During a
Senate hearing yesterday, Tim McAfee, director of the Office on
Smoking and Health at the U.S. Centers for Disease Control and
Prevention (CDC), described the marketing of electronic cigarettes
as “a huge experiment” and argued that “it is not fair to our
children to ask them to pay a potential price…for a hypothetical
benefit to adult smokers.” In fact, he said, “it is egregious
to suggest that we need to have kids do this in order for adults to
quit.”
McAfee was referring to the fear that e-cigarettes will
encourage teenagers to smoke, both by getting them hooked on
nicotine and by “renormalizing tobacco use” through ads
presenting a safer, less irksome, noncombustible alternative.
Implicitly recognizing the weak empirical basis for that claim,
McAfee said, “We’re not saying it is a
gateway.”
But they are. Last fall McAfee’s boss, CDC Director Tom Frieden,
claimed “many kids are starting out with e-cigarettes and then
going on to smoke conventional cigarettes.” Frieden frequently
raises the possibility that e-cigarettes will “get another
generation of kids more hooked on nicotine and more likely to smoke
cigarettes,” as he put it in an
interview with the Los Angeles Times last month.
Yet as Boston University public health professor Michael Siegel
notes, “there is no evidence that e-cigarette use leads to
cigarette smoking among adolescents.”
McAfee,
like Frieden, presents that scientifically unsubstantiated
worry as more believable than the “hypothetical benefit to adults
smokers.” But as Siegel points out, those benefits are in fact
quite real, since we know that smoking is much more dangerous than
vaping and that many people have switched from the former to the
latter. A
survey reported last month in the International Journal of
Environmental Research and Public Health, for example,
collected information from more than 19,000 e-cigarette consumers
around the world, 81 percent of whom had completely stopped
smoking. The former smokers reported significant improvements in
overall health and in specific functions such as breathing,
endurance, smell, and taste. The researchers, led by Greek
cardiologist Konstantinos Farsalinos, concluded that
e-cigarettes “can be effective even in highly dependent
smokers,” that “side effects are minor,” and that “health benefits
are substantial.”
The sample used in that study was drawn mostly from people
who participate in online e-cigarette forums, who may not be
representative of vapers in general. You would expect e-cigarette
enthusiasts to include a disproportionate number of people who had
successfully substituted vaping for smoking. These are nevertheless
actual people who have experienced actual benefits, in contrast
with the entirely hypothetical group of teenagers who never would
have smoked if they had not vaped first, none of whom has been
identified so far. Notably, only 0.5 percent of the e-cigarette
consumers in Farsalinos et al.’s survey said they were not smokers
when they first tried vaping.
Mitch Zeller, director of the Center for Tobacco Products
at the Food and Drug Administration (FDA), testified at the same
hearing as McAfee, but his comments about e-cigarettes were more
temperate and evenhanded. That is encouraging, since the FDA is
charged with
regulating e-cigarettes, which gives it the power to determine
whether they stay on the market and, if so, in what form and on
what terms. But Zeller’s testimony also highlighted the extent to
which the FDA plans to substitute its judgment for that of
consumers.
E-cigarettes “have the potential to do
good, and they have the potential to do harm,” Zeller said.
“It really depends on who is using them and how
they’re being used.” For instance, he said, “If we look at a subset
of smokers who are otherwise unable or unwilling to quit,” and “we
could get all of those people to completely switch all of their
cigarettes for one of these noncombustible products, that would be
good for public health.” Then again, he said, some vapers might
continue smoking and “start to become less interested in quitting,”
which “might not be good for public health.”
Even that way of framing the issue is too categorical. In
Farsalinos et al.’s survey, about a fifth of the respondents did
not quit smoking completely, but they did cut back, on average from
20 to four cigarettes today. Like the former smokers, they reported
health improvements, although the impact was not as big. Hence dual
use could, on balance, reduce tobacco-related disease and death,
even if some of those smokers might have quit completely had they
never tried vaping.
More fundamentally, the FDA’s approach makes sense only if you
agree that the government should strive to minimize morbidity and
mortality for the population as a whole, as opposed to letting
individuals make their own choices. As Zeller explained, “our
job as the regulator is to figure out what is going on at the
population level.” In other words, it’s not enough to show that
e-cigarettes are safer than the conventional kind, or that
individual smokers can dramatically reduce the hazards they face by
switching. You also have to show that the resulting reduction in
morbidity and mortality is greater than any possible increase in
morbidity and mortality among people who start or continue smoking
because e-cigarettes are available. “I would absolutely concede
that any of these products at an individual level can do good,”
Zeller said, but “the decisions that we have to make are not going
to be made about what might be good for the theoretical
individual.” And that, in a nutshell, is what’s wrong with the
collectivist logic of “public health.”
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