[This article is excerpted from Stop Smoking Start Vaping by Dr. Colin Mendelsohn. Copyright © 2022.]
For decades, tobacco control and public health organizations have sought to stigmatize tobacco, nicotine, smoking and smokers. The invention of vaping, a far safer nicotine alternative which looks like smoking, is a threat to their strongly-held views and the traditional approach.
Attitudes to vaping nicotine are shaped less by the scientific evidence and more by this longstanding prohibitionist approach. Other factors such as moral judgements, values and priorities, politics, vested interests and financial factors also play a role. These considerations help to explain why different organizations have diametrically opposed views, despite using the same evidence.
Australian federal and state governments, Heart Foundation Australia, Cancer Council Australia and the Australian Medical Association oppose vaping nicotine. Their position is in stark contrast to the United Kingdom government, the British Heart Foundation, Cancer Research UK and the British Medical Association, which support vaping nicotine as an opportunity to save lives.
Australia has been successful in reducing smoking rates by promoting complete abstinence from tobacco and nicotine. Tobacco harm reduction has not been part of the traditional approach and is seen by some as a threat to it.
This contrasts with the UK’s longstanding support for tobacco harm reduction. The UK Royal College of Physicians published its first report supporting harm reduction for nicotine products in 2007. This was followed by support from the National Institute for Health and Care Excellence in 2013 and subsequent reports from the Royal College of Physicians in 2014, 2016 and 2021. The 2021 report stated:
“On the basis of available evidence, the RCP believes that e-cigarettes could lead to significant falls in the prevalence of smoking in the UK, prevent many deaths and episodes of serious illness, and help to reduce the social inequalities in health that tobacco smoking currently exacerbates.”
Australia’s zero tolerance of nicotine is not consistent with our approach to other forms of harm reduction. We accept the use of methadone for people who use heroin but not clean forms of nicotine to reduce the harm from smoking, Australia’s biggest preventable killer.
It is also not consistent with Australia’s National Tobacco Strategy and National Drug Strategy, both of which include a legitimate and integral role for harm reduction.
The goal of tobacco control should be to end the death and suffering from smoking, not to eliminate nicotine from society. Nicotine is part of the problem, but it can also be part of the solution as a harm reduction tool. The “war on nicotine,” just like the War on Drugs and other forms of prohibition, is doomed to failure.
Opposition to harm reduction policy has a “strong underlying tone of moralism” according to distinguished Professor of Public Health Ken Warner from the University of Michigan.*
Some opponents of vaping believe that any use of an “addictive” substance is wrong. Anything that looks like a cigarette or works like one and delivers nicotine is seen as sinful or immoral and must be eliminated, and this takes priority even when there are substantial health benefits.
Warner notes “a distinctly puritanical streak within the public health community” that will only accept “Just say no” when it comes to nicotine. It is especially unacceptable if people get pleasure from vaping nicotine, choose to do it recreationally or if the tobacco industry is involved in some way. The game plan of Big Public Health has been to punish, coerce and stigmatize smokers (and now vapers) until they change their wicked ways.
Moral and emotional arguments are common on issues such as illicit drugs, alcohol, the sex industry and sex outside marriage. For example, a preacher opposed to sex before marriage would be horrified at the prospect of distributing condoms to young people, even though this would prevent pregnancy and sexually transmitted disease. In the same way, the moral objection to vaping nicotine will result in more deaths from smoking.
Moral judgements have a strong influence over public policy on harm reduction. This helps to explain why compelling evidence alone is not be enough to bring about sensible regulations on vaping.
Our values, priorities and goals influence how we interpret the evidence. For example, if you believe that even the smallest risk to young people from vaping is not justified at any cost, you will oppose it even if there are substantial and immediate benefits for established adult smokers.
The Thoracic Society of Australia and New Zealand is a vocal opponent of vaping and understandably opposes anything which may harm the lungs. Vaping is not as pure as mountain air and long-term use may cause some harm to the lungs. However, their opposition to vaping nicotine is counterproductive. The harm from smoking is much greater and vaping has the potential to dramatically reduce lung disease in smokers who switch.
Policy decisions involve trade-offs and compromises. Policy on vaping should be based on its overall impact on public health, not on areas of narrow interest. For example, the small potential risk of vaping to young people is dwarfed by the substantial and immediate benefits of quitting by adult smokers. Furthermore, the risk to young people can be minimized with sensible regulation and enforcement.
Tobacco control warriors have long fought a noble crusade to destroy the tobacco companies, whose deadly products kill up to two in three long-term smokers. This industry has repeatedly misled the public, blocked reforms with legal action and put profits before public health. The campaign against Big Tobacco has been driven by science, passion and the high moral ground.
Since tobacco companies entered the vaping market, the focus of tobacco control shifted to attack vaping to punish the tobacco industry. There is a view that “If the tobacco companies are involved in vaping, it must be a bad thing and must be opposed.” As tobacco harm reduction expert Clive Bates explains:
“The war on smoking morphed into a war on nicotine. The machine built for fighting smoking swiveled its gun turrets and started blasting away at the new products and their supporters… The leaders grew up as veterans of the ‘tobacco wars’ and continued their fight on the new fronts.’”
However, this is counterproductive, as nicotine vaporizers are life-saving products which compete directly with cigarettes. Furthermore, the tobacco companies only control a small share of the vaping market. The war against the tobacco industry appears to have taken precedence over the primary goal of public health, which is to reduce the death and disease from smoking.
The tragic irony is that those who oppose vaping are supporting the very thing they are trying to eradicate: combustible cigarette sales. Vaping is a disruptive threat to the very existence of the tobacco industry, just like renewable energy is to fossil fuels. Attacks on vaping to punish the cigarette companies perversely lead to more people smoking and bigger tobacco company profits.
Some public health organizations and individuals are threatened by solutions that may reduce their relevance and try to defend the status quo.
Tobacco control organizations have constructed a machine for fighting the tobacco industry and smoking and now they are saying their machine is still needed to fight the new evil, vaping nicotine. Opposing vaping provides a justification for their continuing role.
They have prior positions to defend, organizations to run, funders’ interests to respect, and rely on government, pharmaceutical and philanthropic funding to support their ongoing research, conferences, wages and campaigns.
However, instead of improving public health, this strategy has the opposite effect and will undoubtedly undermine their reputations and public confidence in them.
Some tobacco control professionals see vaping nicotine as a threat to their legacy and prestige. Vaping was developed outside the tobacco control movement and pharmaceutical industry and triggers the NIH Syndrome (“not invented here”). It is opposed because it was not their idea, and especially because it has the temerity to be so effective. Vaping threatens the abstinence-only narrative they have spent their professional lives promoting.
According to behavioral scientist Rory Sutherland, in his book Alchemy: The Surprising Power of Ideas that Don’t Make Sense, the last thing they want to hear is that “the problem to which you have dedicated your life and from which your social status derives is no longer a problem anymore.”
Mark Tyndall, professor in the School of Population and Public Health at the University of British Columbia in Canada goes one step further. He says:
“Instead of viewing vaping as a disruptive technology that could actually replace cigarettes, ‘tobacco control’ advocates see vaping as a technology that could actually replace them and their abstinence-based programs that are largely ineffective.”
Vaping is a paradigm shift and does not sit well with the traditional strategy of the tobacco control movement.
Governments are driven by minimizing political risk. It is politically safer to take no action on vaping.
Joshua Newman, professor of social sciences at Monash University, Melbourne, wrote about e-cigarette regulation in Australia**:
“Australian governments have not been following an evidence-based approach and, further … these governments are instead content to minimize political risk by either taking no action or by adapting existing legislation.”
Since vaping products are used by a relatively small number of voters and public perceptions about vaping are negative, there are few political rewards for proactive regulation. More kudos can be gained by appearing to be “tough on the tobacco companies” or “protecting our children.”
Public health policy should always be based on the best available scientific evidence. However, in reality this only seems to occur when the evidence aligns with political objectives.
According to Professor Steve Allsop, former director at the National Drug Research Institute at Curtin University, “research is about evidence, fidelity and logical argument while politics is about the next election, perceptions, bargains and timing.”
Groupthink (or “tribalism”) is “a phenomenon that occurs when a group of well-intentioned people makes irrational or non-optimal decisions spurred by the urge to conform or the belief that dissent is impossible.”
Groupthink operates within public health organizations and is a powerful and disruptive force. “Smart people are vulnerable to putting the tribe before truth,” explains Yale psychology Professor Dan Kahan. Even smart people with good scientific literacy interpret the evidence selectively to reach a view that is consistent with the views and identity of their tribe. At the same time, they dismiss evidence that undermines the group beliefs.
Compliance is understandable. Taking a contradictory view on vaping risks career and funding opportunities, and disapproval from peers. It is safer to “follow the flock.”
At a national level, the Australian health organizations are locked in an echo chamber of groupthink on vaping. Organizations typically justify their position based on the support of other groups with similar views.
New technologies generate fear and skepticism and are often resisted even when there are substantial benefits.
In the book, Innovation and Its Enemies: Why People Resist New Technologies, the late Professor Calestous Juma from Harvard University explains how innovations that are widely accepted today, such as coffee, margarine and refrigeration were ferociously opposed when first introduced. He writes:
“Claims about the promise of new technology are at times greeted with skepticism, vilification, or outright opposition—often dominated by slander, innuendo, scare tactics, conspiracy theories, and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks.”
Vaping is a serious financial threat to organizations that benefit from tobacco taxes.
Tobacco taxes generated AUD$17.4 billion in Australia in 2019-20, the fourth highest tax after company tax, income tax and goods and services tax. As tobacco researcher Dr. Carl Phillips notes, “Governments derive enormous revenue from taxing cigarettes and generally lose that when smokers switch to vaping.”
It is often said that the government is addicted to tobacco tax revenue more than people are addicted to smoking.
The Australian government frames tobacco tax increases as a public health strategy. However, most smokers believe it is a cynical tax grab by a greedy government, exploiting and punishing smokers for their addiction. Tobacco taxes are having a diminishing effect on smoking rates at the current eye-watering levels but they certainly help to balance the budget. The vast majority of this money goes into general revenue and only a tiny portion is used to help smokers quit, the stated aim of the policy.
Without combustible products, there is no need for tobacco control organizations. Their existing infrastructure was built on the harms of smoking and it has to find new harms to maintain its relevance and funding.
Phillips says, “The very people who lead anti-smoking efforts have a serious financial conflict of interest about succeeding,” and vaping is clearly a threat.
Vaping nicotine is also opposed by Big Pharma in Australia. Vaping improves health and reduces the need for medicines generally and stop-smoking medication in particular.
In the United States in 1998, 46 states and some territories came to an agreement with the tobacco industry called the Master Settlement Agreement (MSA). The industry agreed to pay the states each year a sum based on their smoking rate to compensate for the costs of treating sick and dying smokers. Some states arranged to borrow against this future income stream but got into difficulties when the decline in smoking rates fell faster than anticipated after vaping became popular. The states with the greatest resulting financial debt are also the very states most hostile to vaping.
Funding of organizations by philanthropists can also influence policy. Billionaire Michael Bloomberg is strongly opposed to vaping and funds a range of organizations which support his agenda, such as the World Health Organization and the Campaign for Tobacco-Free Kids in the US. Many authorities have questioned the influence of this funding over the scientific integrity of these organizations.
There is a fundamental difference between how medical organizations and consumers view vaping.
The traditional medical model involves going from smoking to complete abstinence as a medical treatment, with professional support and counseling and pharmaceutical aids. Medical treatments are not “enjoyable.” They are delivered by doctors and are managed by the medicines regulator, the Therapeutic Goods Administration. Success is when smoking and nicotine are completely eliminated.
However, many vapers see it differently. To them, vaping is about replacing one pleasurable consumer behavior with another, far less harmful one. Vaping allows them to continue to enjoy nicotine as well as the many rituals, sensations and social pleasures of smoking. They learn about vaping from other vapers, Facebook groups and online reviewers. Many appreciate the supportive subculture and hobby component of vaping. Success is when smoking is eliminated.
When a large number of Australians tell lawmakers that something is working well for them, they should listen carefully and respectfully. They should acknowledge their lived experience, “meet them where they are” and empower them to make better decisions about their health.
Vaping nicotine should be regulated by the Australian Competition and Consumer Commission like other consumer products. No other Western country treats nicotine for vaping solely as a medicine and none requires a doctor’s prescription.
* Warner KE. How to Think—Not Feel—about Tobacco Harm Reduction. Nicotine Tob
Res. 2018
**Newman J. Evidence-based policy or risk minimisation? The regulation of e-cigarettes
in Australia. Evidence & Policy. 2019
Top photograph by Waldemar Brandt on Unsplash
Stop Smoking Start Vaping, by Dr. Colin Mendelsohn, dispels the myths about vaping nicotine and outlines the evidence in an easy-to-read style with over 400 scientific references. It also provides step-by-step advice on how to make the switch from smoking tobacco, and why vaping is controversial.