Public Health’s Truth Quandary

It should be obvious that researchers seeking to provide solid evidence that would be helpful in improving the health and welfare of the public would have the highest regard for truth: Not only discovering the truth but eagerly wanting that truth to be revealed. But, if you’re a tobacco researcher in public health, telling some truths is cause for concern because doing so could have “unfortunate effects.” The latest exhibit is a study released by Jessica K. Pepper, M. Justin Byron, Kurt M. Ribisl, and Noel T. Brewer in the journal Preventative Medicine. (paywalled link.)  

The study itself, “How hearing about harmful chemicals affects smokers’ interest in dual-use of cigarettes and e-cigarettes,” is pretty much junk. The researchers asked smokers to consider scenarios in which regular cigarettes are presented as having the same or vastly greater levels of toxic chemicals than e-cigarettes. Not surprisingly, smokers armed with the truthful information about the vast differences in harmful chemicals between the two products indicated they would be more likely to try e-cigarettes. If a smoker were to act on this accurate risk perception, quite naturally, they might try an e-cigarette and could wind up being a “dual user.” The authors declare this outcome to be a health problem. But they do so without fully defining dual-use, nor offering any model of how dual use would exact significant population-wide harms.  (The New Nicotine Alliance and Paul Barnes offer a more detailed scientific critique of the of the study).

One of the more interesting things this study reveals is not about smoking or e-cigarettes, but about the mindset of the authors and their queasiness in dealing with the truth. They offer the following conclusion:

FDA is required to publicly display information about the quantities of chemicals in cigarettes and cigarette smoke in a way that is not misleading. This information, if paired with information from advertising or FDA disclosures indicating that e-cigarette aerosol contains lower amounts of those same chemicals, could have the unfortunate effect of encouraging smokers to become dual users or increase their existing dual use under the mistaken impression that they are significantly reducing their health risks.

Ignore the incredibly blinkered bias, unfounded assumptions, and scientifically illiterate conclusions contained in these sentences, none of which follow from the present research. We’ve seen these kinds of assertions from public health researchers dozens of times before. But, these researchers have come face-to-face with another common problem in public health thinking: Telling people the truth–a real truth, not the half-truths they typically traffic in–may not be such a wise thing to do. Telling the public the full truth about the toxicity of cigarettes, in comparison to the relatively low toxicity of e-cigarettes, is worrisome and worthy of debate, according to the Preventative Medicine authors. This worry is a clear marker that intellectual and ethical problems lie at the core of the public health enterprise. How does one wind up in a spot where telling the public the truth about the harmful constituents in cigarette smoke presents a troubling problem? Arguably, telling smokers the truth about the risks of smoking is the most effective public health intervention of all time. But, suddenly, now it’s not such a great idea?

One can only get to where public health is today, becoming a little too uncomfortable with telling a truth they’ve been telling for decades, by holding a number of core beliefs about themselves and the people they claim to serve. Decades ago, public health identified the problem: Smoking was causing untold disease and early death. The solution to this was fairly simple: Get people to stop smoking. This is where public health jumped the tracks and continues to plow through the ditch. Instead of also looking for ways to substantially reduce the harms of smoking, they concentrated exclusively on reducing the number of people who smoke. That was, and is, their singular goal and solution to death and disease attributed to smoking. Another way, one that eliminates by far most of the risk, but not all of it, is unacceptable. Witness the number of reduced-harm tobacco products approved as such by the FDA and championed by public health: Zero. On the contrary, public health has done everything in its power to keep smoking as dangerous as possible. This practice, keeping smoking dangerous, directly serves their singular goal of inducing as many people as possible to give up smoking.  

Once public health began to ignore what it was about smoking that caused harm and refused to look for ways or other products, that reduced that harm, they revealed their prohibitionist goals.  They took an abstinence-only position and got exclusively into the people manipulation business. This was quite obvious for anyone to see. So obvious, in fact, that they had to come up with a euphemistic name for their own branch of soft science: Tobacco Control. When your goal is to dissuade, cajole, and basically propagandize people out of their preferred behavior, and onto the behaviors that you have determined are correct, then any tactic is acceptable if it achieves the desired result. If the truth, in the not-so-enlightened view of public health, may move the public away from the correct, narrowly prescribed behaviors, then the truth is easily viewed as a potential liability.  

Moreover, in even suggesting that when it comes to nicotine and tobacco use there are some truths too dangerous to tell, the stench of condescension is unmistakable. In the mind of public health, if exposed to the fact that cigarette smoke contains vastly more harmful chemicals than e-cigarette vapor, those pesky smokers might get their own ideas about improving their health. Rather than obediently quit smoking, they might become a dual user. In truth, dual use has scant chance of making smokers worse off than continuing to smoke or enduring multiple failed quit attempts. It’s a fairly safe assumption that most smokers who seriously explore using e-cigarettes are already concerned about their health and intend to smoke less. A smoker may know more than public health about their own situation, what might work best for them, the risks of smoking versus vaping, and that dual use harms are mere speculation. But, that scenario is an anathema to public health’s command and control philosophy. It is to see their manipulative influence of smokers, and their prohibitionist endgame, begin to slip away.   

Public health losing control is the true “unfortunate effect” mentioned above. When a researcher, organization or government agency begins to view speaking the truth as problematic, they are not really in the truth-seeking or truth-dissemination business. They are a we-know-best, just-do-as-we-say political special interest group that sees information (truthful or not) as a tool to be selectively used to advance their agenda. When anyone considers employing the truth sparingly, then whatever else they claim could easily be the result of treating the truth as something to be managed and used strategically. That is, when someone from public health acts this way, you should be suspicious they have little intention of being straight with you and are really pushing you toward the limited options they prescribe. You would be right to be wary of their manipulation and deception. Their goals for you are clear. But, are they the right goals for you? That is your decision, not theirs.

Dr. Brian Carter

CASAA Director of Scientific Communications

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