Understanding the war on vaping
By Clive Bates
How did vaping emerge, and why do so many in public health oppose it? It is a perplexing question, but the explanation starts with innovation.
The essential development was progress with a critical technology—the lithium-ion battery—that made new categories of consumer nicotine product possible in a compact form acceptable to consumers. Driven by the insatiable demand for miniaturization from mobile phones and other portable devices, these batteries have improved to deliver ever greater energy density (essential for good battery life) and power density (essential for rapid heating and responsiveness to human interaction). In one sense, vaping and heated-tobacco products are novel energy technologies. The critical innovation is that they change the heat source used to form the inhalable nicotine-bearing aerosol from combustion to electricity. Burning tobacco generates the heat, and the tobacco smoke is the aerosol, but the products of combustion are also the prime driver of the disease burden. There is no combustion with electrical heating, so no products of combustion and therefore much lower disease risk. This is the fundamental, game-changing innovation.
Once the lithium-ion battery had overcome the primary heat source problem, innovators had at their disposal a platform for further innovation. In his recent book, How Innovation Works, Matt Ridley analyzes the origins of innovation:
“The main ingredient in the secret sauce that leads to innovation is freedom. Freedom to exchange, experiment, invest and fail; freedom from appropriation or restriction by chiefs, priests and thieves; freedom on the part of consumers to reward the innovations they like and reject the ones they do not.”
So in the relatively open regulatory environment of the past decade, we see a wave of intense innovator activity, all tested and selected in the marketplace through rapid introduction and consumer uptake or rejection in a process that mirrors natural selection in ecology. The surge of innovation includes the emergence of a vast range of flavors and branding, refillable devices, mods and tanks, variable power, temperature control and new heating element designs. It brought on “sub-ohm” devices designed for the consumption of large volumes of weak liquids and “pod” devices designed for the consumption of low volumes of high strength liquid from a compact device. Some of the innovation has been elegantly synergistic. For example, the use of acids in pod devices allowed for the formation of “protonated” nicotine salts, which improved pharmacokinetic nicotine delivery to a level that could rival cigarettes. But these acids also facilitate the use of high-strength nicotine liquids by reducing harshness. Higher strengths mean users inhale lower quantities of liquid, so less heating is required, allowing for smaller batteries and a more compact and consumer-friendly format. That has turned out to be a very successful combination.
Alongside the developments in technology, there have been major commercial and social innovations. Vape shops provide a service that helps people quit, but outside a medical or treatment paradigm without labeling their customers as “patients” suffering from a psychiatric disorder. Innovation has been driven spontaneously through social media with influential product reviewers using YouTube and other social media to exert “selection pressure” on innovators. A vaping subculture of user-driven camaraderie, support, advice, and scientific and engineering insight has flourished and provided users with a sense of purpose and independence of manufacturers and public health activists.
These developments have combined to create a powerful rival “value proposition” to cigarettes and smoking—an alternative way to use the relatively mild lifestyle drug nicotine but without nearly all the lethal side effects. For public health campaigners, it should be a triumph—and recognized as the approaching endgame for the burden of cancer, heart and lung disease, and premature death caused by nicotine consumption through smoking. Isn’t this precisely what we should look for in innovation?
Not everyone agrees.
Despite this promise, thousands of well-funded and dedicated tobacco control activists and academics oppose these developments. The question is: Why? What is driving this opposition?
The coalition opposing vaping is formidable, drawing together the World Health Organization, major regulators, public health agencies like the Centers for Disease Control and Prevention in the United States, hundreds of academics and research funders, health and medical societies, activist groups and journalists. But why has this coalition directed its firepower against tobacco harm reduction, even though many of the same actors would support harm reduction for illicit drugs, HIV and sexual health?
We should start by considering if the opposition is grounded in a legitimate analysis of public health objectives and an imperative to do the right thing. I believe we can dispose of this explanation quite quickly. If that were the case, we would see much more intellectual energy consumed over trade-offs and agonizing over the likely unintended consequences of policy proposals. There would be a richer discussion of objectives, ethical dilemmas, risk, uncertainty and precaution. Even if that discussion came to a result that opposed vaping and tobacco harm reduction, the analysis to reach that conclusion would look very different to the overconfident assertions seen in practice. For example, the call to “ban flavors,” “raise taxes” or “cap nicotine strengths” would come wrapped in concern for the effects on adult smoking cessation, the welfare of adolescent smokers, illicit trade, home mixing and workarounds, and displacement to other risk behaviors. But we never see this.
A common suggestion is to “follow the money,” with an insinuation that the opponents of tobacco harm reduction are pursuing grants, tax revenues and employment opportunities and may have stakes in rival business models. Money plays a role and may have a reinforcing effect. It allows for the opposition to form at a very large scale. However, it does not explain why the money is aligned with opposition to tobacco harm reduction. I think the money follows the prevailing mindset or group think in the field rather than the other way around.
There are two more promising explanations. First, tobacco harm reduction and its innovation model are profoundly countercultural for tobacco control activists and academics. The tobacco control toolkit is filled with punitive, restrictive and coercive tools, wielded with the daunting authority of health and medical experts. It mainly sees the private sector as the root of the problem and governments or nonprofits as providing the solutions. It is called tobacco control for a reason. In contrast, a public health model that works through the free-play of pleasure-seeking consumers interacting with profit-seeking innovators in a lightly regulated and competitive market does not easily fit within that toolbox or that culture.
The second explanation is institutional inertia. Between 1980 and 2010, funders, academics, activists, regulators, politicians and many committed journalists came together and built a powerful fighting machine to challenge Big Tobacco and drive down smoking. But by 2010, the tobacco wars were becoming stale and somewhat intractable and the troops tired and bored. Innovation such as vaping and heated-tobacco have provided new and revitalizing enemies. Over the last decade, the war on smoking morphed into a war on nicotine. The machine built for fighting smoking swiveled its gun turrets and started blasting away at the new products and their supporters. It did that because that is what those organizations do—it’s in their institutional DNA. The leaders grew up as veterans of the “tobacco wars” and continued their fight on the new fronts. The involvement of the traditional enemy, the tobacco industry, made that much easier given the assumption that there is a permanent irreconcilable conflict between the tobacco industry’s interests and public health.
In the medium term, the outlook is pessimistic. Nik Modi, an investment analyst with RBC Capital Markets, wrote in January 2021, “Now that the e-cig/vapor threat has been neutralized, we are expecting much more stable cigarette category trends.” That is the kind of “win” that should cause a rethink by the victors. But in the longer term, I am optimistic. The change in energy technology marks a fundamental shift in the industry. I do not believe it will be possible to suppress this innovation indefinitely, and the tobacco control coalition will suffer fatal reputational damage if it tries.
In his brilliant book, Innovation and its Enemies: Why People Resist New Technologies, the late Calestous Juma showed how innovations that are commonplace today, such as coffee, margarine and refrigeration, were ferociously opposed when they emerged. Juma says:
“Debates over new technology are part of a long history of social discourse over new products. Claims about the promise of new technology are at times greeted with skepticism, vilification or outright opposition—often dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks.”
That describes the opposition to vaping and tobacco harm reduction very well. But it also shows that time and knowledge will ultimately prevail. What a shame that so much more harm will be done while tobacco control activists adjust to disruptive innovation.
There are two more promising explanations. First, tobacco harm reduction and its innovation model are profoundly countercultural for tobacco control activists and academics. The tobacco control toolkit is filled with punitive, restrictive and coercive tools, wielded with the daunting authority of health and medical experts. It mainly sees the private sector as the root of the problem and governments or nonprofits as providing the solutions. It is called tobacco control for a reason. In contrast, a public health model that works through the free-play of pleasure-seeking consumers interacting with profit-seeking innovators in a lightly regulated and competitive market does not easily fit within that toolbox or that culture.
The second explanation is institutional inertia. Between 1980 and 2010, funders, academics, activists, regulators, politicians and many committed journalists came together and built a powerful fighting machine to challenge Big Tobacco and drive down smoking. But by 2010, the tobacco wars were becoming stale and somewhat intractable and the troops tired and bored. Innovation such as vaping and heated-tobacco have provided new and revitalizing enemies. Over the last decade, the war on smoking morphed into a war on nicotine. The machine built for fighting smoking swiveled its gun turrets and started blasting away at the new products and their supporters. It did that because that is what those organizations do—it’s in their institutional DNA. The leaders grew up as veterans of the “tobacco wars” and continued their fight on the new fronts. The involvement of the traditional enemy, the tobacco industry, made that much easier given the assumption that there is a permanent irreconcilable conflict between the tobacco industry’s interests and public health.
In the medium term, the outlook is pessimistic. Nik Modi, an investment analyst with RBC Capital Markets, wrote in January 2021, “Now that the e-cig/vapor threat has been neutralized, we are expecting much more stable cigarette category trends.” That is the kind of “win” that should cause a rethink by the victors. But in the longer term, I am optimistic. The change in energy technology marks a fundamental shift in the industry. I do not believe it will be possible to suppress this innovation indefinitely, and the tobacco control coalition will suffer fatal reputational damage if it tries.
In his brilliant book, Innovation and its Enemies: Why People Resist New Technologies, the late Calestous Juma showed how innovations that are commonplace today, such as coffee, margarine and refrigeration, were ferociously opposed when they emerged. Juma says:
“Debates over new technology are part of a long history of social discourse over new products. Claims about the promise of new technology are at times greeted with skepticism, vilification or outright opposition—often dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks.”
That describes the opposition to vaping and tobacco harm reduction very well. But it also shows that time and knowledge will ultimately prevail. What a shame that so much more harm will be done while tobacco control activists adjust to disruptive innovation.
