The paradox of ecigarettes and health

Another day, another strange article about ecigarettes from the health sector.  This time it’s Annabel Ferriman from the BMJ writing about the recent VIP TV advert.

I thought the ad was strange and in poor taste, but I certainly can’t see how, for example, it appeals to children when it’s almost as far from fun cartoon flavours as it’s possible to be – and at other times that’s exactly when ecigs have been said to be targeting kids.

However, I don’t want to go over old ground on this, and there are ecig ads like this E-Lites one that make me uncomfortable too.  The brief point I want to make here is about a paradox in this kind of concern about ecigs.

Ferriman – like me to be honest in the case of the E-Lites print advert – is uncomfortable with the impression that ecig advertising might attract people (back) to smoking.  Now that seems relatively unlikely, especially given the stats the ONS has just released about smoking and ecig use, but at the same time it could be argued that although so far ecigs haven’t attracted non-smokers, and don’t seem to be increasing smoking rates, up to this point that kind of advertising hasn’t been employed, so we should be cautious about its possible effects.

But here’s the paradox.  According to this logic, manufacturers of ecigs should appeal only to existing smokers.  But if they’re going to do this targeting, they’ll need to rely on the one thing that separates smokers from non-smokers: smoking.  And yet as soon as there’s some attempt to link this new product with smoking, some members of the health community seem to cry foul and claim that, in Ferriman’s words, this is ‘thrusting the habit back in my face’.

The whole attraction of ecigs as a harm reduction tool is that they are similar to smoking, given what we know about visual and physical cues being important elements of habit and addiction.

Of course there’s the possibility that ecig manufacturers could somehow attract consumers without making the product attractive, and target smokers without linking ecigs to smoking, but I can’t easily see how.  I just can’t see how any approach to ecigs can be developed that maintains their effectiveness as a safer alternative to smoking while being acceptable to critics like Ferriman.

Should drunkenness be a crime?

This week a report by Alcohol Research UK and the Alcohol Academy has been published, looking at how it might be possible to improve use of the existing law on serving alcohol to people who are drunk.  I think it’s fair to sum it up (extremely briefly) as noting that there aren’t many prosecutions under this law, leading to a discussion of whether this law could be employed more actively to deal with some of the problems Britain might be said to face in relation to alcohol.  It’s well worth a read in full, as an example of clear, careful, open and pragmatic writing on alcohol policy.

Phil Mellows has written clearly and sensibly, as usual, on the practicalities of enforcing the law, and likened drunkenness to love: it’s hard to pin down in scientific terms, but you know it when you see it.  Rob Pryce wrote briefly about the purpose of having a law that effectively bans drunkenness, asking whether we should focus on the actual offences or harms, rather than some proximate causes.  My interest falls somewhere in between the two.

The whole issue, if we’re interested in thinking about whether this law should exist, and how it should be enforced, revolves around a balancing act: do the pleasures and benefits of drunkenness outweigh the risks of people hurting themselves and others.  Don’t imagine this is an easy policy decision.

A useful example is this context is legislation around driving.  We don’t simply have offences of causing harm while driving, or even driving dangerously (even if no-one was actually hurt); we also have an offence of driving while under the influence of alcohol – regardless of any other factors.

However, in this context, counterintuitively, the offence of speeding is a more relevant comparison.  By definition going at a certain speed in particular areas is defined as dangerous.  The point is that we don’t always focus on just the harmful outcomes when creating laws and regulations, and in certain contexts that seems perfectly natural.

[I should acknowledge that the report was talking about the offence that bar staff might commit by serving people who are drunk; that’s not quite the same thing as making it an offence to be drunk, but it makes it offence to make people drunk, which for some purposes is much the same thing – particularly when there’s a dedicated offence of being drunk and disorderly.  The relevant point is that public drunkenness is condemned, as I discuss in a minute.]

Having thought through the issue in this way, I’m much more sympathetic to the law than I was when debating it with the authors of the report and others on Twitter.  Then, I was taking much the same position as Rob Pryce in asking why drunkenness should be an offence in itself.  However, on balance, I think I still oppose it.  I think there are a couple of issues that set it apart from drink driving or dangerous driving.

First, what is the nature of the relationship between alcohol and dangerous driving, health or crime?

The reason we ban drink driving is that, regardless of norms or morals, people’s response times fall when they’ve been consuming alcohol, which makes them less safe drivers regardless of their intentions or motivations.  By contrast, I’d suggest the relationship between alcohol and violence or other crimes is not so straightforward – and this is Rob’s point to some extent.  Drunkenness is ‘learned behaviour’, as I never tire of pointing out, and so there’s no inevitable causal link in the same way as alcohol damages reaction times.

The case of health concerns is slightly different.  Drunkenness might be a good proxy for quantity consumed, which reflects likely health harm, and thus someone should perhaps stop drinking for their own good as much as anyone else’s.

But here we face issues of liberalism.  It’s my business if I harm my health through drinking – and the only challenge is if there are shared (NHS) costs associated with that.  But once certain activities are deemed problematic, there’s something of a slippery slope, as so many illnesses have patient decisions at some point in the causal chain and thus could somehow have been ‘avoided’.

The second issue is more fundamental.  It relates to how, with each alcohol policy decision, we’re balancing positives against risks to the drinker and others.  There are huge risks with people driving drunk, and it’s hard to endorse someone taking pleasure in the act of driving specifically while drunk on a public road.  It’s quite a different thing to condemn drunkenness not while being in charge of a car, but while simply being.  There are some definite - and I would argue legitimate - pleasures relating to being in that state, though not everyone will enjoy it and some will draw the line of pleasure at different points.

At the same time, though, just like the risks of driving while intoxicated aren’t just about someone’s own driving, but their ability to respond to other hazards or mistakes, so it could be argued that there are greater or different risks associated with being drunk in a public space with other drinkers than at home.  Hence it’s not illegal for you to pour yourself another G&T, but it is if Wetherspoon’s staff do it for you when you already seem the worse for wear.  It's illegal to drive at 40mph in some areas, but not others.

So where does that all get me in my views on serving people alcohol when they’re already ‘drunk’?  I don’t think I’m quite convinced the law should exist, but equally it’s not as straightforward as I’d initially thought: there is a case that says we ban everyone from doing certain things like driving over 30mph in a built-up area on the basis that there are risks regardless of your abilities as a driver and even if the proportion of accidents would be relatively small if we drove at 40mph instead.

Maybe, given the time I’ve given to sceptical conservatism lately, I should put my money where my mouth is and agree with the pragmatism of what is a clear, measured report looking for ways to use existing laws and regulations to address what most people would agree are problems.  Just don’t trample too hard on the carnivalesque – the fictional experiences of Pentheus and Neil Howie don’t bode well.

On the irrationality of drug policy

The reports on drug policy released last week by the UK Government have prompted a raft of interesting responses.  One of the wider interpretations is Desmond Manderson’s piece for The Conversation.

He takes a different perspective from much commentary by going back to basics and asking what prohibitive drugs laws are for, arguing that ‘the legal structure of drug laws is not an attempt to regulate or solve a problem, but on the contrary an attempt to dramatise a worldview’.  That is, prohibition reflects the desire for there to be clear lines between right and wrong and for authority to be able to enforce this.

In such an interpretation, policymakers are seen as being ‘afraid’ of ‘a “permissive” world in which such bright lines cannot be drawn’, making them act ‘like men possessed’.  I’d suggest instead that drug policy is a good case study of how nuanced and complex policymaking can be.

Think of harm reduction measures – and Manderson laments how these are undervalued in drug policy discussions.  Needle exchanges in Britain are a good example of pragmatic policymaking, conflicting with other elements of policy and broader ‘world views’, but somehow working.  Needle exchanges are state-funded facilities that – in one interpretation – facilitate law-breaking.*  But they were established by a Conservative government, and reveal that it is Manderson who is thinking more in terms of ‘bright lines’ than the politicians.

Politicians, in practice, often take a classically conservative view of the world.  That is, they are cautious about fundamentally reshaping policy.  Sometimes this is seen as the result of them being captured by the civil service or focus group findings, and it can lead to the feeling – expressed in relation to Prime Ministers at least from Harold Wilson to David Cameron that they have betrayed their party and the true believers.

Many laws and policies are not followed absolutely.  Whenever anyone (like Peter Hitchens) complains that drugs policies are not enforced, I wonder about driving and the possibility that there might be some people who have not been prosecuted on occasions when they have gone over the speed limit.

The reality of the situation regarding drug laws is not that politicians are ‘possessed’ or even necessarily ill-motivated.  It’s that they would argue – as Paul Hayes does – that drug policy in the UK isn’t disastrous, and there’s huge uncertainty around the potential effects of changing the law.  Yes, the current arrangement is a fudge and a fiction, but that’s the nature of policy and law, and any change is indeed a gamble.

It’s the politicians that are much more comfortable with this idea of inconsistent yet pragmatic compromise than detached academics and commentators.  It’s just possible that an illusion is sometimes better than perfect rationality.  This isn’t to say that we couldn’t improve drugs policy, or improve the debate by being open about the compromises involved, but I’d suggest that the decision-making politicians aren’t possessed – unless it’s by the spirit of Burke or Oakeshott.

*Technically, the offence in relation to drugs is possession rather than use, but the point that there is a conflict with wider world views still holds.