Own-goal concessions by advocates for better low-risk tobacco/nicotine product policy

Major barriers to promoting tobacco harm reduction are premised on two assumptions that are indefensible: “gateway” and “teens should never”

I interrupt my glacial progress through my almost-done drafts to bat out something new. I recently read a couple of scholarly summaries of scientific papers that were challenging some claims that are used to justify draconian tobacco control regulation of vapes and other low-risk tobacco/nicotine products. I was frustrated by the implicit, and even explicit, acceptance of some of the premises of the tobacco controllers.

“Gateway” is an extraordinary claim that requires extraordinary evidence

A common premise of the war on low-risk products is that they are a gateway to smoking. That is, the claim is that the existence or availability of those products will cause some people who never would have smoked to start consuming the low-risk products and then switch to smoking. Making such a claim allows those who want to ban or otherwise interfere with low-risk products to avoid the inconvenient fact that the products are approximately harmless, and claim that they will nevertheless cause substantial harm (the health impact of the smoking they cause). This is, of course, physically possible. But possible is insufficient, so tobacco controllers try to provide evidence it is occurring. Here’s the thing: it is the wrong flavor of evidence.

For some hypotheses it is sufficient to show that the empirical evidence generally matches the claim. Suppose you want to support the very plausible claim that football clubs with higher capitalization do better in their leagues. You can just do a scatterplot of the two variables for one year and observe it matches the prediction. Sure, there will be some confounding, and some incommensurability across leagues, and some lagged effects, and whatever. You could come up with a story that the observed correlation was an artifact of these. But the original claim was close enough to self-evident that demonstrating a correlation with one quick and dirty measure is enough to move forward with the claim as a premise.

Tobacco controllers like to pretend that the plausibility of the gateway claim is close to self-evident, and those arguing against them pretty much never challenge them on this. This lets them present data with correlations that are consistent with there being such an effect, but also are consistent with quite a few alternative hypotheses that involve no such effect, and say “see, there it is.”

Opponents of the claim sometimes respond to this by pointing out the alternative hypotheses or even re-analyzing the data to show that other conclusions are better supported than the gateway claim. But in so doing, they actually tend to support the original claim by giving it too much credit. They implicitly suggest that sloppy quick-and-dirty evidence as weak as what the tobacco controllers always present could support the claim (implicitly: because it is self-evidently plausible) but for technical reasons one particular bit of supposed evidence does not really support it. But the gateway to cigarettes claim is not almost self-evident. It is the furthest thing from that. It is an extraordinary claim, and so demands extraordinary evidence, carefully designed research that produces correlations that could not possibly be explained with any remotely plausible alternative story.

If you ask a proponent of the gateway claim to tell you why they think it is even plausible (always what you should do with things like this if you get a chance!), you are likely to just get sputtering in response, because they have never actually thought about this rather important point. Once they settle, you will probably hear something like “because people who use one drug (or delivery system) move on to more harmful ones”, which is an empirical claim that has pretty much never been supported for any such “moving on”. It was discredited when it was manufactured to support wars on cannabis, and it is certainly not a common enough phenomenon that you can just assume it will appear in any circumstances. Just ask the billion coffee drinkers who have never “moved on” to cocaine. Or the hundreds of millions of tea drinkers who refuse to “move on” to coffee even though it is better in every way.

But that is not the strongest argument against the gateway to cigarettes claim. The knockout argument -- one that should appear every time someone is responding to a gateway claim -- comes from unpacking exactly what the claim is (something proponents never do, for obvious reasons).

The claim is about someone who would never have smoked in a world without vaping (otherwise it is not a gateway case), perhaps because of the universally-known health risks, or the aesthetics, or the inconvenience, or the social disdain many communities now have for it. That person takes up vaping, and thus have a nicotine consumption method that they are accustomed to and that avoids whatever motivation that made them someone who would never have just taken up smoking. And then some dark magic occurs, and they forget about whatever it was that would have kept them from smoking in a world without vapes, ignore all the other disadvantages of smoking, and take up a practice that they are unaccustomed to and that most newbies find distinctly unpleasant except for the nicotine delivery (which they already have in a pleasant low-risk form). Why would someone ever follow that path? Yeah, ok, it is possible. There are a lot of people in the world, so it has probably happened once. But it is difficult to believe it is anything other than vanishingly rare. It seems unlikely enough that we should demand extraordinary evidence before seriously considering it to be true. The weak evidence that is produced to supposedly support this extraordinary claim is along the lines of saying “there is life on Mars because water is consistent with life and we found water there.” Mere consistency with the part of the story is adequate for a quick confirmation of claims that are apparently true, like with the football clubs example, but far more is needed for a claim that contradicts reasonable expectations.

The key thing the proponents of the claim would have to argue is that smoking is somehow better than vaping (have you ever heard them say that?). Something like my jab at tea drinking -- coffee tastes better and delivers more caffeine, and so it makes some sense to move on to it. If we steelman the gateway proponents’ argument for them, because they never actually defend it, it seem to pretty much come down to those same possibilities. Their claim could be that smoking quickly delivers a bolus of nicotine, and a lot of would-be never smokers who learn nicotine is nice by vaping decide they like the delivery trajectory from smoking enough better that they will accept the massive additional costs of smoking. This claim would require some serious empirical support (whereas it is actually contrary to most of what we know). But if they made this claim, it would also be an argument for easing restrictions on vaping technology (and other smoke-free products) so vaping can better mimic that aspect of smoking. Since they don’t want to do that, they would never make this (plausible, but unlikely and unsupported) argument. That leaves them arguing that a nontrivial number of these would-be never smokers discover they like the taste and other consumption aesthetics of smoking a lot better. Pretty much no one without a long history of smoking feels that way. And this too would suggest reducing restrictions on vaping technology so everyone has a vaping option they prefer to smoking.

Pretty much the only way to get a real gateway from vaping to smoking is to slam the door shut on vaping. Make vaping difficult enough compared to smoking for a population, and a fair number of people who vape will take up smoking. It happens for short periods when people travel to a place where vaping is criminalized but smoking is considered just fine. Usually they switch back to vaping when they can (I have never had anyone tell me they didn’t) but some might not. A policy change, however, can cause that at the population level. Needless to say, this possible real gateway effect is a strong argument against more regulation, not in favor of it.

But teens should not vape at all

This convenient, debate-ending mantra is not only implicitly endorsed by many proponents of low-risk product availability, but explicitly stated by them. The important subtext that is always present is “...and that is true to a degree that muscular intervention is warranted.” Perhaps some of the pro-availability advocates who endorse this position really mean just “in my vision of perfect world, teens would not use nicotine at all, but it is not that big a deal and so is not worth worrying about”, but unless they spell that out very clearly, they are endorsing the message that people hear: “teen vaping is such a bad thing that a hope of reducing it a little bit is sufficient to justify denying adults free choices about a low-risk consumption choice, lowering adults’ welfare by raising prices and restricting technology and availability, and funding a massive regulatory and enforcement apparatus, one which does a lot of direct harm.”

Someone might actually believe this, of course (probably never having thought it through, and certainly never having run the numbers, and probably being generally clueless about nicotine), but they have hijacked the popular sentiment “all else equal, I would prefer teens never do this” as if it were the same as their extreme position. Every time someone repeats the mantra to try to say “hey I’m one of the good guys! see, I hate all teen vaping too! but that does not mean….” they play right into this.

There are a lot of things that it would probably be better if teens did not ever do, all else equal and no costs incurred to make it happen. Going to nightclubs or watering holes seems like it belongs on that list. We deal with that via age restrictions and just enough enforcement that the restrictions are mostly obeyed. Try to imagine anyone imposing restrictions on those adult venues that were as onerous as what is done to “prevent” (ha!) underage vaping. Driving is something else that kids should probably avoid for their health, but we just let them do it. Canned drinks with heart-stopping levels of stimulants in them, these are barely restricted. Vaping restrictions are wildly disproportionate to the level of risk, or adultness, or fun, or needed responsibility, or whatever it is that makes people say “teens shouldn’t” about these things.

But I will go a step further and say that it is far from self-evident that even the weak “all else equal, it would be better” version of the claim is justified. There is the obvious point that teen vaping displaces some teen smoking, which is obviously a good thing. It plausibly displaces use of other drugs. Youth vaping also probably prevents some kids from being put on psychiatric medicines -- the same ones that smoking filled the niche for back in the day -- and there is no reason to think a vaping habit is worse than an Adderall habit by any material measure. Someone who merely says, “if I could magically eliminate all youth vaping without it costing a dime or inflicting costs on adults, I would do it” has a pretty tough case to make that their choice would bring about a net improvement in the world. And this is even without even introducing arguments about teenagers being people, with rights and preferences, not just objects for adults to control. I don’t recall ever seeing someone make a case even for the weak version. They just recite the mantra. Those who don’t want to support justification for bad policies should not do so.

I happen to think that the best argument for teenagers to delay taking up vaping, or any drug use including caffeine, until they absolutely need it to get through the day (whether that be college, or age 30, or age 60) is that the benefits most drugs offer someone over their lifecycle is finite. They stop working as well (however one personally defines working well) the more you use them -- true for pharmaceuticals, true for mild focusing stimulants like coffee and nicotine, true for alcohol. There are some reasons to believe this diminishing of value is particularly accelerated when starting early. So put it off. Kids are full of energy and have an endless parade of novelty and fun,¹ and so why waste the drugs early? My message to teenagers is that they will be glad that nicotine and caffeine still have a kick when they are decades into adulthood drudgery, and that alcohol or cannabis is still a celebratory experience or intermittent relief from a bad day, rather than something you just do routinely. That seems to land very effectively with them, far more effective than the demeaning and obviously absurd scare tactics they are normally subject to.²

1. I am, of course, sadly aware that some childhoods are not happy and fun and stimulating. That is a bigger problem. And I am aware, as I already noted, that some kids benefit enormously (and largely interchangeably) from drugs like nicotine, caffeine, and their pharmaceutical ADH treatment cousins. The proposed admonition would undoubtedly fall flat with such kids, and for good reason.

2. For those interested in my additional advice to young people on these points: This advice about drugs for fun also extends to quite a few medical treatments (e.g., don’t make steroid treatments a regular thing until you absolutely have to). Don’t snort anything; the danger of a drug becoming harmfully captivating (addictive, in the real sense of the term) increases dramatically with the resulting instant delivery. If your friends are swallowing mystery pills, I don’t recommend it, but it is probably not a big deal. But don’t do the crust-and-snort thing. Similarly, if you insist on using cocaine, try the Sherlock Holmes solution Also, avoid gambling entirely; it poses a much bigger risk of becoming harmful than a bit of social drug use. Save opioids for when and if it is unbearable to not have them, or you have decided that your remaining life is de facto hospice; those can really mess you up fast. Make a plan to experience heroin when you are very old and don’t touch them until then if your health allows. (If you know a high school health class that would like to have me in as a guest lecturer on the topic, let me know.)