In E-cigarettes and the Comparative Politics of Harm Reduction: History, Evidence and Policy, Virginia Berridge, Ronald Bayer, Amy L. Fairchild and Wayne Hall scrutinise the history underlying the current debate over electronic cigarettes. Exploring the reasons for contrasting public health approaches to nicotine use in the US, UK and Australia, this edited volume makes an important contribution to the discourse on e-cigarette policy and public health more generally, writes Hannah Farrimond.
E-Cigarettes and the Comparative Politics of Harm Reduction: History, Evidence, and Policy. Virginia Berridge, Ronald Bayer, Amy L. Fairchild and Wayne Hall (eds.). Palgrave Macmillan. 2023.
Why can’t public health agree on what to do about e-cigarettes? This book aims to answer that conundrum. More specifically, why have entirely divergent regimes of public health control emerged in the US, UK, and Australia? In an era of shrinking resources, this controversy wastes time, energy and confuses the public. So why is a scientific and policy consensus on vaping so elusive?
The editors, Virginia Berridge (UK), Wayne Hall (Australia), and Ronald Bayer and Amy Fairchild (US) have come together to offer us answers. The collective starting point is that policy cannot be about evidence per se; the same set of evidence has produced startlingly different regulatory regimes. Rather, we must look for clues within the histories and values of tobacco control in each country to understand how such schisms have arisen.
The same set of evidence has produced startlingly different regulatory regimes.
The first chapter takes us back to before e-cigarettes. In some ways the pre-histories of public health policy in each country were remarkably similar. All moved from an environmental approach controlling infectious diseases to an epidemiological one identifying modifiable risk factors such as tobacco. Differences were emerging, however, most notably the entrenchment of nicotine replacement therapy in the UK compared with Australia. In the US, young people and children were the target for tobacco control, alongside the more overt use of tobacco denormalisation. Thus, the stage was set for the great e-cigarette showdown.
In the US, young people and children were the target for tobacco control, alongside the more overt use of tobacco denormalisation.
In the next three chapters, the policy history of e-cigarettes for each country is examined. The first to be considered is the UK. Does its relatively positive attitude towards e-cigarettes as a tool for harm reduction make it an outlier or a pioneer (or both)? What follows is a complex account showing that the primary focus has always been to reduce the risk to adult smokers (legislation forbids the selling of vapes to under 18s). It is argued that the seeds of the UK’s harm reduction position stem from its prior harm reduction history, NHS funding of Nicotine Replacement Therapy (NRT) and the positive attitudes of main players such as Public Health England and Action for Smoking on Health (ASH).
This raises a question, however. Why has the UK focused on adult smokers? I would argue that UK public health was able to maintain its harm reduction stance more easily precisely because, for most of that decade or more, the bulk of vapers in the UK were adults. The youth vaping “epidemic” was happening elsewhere, primarily in the US, and to some extent UK public health may have felt insulated from this problem. Disposable vapes have changed this picture, creating issues in terms of littering, child addiction, and public perception. It is harder to maintain an adult-focused policy when there is a risk to “innocent others”, however much this risk may appear small or misunderstood. Youth vaping activates the moral panic of youth drug use. With increased youth rates, the UK is starting to feel the tension between the needs of the two groups as the US did a decade prior.
Disposable vapes have changed [the] picture, creating issues in terms of littering, child addiction, and public perception.
The next chapter examines how Australia ended up taking an almost opposite approach. Here, e-cigarettes have effectively been banned; having been classified as poisons, not available for import and only available (rarely) on prescription. The authors argue that this policy has been driven by concern over the “precautionary principle”: given uncertain risks, we should take precautions. This, coupled with a stance against NRT and fears about the “gateway” effect of e-cigarettes, has meant that few have stood outside the orthodoxy of keeping e-cigarettes under medical legislation. Despite this, 39 percent of Australian smokers have tried an e-cigarette.
One salient point both chapters highlight is the importance of Key Opinion Leaders (KOLs) in leading the charge for or against e-cigarettes. Where they go, most other public health organisations follow (with a few exceptions). Certainly, figures such as Simon Chapman in Australia and Stanton Glantz in the US appear almost mythical. Furthermore, and this is hinted at in the book, tobacco control policies often have an unarticulated national identity aspect to them: harm reduction is the “English” way; Australia is proud of having the lowest smoking rate. Between the heavy influence of KOLs and these collective public health identities, there is a lack of flexibility to respond to new thinking or evidence; all evidence simply becomes incorporated into existing positions.
Tobacco control policies often have an unarticulated national identity aspect to them.
The chapter on the US regulatory scene illustrates this perfectly. Until the recent ban on the e-cigarette company JUUL’s products (now under review), there was an absence of top-down federal regulation, with policy making occurring at state and city levels. US policy has been influenced hugely by the concern over youth vaping. The extensive JUUL use amongst youth is described again and again in quotes from policy actors in the chapter as an “epidemic”. As precedent suggests, in an epidemic, logical decision-making is often superseded by emotional judgement. The final chapter pulls together the threads to argue that evidence itself is not driving policy but values, pre-histories, and emotions.
In an epidemic, logical decision-making is often superseded by emotional judgement.
Overall, the histories given by the authors are impressively complex, with a couple of caveats. One is that the factors identified are all important, but we do not get much of a sense as to which is the most important. Would everything have been different had the KOLs been different? Second, this is a book of details, at an almost forensic level. If you are into tobacco control history, which I am, this is extremely useful as a resource documenting this period in history. If you are a more casual reader interested in public health in general, it might not appeal so much. Finally, due to space, very little discussion occurs about the huge international drug policy changes occurring simultaneously in relation to cannabis decriminalisation and legalisation. Why does the need for precaution and fear for “innocent others” not drive policy so strongly here? Are values less important than we think?
This book makes an important contribution to the history of e-cigarette policy and public health more generally. It is convincing in its main premise, that “it’s not about evidence, it’s about emotion’” (49). Where that takes international tobacco control next is still unclear.
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