Wrestling with Curiosity and Fear About Nicotine

As Conscienhealth recently wrote, we need more curiosity in the fields of nutrition and obesity. That includes a willingness to challenge our pre-existing beliefs. I submit that this is true in nicotine research, too, even among our most capable researchers.

Risk Perceptions

Last week, JAMA published a report on trends in relative risk perceptions between e-cigarettes and conventional cigarettes held by the American public from 2012 to 2017, relying on two different repeating, cross-sectional surveys. Huang et al noted:

Both national surveys show that from 2012 to 2017, the proportion of US adults who perceived e-cigarettes as less harmful than cigarettes decreased significantly… the perception of e-cigarettes to be equally or more harmful than cigarettes increased significantly.

They also wrote:

Confusion between relative risk and absolute risk of e-cigarettes may contribute to framing bias in risk communication and result in media reports and press releases in which absolute harm is overstated and relative harm is downplayed. Lack of accurate, consistent, and proactive risk communications to the public from scientists may also contribute to the confusion about the health risks of e-cigarettes.

At the same time, JAMA also published a commentary from a prolific UCSF professor, Stanton Glantz, PhD. Professor Glantz has been increasingly vigorous in his opposition to vaping and other smoking harm reduction efforts. He has also contributed to a number of reports that assert its harmfulness (even in the face of criticism—eg, see Villanti et al regarding the claim that vaping reduces smoking cessation). In JAMA, he concluded, based on this assessment of the available evidence:

From this perspective [of overall public health effects], the declining public perception that e-cigarettes are less harmful than cigarettes is a good thing that may turn out to be where the scientific consensus lands as the new evidence on the harms of e-cigarettes continues to accumulate.

Media coverage of these publications revealed the tension between recommendations of Huang et al and Glantz (eg, CNN).

Finding a Middle Ground

Recently, University of Bristol’s Professor Marcus Munafo gave an interview on the BBC Inside Health podcast. He described the debate about nicotine and vaping. He offered a persuasive accounting for the present, stubborn stalemate. Then he concluded with this:

…but to reach that middle ground that you mentioned, that balanced position, does require healthy debate where we genuinely engage with the nuances around these arguments and accept the possibility that we might be wrong. And when you bring very strong feelings to those discussions, it can be difficult to move your position.

Is the kind of genuine engagement Professor Munafo calls for possible? Even in a perception and media environment grounded in the misperceptions reported by Huang et al? Imagine the debate about vaccines if the proportions accepting their benefits or doubting them were essentially flipped. That is the current situation around nicotine and harm reduction.

We must do better and be better – by being more curious!

Today’s post comes from our friend Joe Gitchell, who has devoted his career to behavioral health and especially nicotine and tobacco policy. By way of disclosures, he tells us:

My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including smokeless tobacco and vapor products) to RJ Reynolds Vapor Company and RAI Services Company, subsidiaries of Reynolds American Inc. British American Tobacco purchased Reynolds American Inc. in July 2017. I also own an interest in intellectual property for a novel nicotine medication that has not been developed or commercialized.

Tobaccos, photograph © Sascha Kohlmann / flickr

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April 6, 2019

5 Responses to “Wrestling with Curiosity and Fear About Nicotine”

  1. April 08, 2019 at 10:59 am, David Sweanor said:

    I think a fundamental barrier to the sought genuine engagement and healthy debate on issues of nicotine is the same as we increasingly see on obesity and have long seen on drug use, sexual behaviors, alcohol consumption and anything else where there is (to quote from Allan Brandt’s history of venereal disease, No Magic Bullet) “a persistent tension between a rational, scientific program and a behavioral, moralistic approach”. This insight is also summed up with the quip about respecting those who seek the truth but being suspicious of those who claim to have found it.

    In any discussion it is important to know the underlying assumptions of the participants. To attribute a genuine interest in using science and reason to seek truth is an error when dealing with someone who is motivated by an underlying ideological, religious or financial interest. One should not, for instance, assume that an anti-vaxxer is genuinely interested in the research on vaccines and autism, a creationist on how evolution can explain the human eye or a nicotine abstinence ideologue on the relative risks of alternatives to cigarettes.

    Curiosity is essential in truth seeking. But we also need to use our curiosity in ascertaining whether those with whom we might seek to engage are similarly motivated. Simply put, are we engaging with someone imbued with the principles of the Enlightenment or the Inquisition?

  2. April 08, 2019 at 1:52 pm, Joe Gitchell said:

    David Sweanor’s closing question is an uncomfortable one for me and I suspect for others–I really prefer to assume positive intent in everyone and that by talking things through, we can get closer to understanding.

    Can we hold all of ourselves to Enlightenment principles, and try even harder to embrace the #DiscomfortOfThought?

    I find the links below to be powerful tools and reminders to foster more constructive exchanges of views. Can we at least set the expectation that participants being willing to endorse such practical advice?


  3. April 09, 2019 at 11:10 am, Dave Kalayjian said:

    Hi Joe. Thanks for sharing a very erudite presentation (and response) about this timely topic. From an old curmudgeon, a couple of thoughts. First, I agree with both you and Mr. Sweanor that integrity in scientific or ethical inquiry is a precious, and uncommon, quality. I have long been suspect about business and academic relationships in medical research.The fee for service model of medical practice raises the same concerns in local medical offices. A practice, for example, with an amortized piece of equipment is tempted to over-prescribe use of that equipment. Secondly, I intuitively see very little value, and potential serious downside, to encouraging young people to take up vaping. My grands tell me the practice is becoming widespread, even at the elementary school level. It may make Juul very profitable, but I worry about long term downside. As I said, musings from an old guy! Best, Dave

  4. April 09, 2019 at 3:32 pm, Joe Gitchell said:

    Dr. Kalayjian (aka Uncle Dave!) – your curmudgeonly views are welcome and fair. Thank you.

    The role of incentives of all sort, financial and non-financial, is important to bear in mind.

    I think you won’t hear too many anywhere actually encouraging youth to take up vaping, but short of that extreme is where things get more interesting.

    If folks are keen to dig deeper, I would recommend some homework:

    Watch this amazing “medicine for the community” lecture from Dr. Andrea Villanti of UVM (its blank air for the first 35 minutes; she then presents for about an hour and takes questions for the balance):

    Read the Zeller piece laying out key questions FDA is facing and companion commentaries, and then read Clive’s answers:

    With that pre-work done, I think we can have a more effective discussion about your second point.

    Thank you!

  5. April 11, 2019 at 5:57 am, Joe Gitchell said:

    Prompted be a twitter thread of student journalism opinion pieces on vaping, I remembered this one in the Iowa State Daily from May of 2015.

    I would hope that all of us would approach questions of such import as trying to improve public welfare in the face of the greatest cause of preventable premature morbidity and mortality with the same curiosity and humility as young Ms. Madison Ward.