Thursday, 27 June 2013

E-cigarettes and a new culture of intoxication?

I've talked about e-cigarettes before, and they still fascinate me as a case study in intoxication, whether it's the comparison with alcohol and the idea that there might be a 'complex', 'premium' aspect to the product beyond the nicotine, or the comparison with medicines.

One of the ongoing issues with e-cigarettes is the possible 'gateway effect'.  That is: if they're not properly regulated, young people will be able to easily get their hands on them, and then they might develop a nicotine addiction and graduate to the hard (harmful) stuff, 'real' tobacco.

Clive Bates has challenged this idea on his blog, and I'm inclined to agree with much of what he says.  However, it led to an exchange on Twitter with Andrew Brown, who pointed out this brand of e-cigarettes, which particularly plays on the connection with 'real' cigarettes.  The packs look like cigarette packets, even down to mimicry of the paper seal you sometimes get, and the e-cigs themselves look almost exactly like 'real' cigarettes, with a 'filter' and a white main section.  The tastes and strengths are described by direct comparisons with certain brands of cigarettes, the word 'smoke' is used right across the website and branding, and the advertising slogan appears to be it's "OK [to] enjoy smoking again".[1]

Andrew has posted very promptly on this, following another Twitter exchange today.  Because he's sensible, thoughtful, and expresses himself clearly, he's careful to note that he's not actually sure what the right action might be.  I'm going to have a go at pinning down what I think, as the next step in what could hopefully be a helpful debate, but as a result this has been dashed off quite quickly, so apologies if it's not as neat and clear as it might be.

The issue here, placing ourselves in the position of all-powerful regulator, is working out what we might want e-cigarettes to do - and what we might not want to see.  So, one of the advantages to making e-cigarettes look like 'real' cigarettes is that they might be more attractive to current smokers, hopefully shifting them to what is generally understood to be a less harmful pastime.  However, the flipside of this is the fear about the 'gateway': if they're so similar, what stops someone (generally understood to be younger) shifting the other way?  And, regardless of age, there's concern from organisations like the BMA that e-cigs, particularly if 'vaped' indoors and in public, will re-normalise smoking, unravelling the apparent effect of the smoking ban that has made smoking seem abnormal.  I can see how this could be the danger with a poster that might seem to say it's OK to smoke again.

You'll probably have noticed by now that I keep referring to 'real' cigarettes, when I could have used a word like 'conventional' or 'traditional'.  This is deliberate.  If e-cigs are seen as a replacement, then the possibility is that they're forever be understood as an imitation, an echo, a shadow of the 'real' thing.

Attending the Under Control conference last weekend got me thinking about the pleasures of drug-taking.  (Well I did drink some ether and plenty of beer.)  So did reading this book chapter by Steve Wakeman about novel psychoactive compounds (NPCs) or as they're more commonly know, legal highs.  The point is, there's pleasure potentially associated with lot of aspects of taking what's seen as an intoxicating substance: the social aspect; something approaching a 'pure' intoxication; conversely an ability not to feel intoxicated; perhaps the frisson of doing something illicit, or frowned upon, or dangerous.

Few people will find the final of these thrills as important as Wakeman's participants, one of whom decided that there wasn't much of a buzz in highs that were legal, and so decided to snort them off his dashboard while driving (though he waited till he was stopped at traffic lights - safety first, kids!).  However, as I've said before, there can be something of a frisson in smoking, knowing that it might kill you.  This could be particularly powerful when combined with the sense of invincibility of youth that means you don't really believe it'll kill you.

This idea of cigarettes as attractive in part because they're dangerous would, I'd suggest, only be strengthened by the view that they are the 'real' thing, in contrast to bowdlerised e-cigs.  Of course, if e-cigs are a nicotine replacement therapy, as the UK Government seems to think, then this is precisely the view that must be taken.  According to this view, and following Ingrid Walker's presentation at Under Control[2], the medicine (e-cigs) is likely to be presented as involving choice and health, compared to the destruction and failure of the tobacco.  (We're going back to Sarah Wollaston's strange claim that tobacco only brings bad breath, disease and death.)

I'd suggest that this perspective - whereby e-cigs are simply there to wean people off smoking - is one that governments can feel comfortable with.  This gives a reason for having an intoxicant on the market - it's there to divert people from another.  However, if we're serious about getting people to move away from tobacco, I'd suggest this dynamic of real/fake isn't helpful.  To some extent, OK-cigs know this, and that's (paradoxically) why they've gone out of their way to mimic traditional cigarettes: they want people to feel that their product is somehow real.

But my point would be that the mimicry can only go so far.  I think it would be more powerful to be able to say:

"Here's something - not a cigarette - that does the same thing, but better.  It gives a high, but without so much danger - and also with more choice of what the device looks like and what the vapour tastes like.  There's much more choice, and less danger."

OK, you lose some of the James Dean frisson, but you can present e-cigs as positive and something worth doing in their own right, rather than a healthy, diet, responsible version of smoking.  You'd also cut down the dangers of re-normalising smoking or offering a gateway to cigarettes.  It is clear that this is in the minds of some people who are currently selling e-cigs, with the shop in Camden quoted in this article sounding like it's trying to carve out a particular niche for the market.

This approach would also have positives in terms of resolving the Wetherspoon's issue.  At the moment, regulating indoor 'vaping' is difficult.  If device manufacturers stepped away from conventional mouldings (maybe branching out into something like these) then that would make it easier.  Perhaps there could be special categories for different types of e-cigs: if you wanted to go down the medicine route, fine, you could make the device look like a traditional cigarette; if you wanted to market it as a new nicotine product, then you have to deliberately move away from mimicry.  Of course, there'd be difficulties in setting down guidelines like this clearly, but there'd be some merit - and it does happen in the field of BB guns, which can't look too much like 'real' guns.

Of course the reason the Government wouldn't feel comfortable with this is that it would be licensing something that could be labelled a new intoxicant.  Although I can't go into it here, I see a general reluctance to countenance the pleasure of intoxication in itself by government, and in this case there's also the additional factor that the drug (nicotine itself, not found in tobacco) cannot be dressed up as 'natural'.  However, in the context of 'legal highs', which governments around the world have struggled to regulate for, there's the possibility that these sorts of debates will be forced to move to new ground.  E-cigarettes are a much easier target than Benzo Fury or the latest NPC, but it's hard not to see the inconsistency in the situation.

Caffeinated drinks offer an interesting comparison.  Coffee or tea might be constructed as 'natural', but Red Bull and Relentless are not.  They are presented in the 'hit' or 'kick' formula that's familiar from the alcohol industry's response to rave culture.  I have heard youth workers and those involved in drug treatment express concern that these could be the next major issue for the substance misuse sector.[3]  And yet they are legal.

There are all sorts of other issues involved in this debate, which I don't have time to discuss here.  Most notably: first, the involvement of 'big tobacco', which I think could actually potentially be a positive thing (imagine if those interests were shifted to selling something less harmful); and second, the nature of addiction and free choice within a market.  However, I'm happy to leave this post with this question: why shouldn't e-cigarettes operate a little like energy drinks, carving out a market niche distinct from their traditional (natural) forebears?  There's plenty of possible challenges to this position - perhaps most powerfully something thinking about addiction - but I'd suggest it's an interesting alternative starting point for thinking about the issue, rather than seeing e-cigs as re-packaged nicotine inhalers.

[1]Alasdair Forsyth has made the interesting point that this approach might be in breach of a code or law, as the e-cigs don't actually produce any smoke...

[2]I should say that I might be mis-representing this as I'm getting it second-hand - I couldn't go as I felt I ought to think of the day-job and go to presentations (which were themselves fascinating) about methadone maintenance and safe injecting rooms.

[3]I think this is somewhat overstating the case, with there still being plenty of heroin use across the country, not to mention ketamine and mephedrone.

Sunday, 16 June 2013

Public health realpolitik

I've written two posts recently about the role of the industry in alcohol and tobacco policy.  The principle behind these was that, following a particular model of how policymaking could or should be done, there's a role for both industries - so long as it's at the right stage of the process: defining what's a problem about tobacco or alcohol, and what sort of government actions are legitimate.  There's less of a role for the industry (if any) in assessing the validity of research evidence.

I started to think about this issue again recently when the Daily Express, amongst others, ran a story noting that the risk of cancer increased with the consumption of just two drinks in a year.  Some responded to this idea by suggesting that the public health lobby was in danger of becoming a 'lunatic fringe', and comparing it to the temperance movement.

This critique is based on the idea that such a small level of risk is largely irrelevant to people who don't live their lives as risk minimisers.  There's also the additional concern around 'crying wolf' that I've noted before with reference to 'binge' drinking social marketing: if you tell people a couple of drinks a year (or even a month) is seriously bad for you, then they might not listen when you're telling them that more than 21 units a week is genuinely risky (if that's a more important message to get across).

There are some fundamental arguments here about the nature of alcohol and the role of public health professionals and researchers.  One of the key distinctions between smoking and drinking in terms of public health ambitions and tactics, apart from the issue of passive smoking, is that there is generally considered to be a 'safe' limit of alcohol consumption.  Indeed, sometimes certain amounts of alcohol are understood to be beneficialThis impression is only strengthened by 'responsible' or 'sensible' consumption levels, which then offer a concept on which to hang a narrative that constructs your own drinking as unproblematic.*

The presentation of this sort of finding that two beers a year might harm your health could be seen as attempt to change this impression.  If just two beers a year can increase risk levels, then the message seems to be that there's no safe level of consumption.  This is certainly what Stephen McGowan thought on Twitter, and to some extent it seems to be the motivation of Ian Gilmore in commenting on the findings that drinking even within the government guidelines can be risky and has links with cancer.

There are genuine arguments here about how best to communicate public health messages.  However, I'm not sure that this is actually based on calculations about how to best to engage people or change their approach to alcohol.  It seems more sensible to view it in the context of the arguments about the appropriate role of the alcohol industry in policymaking and the assessment of evidence.

Taking this perspective, the whole approach of both 'sides' in the debate (public health and the industry) is somewhat dispiriting.  On the one hand the industry steps in to rubbish research findings, when what it's really saying is that regulation of the industry doesn't fit the principles of maintaining the free market and personal responsibility that the government is often keen on in other contexts.  On the other, public health lobbyists are driven to stress that any form of alcohol consumption is problematic, in order to compete with the attempts of the industry to downplay the link between consumption and health harm.

Neither of these positions is helpful for an open, clear debate.  I can get particularly frustrated with a public health position because I think there's real opportunities for great work in this area.  With the move to local authorities there could be steps to improve wellbeing by integrating work with transport networks to encourage walking and cycling, with schools to encourage healthy eating, and with adult and community services to look at fostering the sort of social capital that we know improves health in the long term.  There's the opportunity to take a broader view of people's health, and really consider the wellbeing element as well as health as the absence of sickness.

However, the sort of risk minimisation approach symbolised by the 'two beers' story and all the talk of 'avoidable deaths' is too narrow.  Risk is unavoidable, and all lives end in death.  This isn't just about a critique of the Longer Lives project; I want to suggest that a grown-up debate about wellbeing would accept that sometimes drinking at a 'risky' level could still be beneficial for someone's wellbeing - particularly later in life.  (And this is in addition to the point I've made before about how rationalism needn't be a universal aspiration.)

The reason the public health lobby can't bring itself to do this, I'd suggest, is that it sees itself as locked into some kind of dialectical confrontation with the alcohol industry.  It's taking the view of a hardened haggler in a market: start with a ridiculously low offer, and you'll end up with something reasonable and acceptable, because the seller will start with a price far higher than the item's worth.

I'd suggest that this kind of adversarial approach does nobody any favours.  Public health gets branded as a 'lunatic fringe', and the industry gets labelled as misrepresenting, distorting and undermining research evidence.  Drinkers probably simply get on with their lives none the wiser either way.

My soft spot for corporatism wants me to suggest that this would be the solution, getting everyone together to discuss the issues.  But actually this is a little naive.  I forget that this approach brought down both Tory and Labour governments in the 1970s.  To some extent you could see corporatism, with its views of opposing factions, as cementing this adversarial approach.

But, in that case, how else can we approach policymaking?  How can we ensure that stakeholders take a grown-up approach?  That fundamentally requires a certain level of trust from both sides that the other will be sensible too.  It requires the different players to understand their roles, and stick to them.  Public health won't want to stop (excessively) highlighting the health harms alcohol can cause while the industry keeps its current tack, as that would mean the overall balance of the message to the public on alcohol would be (in their eyes) too positive.

The only way to encourage this that I can see is to have a strong government that is clear about the different roles of the various stakeholders in the policy-making process.  I can't see that being the government we have now.

*This is particularly the case when 'binge' drinking is largely defined in terms of an attitude towards to alcohol (drinking to get drunk), and so those who deny this motivation are able to construct an idea of 'responsibility' that isn't exactly what the public health lobby, at least, would like to see.

Saturday, 8 June 2013

Tobacco funding think tanks

A week ago, The Observer reported that the Adam Smith Institute and the Institute for Economic Affairs both accepted funding from 'Big Tobacco'.  Most people, I would have thought, would find this unsurprising.  I certainly did, but more importantly I don't find it particularly shocking or outrageous.
I'm slightly concerned about writing this post, as it could be read as support for the tobacco industry, and some might see it as naive at best in seeing them as having a legitimate role in society.  I want to make it clear that this isn't what I'm suggesting (or even discussing).  I think it's fair to say that the industry has not always accepted responsibility where it might, and I'm of the opinion that if tobacco were discovered today I wouldn't want it to be legal.  However, we are currently living in a country where tobacco is legal and it is important to analyse how people understand policymaking in relation to this issue.  I want to suggest that a black and white, good and evil framework for understanding the issues is unhelpful, and may serve to fuel people's opposition to public health aims.
As a starting point, it's worth noting that the fundamental basis for the industry funding of think tanks being a news story worthy of attention is that there is some concern about transparency: perhaps the ASI and IEA were being secretive about who gives them money, which potentially contradicts WHO guidelines.
I'd certainly want this information to be openly available, for reasons I'll discuss later, but this wasn't actually the tone of the article and people's responses to it.  According to ASH Chief Exec, accepting tobacco funding 'completely undermines' one's position on related policies.  David Nutt remarked in mock-shock on Twitter 'And they're influencing govt policy?'  Neither of these objections is based on the apparent secrecy; they're attacking the more fundamental (rather than procedural) point that the tobacco industry shouldn't influence government policy, however indirectly.
Setting aside the issue of transparency (which admittedly is genuinely serious and raises fundamental questions about the role of business in policymaking), there are two reasons why I'm not perturbed - or at least, don't think this funding is illegitimate or shocking.
First, I've got a bit of a soft spot for corporatist, stakeholder government/decision-making, which probably influences how I start to think about the issue.  This is probably in part a romanticising of beer and sandwiches and life before Thatcherism - and it's certainly a romanticising of the role the tobacco industry has played in policy debates over the years.
However, it does have a sound basis simply because most policy issues have multiple implications and almost infinite possible perspectives, as I've suggested before here and here.  All policy-making is something of a compromise, so it's probably helpful to listen to a range of perspectives and points.  The tobacco industry will obviously defend itself, but then you'd also listen to a public health perspective, or someone with a more critical view of the role of corporations and profit in society.
Now, this might seem in contradiction of the WHO guidance on tobacco and policymaking, but actually what those guidelines talk about is partnership between government and industry, and voluntary codes of regulation.  They don't suggest banning the industry expressing its views as much as actually participating in the drafting of policy.
The second reason I'm not so shocked is that I think I take a slightly different approach to people's motivations.
The tobacco industry, like the alcohol industry, will use liberal (or libertarian) arguments to claim that individual consumers' choices should be respected and it's simply supplying a legal product in a regulated market.  On the other hand, some public health campaigners would characterise big tobacco as 'evil', self-interested and calculating - or even say that 'evil' isn't a strong enough word.
I'm interested here in analysing these ideas of free market liberalism presented by the industry.  I would emphasise at this point that worldviews and ideology aren't neutral, consistent, coherent, objective or independent and impartial.  My worldview is likely to say something about my background and my current activities (though it won't entirely explain them or be consistent with them).  This is partly because I might try to do things that are consistent with some set of values I consider to be important to me.  However, it's also because a worldview is in some senses a rationalisation of where we find ourselves, to help ensure some kind of psychological coherence.*
That people who work for tobacco firms have free market views isn't just a front; it's likely to be both cause and effect of their working for these firms.  It would be hard to work for an industry if you didn't, at some level, believe in some principles that make the tasks you undertake legitimate, even if this is some warped notion of the 'invisible hand' and the magic of the market that sees individuals' selfishness as part of a functioning mechanism that delivers positive outcomes for all.
The think tanks the Observer article mentions have mission statements that fit perfectly with such an outlook on political economy:
            The IEA is the UK's original free-market think-tank, founded in 1955. Our   mission is to improve understanding of the fundamental institutions of a free           society by analysing and expounding the role of markets in solving economic     and social problems.

            The Adam Smith Institute ... works to promote libertarian and free market    ideas ... the Institute is today at the forefront of making the case for free   markets and a free society in the United Kingdom.

I might be being generous, but I would suggest that those working for these think tanks 'genuinely' believe in these principles, rather than seeing themselves as some kind of Trojan Horse or entryists changing the nature of political debate to benefit their sectional interests.  Their acceptance of tobacco money should not be seen as some kind of Faustian pact, because this is not how they would see it.  Rather, it should be understood as the coming together of two similarly-minded actors in the policy debate.
It is not simply because they're taking tobacco money that the IEA and ASI are against increased regulation of the tobacco industry; the tobacco industry supports these particular think tanks because they are against industry regulation to begin with.  The same arguments apply to Labour and the unions, for example.
This is not a one-way causal relationship, as I've already suggested, and as such this is the point where the importance of transparency comes in.  Worldviews are not neutral, objective or impartial; they are particular perspectives, which owe something to the position and experiences of their adherents.  It's not unimportant that free market ideology in this context benefits big tobacco, and so if the argument is coming from this perspective, that might mean something different than if the claim is coming from a public health expert.  If organisations aren't clear about the sources of their funding it makes it more difficult to assess their perspective.
However, this is quite a different thing to considering the view irrelevant or illegitimate.  The public health perspective is equally as partial when it claims that smoking 'brings nothing but bad breath disease & death'.  The questions are about balancing freedom, profit, health, pleasure - and at a societal level, not as an individual, personal decision.
We don't get any closer to a resolution of the issue by framing the debate as a battle of good and evil.  Instead we should debate openly the principles that should underlie tobacco policy, the perceived problems and benefits of smoking and the industry according to these principles, and then assess proposals as potential solutions to these.  We're not helped in this if we see think tanks as amoral puppets of an amoral tobacco industry.
*I'm not saying that we ever achieve this kind of coherence - and crucially, it's not entirely conscious or calculating, just like worldviews themselves.  (Otherwise we wouldn't need analysis; people would just tell us what they think and that would be that.)  This is a common way of looking at how people understand and negotiate the world across the social sciences, not just in psychology.  The idea of habitus outlined by Bourdieu and others is one example.