searched for the keywords & phrases “may, might, could, potentially, risk, concern, unknown, uncertain, long term” then ranked based on the number of occurrences of those terms, divided by the word count of the document. The raw number was then multiplied by 1000 & forms a Fear, Uncertainty & Doubt Quotient (FUD-Q). Here are the top 10 scores of FUD-Q from the ANTZ submissions.

Sub # Author FUD-Q
249 Dr Becky Freeman 5.02
183 RACGP 1.30
297 Attachment A – Department of Health 1.10
167 National Health and Medical Research Council 1.09
293 Pfizer Australia 1.01
329 Royal Australasian College of Surgeons 0.99
328 Quit Victoria 0.98
313 Professor Simon Chapman 0.84
297 Attachment A – Department of Health 0.80
256 Centre for Adolescent Health, Royal Children’s Hospital 0.80

Top ten quotients for the same government inquiry, this time focusing on the terms “long term, long-term, years, decades”.

Sub # Name FUD-Q
293 Pfizer Australia 0.81
313.1 (Simon Chapman) Supplementary 0.71
226 Department of Health, Queensland Government 0.69
269 Associate Professor Renee Bittoun 0.56
328 Quit Victoria 0.55
276 Royal Australasian College of Physicians 0.54
301.1 Supplementary – Public Health Association of Australia 0.51
183 RACGP 0.49
313 Professor Simon Chapman 0.48
301 Public Health Association of Australia 0.47

“While flavouring compounds found in some ENDS are generally recognised as safe for ingestion, the effects of exposure to these compounds through inhalation is unknown. Limited literature on the topic indicates that most flavourants, in addition to being irritants, may pose appreciable health risks from long-term use.”

Pfizer Australia
Submission 293

Time has moved on since that inquiry. In the meantime, the TGA has issued guidance in the form of Therapeutic Goods Order 110, which lists substances that should not be including in the flavourings of e‑liquids. But those common sense exclusions are ignored by people producing flavourants for vapes destined for the black market. A later TGA decision was to require members of the public who seek nicotine containing vapour products to possess a prescription from a doctor. A prescription most are unwilling to provide, leading to a widespread black market that is growing exponentially with each poor decision coming from the federal government or its medical regulator.

“The paucity of clear findings on the long-term use and efficacy of e‑cigarettes as an aid to quitting smoking leaves this a contested issue and signals the urgent need for more independent and thorough studies.”

The Royal Australasian College of Physicians
Submission 276

With doctors like these, who needs executioners? When 60% (UK) to 90% (India) of doctors believe that nicotine itself causes cancer (the International Agency for the Research on Cancer begs to differ), people who smoke would be better served by the RACP taking the effort to educate doctors on the facts. Instead we get statements from them that would discourage those same members of the public from trying e‑cigarettes at all, let alone using them as a long term substitute for the patently more noxious smoke of cigarettes.

“Similar to the evidence about efficacy for smoking cessation, good quality evidence about long term safety of e-cigarettes is lacking.”

Public Health Association of Australia
Submission 301

“Australia’s peak body for public health”, according to their twitter profile, manage to include both of the previous FUD-laden statements in a single sentence. Points for efficiency?

We Just Don’t Know (How Much Harm We Can Manufacture)!

When the ANTZ of today complain that they don’t know the long-term harms of nicotine vapor products, it is easy to imagine them biting their tongue to not go on to add “… because we don’t know how much harm we can manufacture in the next 50 years!”