E-cigs and intoxication

E-cigarettes have become a huge issue in the past year or so.  I’m particularly exposed to this through work – both because they’re understood as a harm reduction device, which links in with drug and alcohol treatment, but also because one of my colleagues is cutting down on ‘real’ cigarettes by using ‘falsies’.

On Twitter, it would be impossible for me not to notice Gerry Stimson, figurehead of UK harm reduction, extolling the virtues of ‘vape-ing’.  The benefits are obvious (and somewhat similar to why getting someone onto a methadone prescription rather than injecting street heroin might be considered positive): you can satisfy the craving for nicotine, and in a way that helps psychologically, with the same action as ‘real’ smoking, but without many of the dangers, which arise from the burning and inhaling of the tobacco.

The idea has been picked up in the media too with the obligatory ‘smoke’ and ‘fire’ headlines.  Tom Riddington and Lionel Shriver have taken contrasting positions in The Guardian, and The Economist has come down somewhat in favour of them.

All these articles make their own valid points, and there are lots of issues to do with regulation and competition that are important to consider.  Riddington is right to wonder whether vapeing is really safe, but The Economist’s conclusion – that there should be regulation and they should only be sold through licensed outlets – is not quite as straightforward as it seems.  As Clive Bates (via Stimson) has pointed out, too much regulation would hamper the industry and potentially make e-cigarettes less attractive to smokers, defeating the harm reduction message.  On the other hand, if bad consequences were discovered, however small, big tobacco would no doubt use this to its own advantage, trumpeting its (current, enforced) honesty about the dangers of tobacco in comparison to the e-cig manufacturers who touted their product as ‘safe’ smoking.

I can’t navigate through all this to a definitive position, but what interests me about the debate, and the innovation in itself, is Lionel Shriver’s point: that what is really being condemned is pleasure in intoxication.  This is no new thing.  As I have argued before (and will again soon in a slightly different way at the Under Control conference), a key part (in fact the only consistent part) of the definition of ‘binge’ drinking under both Labour and Coalition governments has been people’s motivation for drinking: to get drunk.  This desire for intoxication is what is condemned, with its accompanying ‘different culture’ from the everyday.  This is about a particular morality of government, as academics including Fiona Measham and Karenza Moore and Henry Yeomans have also suggested.  This is why, even if they were proved to have no harmful effects whatsoever, the government would find it hard to cope with e-cigarettes: the very idea of intoxication troubles them (and most authorities).*

There is a whole range of analysis about the Protestant work ethic and productiveness that could be done here – and Henry’s done plenty on this already, and anything on eighteenth-century coffee houses might well still apply for the general middle-class productiveness argument.  What I’m interested in, though, is how this could relate to actual (or potential) smokers or ‘vapers’.

It could be argued that the desire for (or at least attraction of) intoxication is widely spread across the animal kingdom, and therefore this is something of a ‘natural’ urge.  However, as any good sociologist will tell you, we live in a world where we construct meanings around certain behaviours.  Pierre Bourdieu, who’s indirectly been in the news this week thanks to Mike Savage and Fiona Devine (amongst others), pointed out that the meanings we construct around food, for example, relate to our standing in society, reflecting a reinforcing it.  In simplistic terms: working class = food as fuel; bourgeoisie = food as a culture, or almost art.  This is particularly striking with today’s food shows on the one hand and food banks on the other, if you believe Suzanne Moore.

I’ve argued before that these ideas can be applied to alcohol: some people drink to get drunk, and others distance themselves from that idea, claiming that they drink for taste or go out for atmosphere and dancing and so forth – or don’t intend to get drunk, but it’s something that ‘just happens’.  This might (though not always) entail different behaviour.  These different groups (or so I argued in my PhD) reflect and reinforce class groups.

Therefore, we know that, despite the apparent universal animal urge, within and between societies, there are different norms around drunkenness, meaning that not everybody acts the same way when they’re intoxicated.  They don’t all get the same pleasures from drinking.  Some of the pleasure of intoxication is for many (all?) people bound up with ideas of transgression – one might even say the carnivalesque**, turning the world upside down for a moment or two.

What’s all this got to do with e-cigs?  Well, for most people smoking in the UK today, they’ll have grown up knowing the habit is bad for you – it’ll quite likely even kill you.***  I can’t help but think that this is somehow tied up with the attraction of cigarettes: the rebelliousness, the live fast die young ethic, and sometimes a nostalgia for a time that was less safety conscious.  There’s something about the prevalence of smoking in films and TV shows like Good Night, and Good Luck or Mad Men that seems to outstrip the actual prevalence (around 40% through the 1960s in the USA).  Admittedly this is an artistic device to signify that the action we’re watching is from a different time, and my perspective is precisely that of someone who is likely to be taken aback by the very image of someone smoking in an office, but in some ways these points only highlight the key insight: that smoking has something otherworldly about it, something ‘different’ or transgressive.

Perhaps smoking occupies a unique spot in the balance of ‘transgressive’ but not too dangerous.  It’s legal, but it’s known to be harmful at any dosage.  Simply smoking at all is demonstrating something of a devil-may-care attitude (or recklessness, irrationality or weakness of will depending on your perspective).  As Lionel Shriver suggests, with e-cigs: ‘You miss dancing on the dark side – the risk, that hint of wickedness. But since your detractors can't have kittens any more, you get something in return: glee.’

The e-cigarette might give the former smoker (now vaper) a hint of ‘glee’, but it wouldn’t have the same danger and glamour.  In fact, if Shriver and others are right, it would simply be intoxication without danger.  Healthy intoxication.  Now there’s a contrast.  Confusing for government, as I’ve already said, but also confusing for everyone else – and perhaps unique at a time when alcohol – even without drunkenness – is increasingly presented as risky in itself.  Who would choose intoxication without risk and transgression, and is such a thing possible in a society like ours?

The possibilities for changing the terms of debate around drugs and alcohol are fascinating.  E-cigs can’t quite become simply ‘responsible’ smoking, like an expensive bottle of red at a dinner party can be dressed up as ‘responsible’ drinking, if there’s nothing to an e-cig except intoxication; there’s no e-cig Malcolm Gluck – or could there be?  ‘Responsible’ intoxication, in the same way that ‘responsible’ drinking becomes not about content but intent.  Health-conscious hedonists.  But this would still be a twist on the Bourdieusian claim that high-status taste is all about distance from necessity/materiality.  ‘Falsies’ for the dinner party but still ‘real’ cigarettes outside the pub?  Maybe another study on intoxication and distinction beckons…

* There’s plenty of points that could be made here about rationality, understanding citizens and self-government (referencing Foucault especially), but I’ll save them for another, more academic, time.

** OK, so I was saying this back in the PhD, but I’ll still link to Hackley et al because I’m generous like that.  I actually have a slightly different take on things, which I’ll be talking about more at the Under Control conference, so do come along…

*** I’m not referencing these points, but comment if you think I’m mistaken or being misleading.

Data recording and London ambulance call outs

Just a very quick Sunday night* post, partly because I'm feeling guilty: I'd promised myself I'd write something this weekend and I hadn't yet managed it.

Over at Mentor Thinks (a blog I think is fantastic), Andrew Brown posted a little while ago about some data released by the London Data Store covering ambulance call-outs.  He suggested that although there might be data quality/recording issues, the trends shown for what were classified as call-outs relating to 'binge' drinking weren't exactly encouraging, as they had risen recently.  I'm going to use this data release as a kind of case study in analysing these sorts of things, and thinking about some of the many possible factors that might be in play.

Now, as I'm sure those who work with me would testify, looking in detail at these sorts of trends is one of my fascinations, and I'm particularly sceptical whenever rising alcohol-related emergency admissions** are mentioned, having seen the number of diagnoses and codes that go into producing the headlines.  As government and wider society have become more concerned about alcohol consumption and 'binge' drinking specifically, so recording practice has developed - hence the Cardiff Model, for example.

You might call this the observer effect, but actually it's not (necessarily) so much a bias as an attempt to improve the quality of the measurement and data. Admittedly, there's often a political element to this too.  (Think of the drug treatment example in my last post: how does an organisation look like it's doing something useful, or convince others of a particular problem?  Numbers.  Ideally ones with pound signs in front of them.)

At the same time, though, I'd be on sticky ground if I was suggesting there's something wrong with recording all the relevant factors in a call-out, particularly on this blog where I've just trumpeted my commitment to clarity of thinking and transparent, well-evidenced decisions.   However, even accepting new data aren't wrong or a form of exaggeration, it might be that comparing them with the old can be misleading.

In this particular example, I did a quick bit of analysis on the ambulance data to filter out seasonal effects.  That meant creating a rolling 12 month figure for admissions.  This is shown in the graph below.  What you'll see is that there isn't a steady upward trend.  There's a pretty steady rise at first, though 2010 and the start of 2011, but then numbers fall and stay pretty much static till the start of 2012.  However, there's a bit of a wobble, and the new steady (and steep!) rise comes in the past 12 months - since April 2012.

Two things occur to me about this pattern.

First, it seems unlikely that there's been a huge rise in 'binge' drinking since April 2012, particularly given recent reported patterns in alcohol consumption amongst younger people (and that's how the ambulance service are defining 'binge' drinking here - alcohol poisoning where the patient is aged under 40).  (In the report I link to there, Chris Sorek talks about the 'hidden binge drinkers' aged 25-44, who are drinking more than their younger counterparts.  Most of them would still be counted in these 'binge' drinking figures, but this still can't explain what is in fact a one-year trend.)

Second, the three phases of the line in the graph seem to match financial years very closely.  Funding is often granted for these periods, meaning that an alcohol liaison post or a Cardiff Model data lead might start over this period.  Or a new policy might come in.  Just having a new policy in place, or a new member of staff leading on this can improve the data no end - as I'm sure plenty of local area alcohol leads can testify.  The line then would rise consistently, as it does, because each month sees a month of the 'old' regime data replaced in the rolling 12 months by one of the 'new' regime.  A consistent policy would lead to a consistent rise, and a relatively straight line - which I would say we have in the graph.

So, what of the broader pattern?  I don't know, is the answer.  In terms of these stats, we'd have to see what happens after April in the new 2013-14 financial year.  In the meantime, I remain unconvinced that there's been a 25% rise in drunkenness or alcohol-related incidents in London over the past 12 months, as one interpretation of the data might suggest (not Andrew's, I hasten to add!).  I'd agree with Andrew, though, that however you cut the data they don't tell a pretty story.  I'm just not sure whether the story's new.

(I'd welcome anyone else's explanations on what might cause the patterns.  I initially wondered about the Olympics, but for reasons of timing and the sorts of tourism it brought about I can't see that it would have any noticeable effect.  As for Euro 2012, timing again shouldn't make the difference, and I can't see why that would show up differently from World Cup 2010, which is way down where the graph starts.)

*Technically Monday morning by the time I've 'published' it...
**I want to be clear that I don't see any inherent problem with general alcohol-related hospital admissions not moving in step with consumption figures; there might well be a time lag with long-term conditions not appearing.  This is why I think the argument sometimes made by the industry that the two are not directly related is disingenuous.  However, changes in recording practice also have a role to play and should be acknowledged if we're to really understand what we're dealing with.

The First Post

For some time, I've been thinking about starting a blog.  Not so much for other people's benefit as much as for my own sanity, to vent my thoughts on various policy issues.  A particular debate on Facebook reminded me that a blog would probably be a better forum for explaining what I think and why, and engaging in some kind of discussion.

The title of the blog comes from L. Susan Stebbing's book, first published in 1939.  She argues in favour of clarity of thought and argument, which includes a certain transparency and honesty along with logic and appropriate use of language.

I've been struck by the importance of this argument over the (relatively few) years I've been working on policy issues.

In the field of higher education, the debate around the reforms introduced by the Coalition Government was characterised by confusion and obfuscation* on all sides.  One of the Government's key motivations for changing the system was, as I understood it, that lending money to a student to spend on education can be classified differently from 'spending' on the Treasury's balance sheet.  This seemed to pass many commentators and academics by.  The Government wasn't up-front about this and seemed to prefer discussing student 'choice' and market ideology.  Academics also missed the point by claiming the humanities were 'losing' their subsidy.  In simple terms, I'd rather read William Cullerne Bown than Stefan Collini.

To take another example, in the field of drug treatment there's an ongoing debate about how much treatment services and the National Treatment Agency (NTA) should trumpet their value to government with reference to how much crime drug users commit (see the NTA's presentations on investing generally and crime specifically, and Chief Exec Paul Hayes' explanation here).  The question is: does justifying treatment in this way stigmatise service users, and is this a bargain worth making?  Really, many people making this argument think what justifies ensuring people have access to treatment is simply some kind of belief in common humanity.  The crime figures are a front to ensure this happens.  This is just one aspect of the huge confusion and obfuscation (again) that characterises debates about drug policy.  I'm not pretending that these sorts of trade-offs could be eliminated from practical politics, but I think a greater awareness of them (and discussion) would be helpful.

So, I think that clarity and logic should characterise policy debates, and I hope this blog will help in this, adding some insights and provocations.

There are two important caveats to this claim:

First, I don't think that humans are, should be, or can be, completely rational and logical.  (I've been reading John Gray and Michael Oakeshott lately.)

Second, even if a policy can be worked out that is rational and logical (evidence-based), this doesn't in itself mean it should be implemented.  (If you don't believe me, try a former White House advisor.)  There may be conflicting priorities, or values.

Recent debates around 'nudging' illustrate these points well, and something about this might well be my next post, but I think this is enough to be going on with for now!

Please let me know any thoughts you have on any posts, or comments more generally.  Also - follow me on Twitter, as I've just set up an account...

*I like this word because, like esoteric, I think of it as being (almost) performative - if you say 'obfuscate', it's a complicated-sounding word that actually somehow does what it means.