Read the paper in full here.
Read the paper in full here.
E-cigarettes have split the public health lobby in two. On one
side are those focused on harm reduction, who see e-cigs as a
substantially safer alternative to cigarettes for people who are
already smokers. On the other are those who see fundamental
lifestyle change as the goal for smokers, and e-cigs as an obstacle
Unfortunately, this latter group seems to be winning out.
Although Public Health England found that e-cigarettes are 95%
less harmful than tobacco cigarettes, many public health activists
and lawmakers remain staunchly opposed to the very products
smokers are choosing.1
Why? This essay attempts to understand the motivations of
public health campaigners against e-cigarettes, and outline how,
despite their rhetoric, their actions are making the product
landscape worse for smokers' health.
For decades now, the dangers of smoking have been well-
known and widely publicized. Scientists have a detailed, though
incomplete, understanding of why smoking harms so many
functions of the human body.
Professor Michael Russell observed that "people smoke for the
nicotine but they die from the tar" forty years ago. In his 2009
obituary, The Guardian said Russell "is rightly regarded as the
father of effective treatment to help smokers quit."2
Governments have tried countless different approaches to
get people to stop smoking, including warning labels, plain
packaging experiments, smoking bans, public service campaigns,
counselling and sin taxes. These have worked with varying
degrees of success. Anti-smoking campaigners frequently
overstate their efficacy – for example, recently, Action on
Smoking in Health (ASH) attributed a fall in smoking numbers
to plain packaging, a policy that had not yet been introduced
during the sample period.3
Yet in terms of the speed and volume with which they have
been adopted by smokers, in e-cigarettes and other reduced-risk
tobacco products it is the private sector, driven by the profit
motive, that may have the final answer to the early death and
disease that harms smokers. Smokers want an enjoyable nicotine
delivery without the harm, and if you offer that to them they will
The rapid adoption of e-cigs has been remarkable. Nearly
3 million Britons use e-cigarettes, virtually all of whom are
either current smokers or people who have given up smoking
A 2013 study found that even at that early stage, and
before widespread advertising of e-cigarettes, three-quarters
of US smokers were aware of the devices and almost half were
open to using them in the future.5 And multiple studies 6 have
concluded that smoking e-cigarettes is at least 95% safer than
smoking conventional cigarettes.7
Professor Russell would have marveled at the simplicity:
nicotine, delivered satisfyingly, without the smoke (and other
dangerous ingredients in burned tobacco).
Yet the well-intentioned public sector is failing its own mission
by opposing e-cigarettes and similar products after years of
trying to help smokers quit.
They can be forgiven for not coming up with the answer
themselves, but their failure, and the systemic reason for it,
provides insight into their vehement opposition to the best
Most big tobacco companies had nothing to do with the first
e-cigarettes, but now virtually all are investing in these less
harmful alternatives to cigarettes. They, like the pioneering
e-cigarette advocates, understand smokers better than old-school
public health authorities.
This point bears considering. Despite spending around £200
million of taxpayer money per year on anti-smoking campaigns
(and recently asking for a 50% budget increase, paid for by even
more taxes on smokers), Britain's public health lobby has been
rapidly eclipsed by a private sector whose only real aim is to
make a profit.8
Because their interests coincide with their customers', both
benefit from safer nicotine-delivery products, and they deliver
genuinely effective harm reduction – products that smokers
actually use –far better than the public health lobby's. There is
no substitute for profit and loss.
Lower-risk nicotine products, and even products that contain
zero nicotine but mimic smoking, have ignited debate
throughout the world. The debate is fueled by smokers who
want the pleasure without the harm versus the regulators who
see this phenomenon as a fundamental threat to their basis for
constantly expanding regulatory control. It is a battle between
harm reduction and absolutism.
THE SELF DEFEATING HEALTH LOBBY
Because e-cigarettes are so much safer, and so effective at
getting smokers to quit or cut down, though the lens of harm
reduction every vape shop employee who works with a smoker to
identify a satisfying and appealing e-cigarette should be viewed
as a front-line quit-smoking counsellor. This counsellor picks up
where existing resources couldn't or wouldn't effectively reach.
In fact, the vape shop worker has the potential to be far more
effective, especially for entrenched smokers. Furthermore, he or
she doesn't cost the taxpayer a penny (unless we count the lost
tax revenue that will be lost when the customer quits smoking
and no longer has to pay sin-taxes on cigarettes).9
So-called "public health" officials and campaigners are actively
working to restrict marketing of e-cigarettes, even to adults.10
Yet the advertising of lower risk products to adult smokers
should be heralded as a public health innovation; a privately
funded, effective, public service campaign.
The measures in the EU's Tobacco Products Directive (TPD)
that will affect e-cigarettes are wide-ranging and sharply restrict
the freedom of e-cigarette producers to sell their products to
smokers, let alone to market them effectively or create new,
These measures include a prohibition on making health claims
about e-cigarettes, including their ability to help smokers quit or
to make comparisons between different kinds of e-cig.
Not only does this sharply curtail information available to
smokers (the lowest-information smokers are also likely to be the
poorest and most vulnerable in society), it massively reduces the
rewards to firms from creating a better, safer e-cig or reducedrisk
product.11 If you cannot tell people that and why your e-cig
is better than the alternatives, and hence cannot profit from
making it safer, then where is the incentive to do so?
Other measures include the facilitation of blanket advertising
bans, which the Scottish government is considering; a
requirement that 30% of the packaging be dedicated to a large
health warning (about the addictiveness of nicotine – which of
course other addictive products like coffee and alcohol are not
required to carry); and strenuous standards about the device
All of these measures will make it harder for firms to compete
on safety to deliver a better, safer product. And yet the TPD
was warmly welcomed by anti-smoking public health groups like
Cancer Research UK,12 and even those like Action on Smoking
and Health who are open to e-cigarettes as a tool for reducing
the harms of smoking.
So why do these supposed-champions of public health turn
a blind eye to the overwhelming evidence that promoters of
dramatically lower-risk nicotine products should be cast not as
villains, but as allies for anyone interested in reducing the harms
caused by smoking?
Perhaps it is due to influence from the pharmaceutical industry,
which offers highly regulated (nicotine and non-nicotine)
alternatives to smoking. Big Pharma, which already paid the
price of admission through regulation, sees innovation as
a threat. It is no wonder that they fund heart associations,
lung associations and cancer groups, to sow doubts about
In the wake, these groups betray their mission and
leave smokers with often ineffective pharmaceutical products,
destined for a quit or die future. And they don't always quit.
Maybe they realize that people enjoy nicotine and other
products which provide pleasure. Perhaps they believe that
if some of these products look like cigarettes, they are, by
definition, bad. Perhaps a best-case defence of this might be that
e-cigs 'normalise' smoking and so encourage impressionable
youngsters to take up the real thing – a proposition that is
defensible but in direct contradiction to the evidence, which
suggests that bans on e-cigarettes lead to significant rises in
teenage smoking rates, indeed it "counteracts 70 percent of the
downward pre-trend in teen cigarette smoking for a given twoyear
Maybe it's all about money. With high cigarette taxes and many
people still smoking, government officials rely on smokers for
the revenue, as if the authorities are just as addicted to cigarettes
as the smokers. But if that were the key basis for the opposition,
it could quickly be resolved by taxing e-cigarettes the same as
cigarettes. This "solution," while profoundly harmful to the
proposition of harm reduction, and thus public health, is already
being imposed in some U.S. states. But even this hasn't satisfied
The answer, I believe, is more foundational, and has to do with
an ongoing power struggle between people whose jobs depend
on government on one hand, and private enterprise on the other.
This explanation is rooted in the public choice school of political
economy, which views government officials as rational, selfinterested
agents in the same way we view consumers, private
firms, and workers.
In this model, public health officials who depend on government
support have a very real stake in being seen to be the only
people who can help people stop smoking. Their own power and
incomes depend on it.
Christoper Snowdon's IEA paper Sock Puppets: How the
Government Lobbies itself and Why lays out in detail the history
and strategies of public health "charities"–often 90% or more
public funded.15 Action on Smoking and Health, for example,
as well as Alcohol Concern, have always had a model of 'statefunded
activism', even according to official archive documents.
In ASH director David Simpson's words "it was a curious
form of brinkmanship, having in one's daily work to attack the
government that was funding you. But this was expected, and
encouraged, so that there was a lot of cooperation behind the
scenes." Public health bureaus and government had a symbiotic
relationship, each enhancing each other's power in the name of
wellbeing. How could private alternatives help?
And their methods for protecting their power and income
generally mean restrictions on the liberty of others. H.L.
Mencken pointed out that "the whole aim of practical politics
is to keep the populace alarmed (and hence clamorous to be
led to safety) by an endless series of hobgoblins, most of them
imaginary." As Ronald Reagan explained with simplicity how
this affects our freedom: "as government expands, liberty
To protect their influence on health policy, boosters of more
government control need to advance the fiction that industry,
driven only by the profit motive, must always be reined in by
government regulations. In asserting their right to regulate,
public health officials will point to the harmfulness of cigarettes.
But does that mean there should be no end to regulation of not
only cigarettes, but to their alternatives?
In the regulators' myopic worldview, industry, driven by greed,
is the only problem, and government is the only solution.
And then came along the e-cigarette, shattering the alwaysbigger-government
narrative. Here, you've got a private sector,
profit-driven innovation that has the potential to save more
human lives than any tobacco tax, warning label, or regulation
People are using these products to quit smoking not because
of the government, but despite it. Public Health England's
emphatic e-cigarette endorsement is the exception to the rule.
This differing approach is the driving force behind the divide
between those who support e-cigarettes as well as newer,
perhaps more satisfying products, and those who support a
"tobacco end-game" which can, by definition, only include
solutions either developed or at least endorsed by government.
Until recently, and despite a heavy-handed regulatory threat,
cigarettes remained a scourge. I frequently wonder why the most
popular consumer products, from telephones to automobiles,
and even carbonated soda have undergone dramatic safety
improvements in my lifetime, yet the cigarette hasn't really
Consumers have accepted and embraced the concept of harm
reduction when it comes to products such as soda. Consider
that even excessive amounts of Diet Coke don't cause obesity
and lead to diabetes. Too much regular Coca-Cola, like all other
sources of calories, can lead to disease. Diet soda is a harm
Just as caffeine addiction may lead some to drink too much
Coke, few (except the biggest nanny-states) suggest that
caffeine should be regulated or banned to fight obesity, despite
similarities to nicotine. But with cigarettes, nicotine has become
the target, even though it's not the cause of the harm.
E-cigarettes aren't the answer. While they've helped a
significant segment of smokers not reached by governmentendorsed
methods, the fact that people still smoke cigarettes
is evidence that more innovation, as well as more accurate
information, is necessary. A survey published by Action on
Smoking and Health this May provides key clues to our public
Among current smokers who had tried using e-cigarettes, but
stopped, 25% said it was because vaping didn't feel like smoking
a cigarette. Another 20% cited the fact that it didn't help them
deal with the cravings for smoking. In case the clues in Figure 8
weren't enough, the results displayed in Figure 9 essentially give
away the answer. It's no longer much of a riddle, and was never
so complicated to begin with: it's just a matter of providing
smokers the satisfaction of smoking without the same harm.
Armed with the ASH survey, a reasonable person might think
that government agencies around the world would now be racing
to come up with a satisfying product that would put an end to
combustible cigarettes. Incentivized by the goal of saving lives,
even a Nobel Prize, we should be seeing requests for proposals,
grants to favored academics, and legislative fact-finding hearings
with smokers in the witness seats, testifying about what it is that
they find so satisfying about smoking. Only this will enable the
government to construct the proper alternative to the cigarette.
If this sounds absurd, it's because it is. Innovative products
aren't developed by governments, because governments, by
their nature, aren't set up to be competitive risk takers in the
Yet the private sector, rightfully driven by the profit motive,
tempered by tolerance for risk, rewards innovation. Perhaps
that's why leading global tobacco companies, from Phillip
Morris International, British American Tobacco, and Japan
Tobacco International, as well as non-tobacco companies and
investors, are all plowing funds into coming up with a range of
next generation products that seek to incorporate the successes
of e-cigarettes, as well as learnings from the shortcomings of the
e-cigarette experience. Just like the vape shop employee, these
investors are the true public health heroes – not those who are
trying to stymie them.
Many of these next generation products heat tobacco enough
to release nicotine and flavor, while drastically reducing the
exposures caused by combustion. Again, this should be good
news for public health.
If a significant percentage of smokers wind up preferring safer
heated tobacco to cigarettes, these companies will be swiftly
rewarded by the market, provided that firms are actually allowed
to sell their reduced harm products. Sadly, regulators are more
apt to punish, rather than reward, those who come up with
solutions that regulators aren't equipped to answer.
There are enough smokers in the world to have several tranches
of products for various individuals. Some individuals who can't
or won't quit may be willing to use a product that removes
almost all the risk, and much of the satisfaction. For others,
even a modest reduction of risk would be an advantage over
smoking, and that choice should exist for those who want it. And
consumers deserve to know the differing risks.
But the options aren't necessarily a linearly connected risksatisfaction
model. With enough profit-motivated risk-taking to
support research and development, the brightest engineers may
envision products that make cigarettes truly obsolete.
Imagine products that are at once more satisfying to smokers
and less harmful than not only yesterday's cigarettes, today's
e-cigarettes, and tomorrow's heated tobacco. And imagine that
they were less expensive than the more harmful options. The
cigarette would go the way of the rotary phone and horse-andbuggy.
Academics and regulators who fantasize about a zero-risk world
are the primary obstacle to this type of innovation. Regulatory
threats and uncertainty are already putting a damper on
Consider the Tobacco Products Directive, discussed above.
Its specific proposals to control the sale and marketing of
e-cigarettes are bad enough by themselves, but they are evidence
of a much deeper misconception of the issue. They so tightly
restrict marketing, not only because they ignore the benefits of
smokers switching to e-cigs, but because they ignore the benefits
of better e-cigs and reduced-risk products coming to market. If
there is no pathway to marketing a safer product to consumers
as being safer, then there is no incentive for safer products to be
Regulators are focused on demanding increasingly more
restrictive and punitive approaches towards smokers, rather than
fostering and encouraging innovative and satisfying alternatives.
They are currently faced with the challenge of regulating
reduced-risk products, and they face a clear choice: to treat them
like cigarettes, because they have tobacco in them, or to treat
them like e-cigarettes, because they may be considerably safer
than smoking. If regulators go down the first path, they will kill
reduced-risk products dead, and smokers will suffer. Preventable
deaths will likely happen, because some smokers who would
have switched to reduced-risk products will not hear about them
or know that they're safer.
But if they're regulated like e-cigarettes, and indeed if the
whole regulatory framework for lower-risk products of all kinds
is reformed to encourage innovation then governments can say
that they've learned from their mistakes and they're working
with the private sector to improve smokers' lives. The objective
should be to give smokers a better, healthier option that they
will willingly choose, not to cut off every option except quitting
altogether. It's the harms of tobacco we should care about, not
The World Health Organization's "World No Tobacco Day"
campaign illustrates how badly public health campaigners have
gone wrong, how they've ignored Professor Russell, ignored the
data from Public Health England, and worst of all, ignored the
needs of smokers.
But most fundamentally, they've ignored the underlying
justification for their authority to regulate us. The deal we had
under the social contract was that we would give up some of
our freedoms, and they would protect our health. But instead of
"World No Tobacco Disease" day, all they've delivered is a pipe
Jeff Stier is a Senior Fellow at the National Center for Public
Policy Research in Washington, D.C., and heads its Risk
1 A McNeill et al, E-cigarettes: an evidence update A report commissioned by Public Health
England (August 2015),