Former software engineer and manager now researching and writing about EA-related topics in harm reduction. Interested in global health and mental health more broadly.
Kristof Redei
Karma: 197
This article from one of their incubatees describes their strategic approach:
Governments spend billions on healthcare and millions more subsidising policy campaigns to fight industries that thrive on harm, trying to protect us from tobacco, ultra-processed food, alcohol and fossil fuels to name a few. Yet year after year, these industries continue to expand, exploit, and interfere with regulation. They privatize profits while socializing costs. The result: fragile health systems, sick populations, and taxpayers footing the bill for preventable disease.
But here’s the thing: we already have the laws to stop them. What we lack is the will, and the funding, to enforce those laws through the courts.
That’s why we launched SHIFT, a catalyst funder for strategic litigation against health-harming corporations. Our aim is straightforward: enforce existing legislation, hold corporations accountable, and stop industries of harm from thriving. Litigation, after all, doesn’t persuade — it compels.They appear to see the tobacco industry as an emblematic example of industries that are net harmful, and legal action as a specifically effective way to fight them:
We believe the fight begins with tobacco because it’s the model for every other harmful industry. It is the deadliest consumer product in history, killing more than 7 million people each year. It is also the most regulated, thanks to the Framework Convention on Tobacco Control (FCTC), the world’s only health-specific treaty.
That treaty, and the precedents already set in tobacco control, give us a unique opportunity. If we can enforce existing laws against tobacco companies, we can create a “halo effect” — precedents that ripple across industries, forcing others to meet higher standards of corporate accountability.One of their other fellows authored a report for the European Respiratory Society that specifically advocates for and “endgame” strategy for eventual full prohibition via generational sales bans:
The power to introduce a generational sales ban, where it will never be legal to sell tobacco products to people born after a certain date, lies firmly within the competence of the Member States. There is no impediment, under EU law, to introducing such an endgame policy on the grounds of public health, given that it can be demonstrated to be both a
proportionate and necessary measure to achieve a legitimate objective.
It isn’t necessary to conclude that the benefits of tobacco are not worth the costs for any user, or that no user would continually make a free choice to consume if fully apprised of the facts, to conclude that the tobacco industry should be eventually abolished.
Agreed. However, the post as I read it isn’t arguing that stricter regulation of some or all tobacco products is inherently unjustified. It’s postulating that our confidence in the claim that it’s net positive is shakier than the current models make it seem, because SMA and other organizations favoring such regulation are ignoring a major factor when modeling its costs and benefits, namely the enjoyment people get from using the products. It’s one thing to disagree about the extent to which this matters and what weight to assign it in a model; it’s another thing to fail to include it altogether.
Of the 1⁄3 of smokers who did not express a desire to quit, I wonder how many of them would express a desire to return to smoking if we were to wave a magic wand that cured addiction and associated cognitive distortions and then asked them to make an actually free choice about whether to resume smoking. Cognitive dissonance is quite a drug! I don’t put that much weight on the fact that each smoker decided to start smoking at some prior point in time as evidence of their preferences in a non-addicted state. Unless the smoker decided to partake the first time that cigarettes were a possibility, they also made decisions not to smoke in the past.
IMO this is a crux of the disagreement the OP has with SMA’s approach. The concept of addiction is doing a lot of work here in justifying treating smoking as a special case in a way that isn’t applied to less socially stigmatized risks like a dangerous hike or regretted choices the OP mentions like those about social media use and diet. I’d be interested in understanding what you mean by “curing addiction” in this context—would it be something like never having known the pleasure of smoking, adding a moment of mindful reflection before each cigarette, or something else? And how can we tell whether someone is making the choices they are making because they are addicted vs. because they have weighed the pros and cons sufficiently for us to believe they are making a free choice?
Of the 2⁄3 of people who smoke and did express a desire to quit despite not having done so, I also wonder how many of them respond in this way at least in part because of the stigma surrounding smoking (this seems to happen in at least some subpopulations). Social desirability bias is also a hell of a drug.
There is no known realistic way to abolish only the part of the industry that sells to people who would prefer to be free of their addiction.
Do you think there’s a known realistic way to abolish the industry as a whole when more than a billion people in the world smoke daily? If yes, what’s a tractable path given the track record of prohibition of psychoactive substances more generally, and tobacco specifically (e.g. recent bans and subsequent reversals in South Africa and Bhutan)? If not, why is this a reasonable goal for an evidence-driven organization to set, compared to educating the public about the risks of smoking and assisting those who desire to quit, as the OP suggests?
Do the WHO’s “best buys” work?
Excellent post. I would add that SMA’s approach to reducing smoking-related harm has another defect that doesn’t require one to have a position on the question of how to model the benefits of smoking, which is their position on much safer, noncombustible forms of tobacco and nicotine use like vaping, nicotine pouches, and snus.
There’s plentiful evidence that all of these products hugely diminish risks to longevity, are the most effective known way to stop smoking, and have a major measurable impact on population-level disease incidence when widely available. An Our World in Data post from a few weeks ago summarizes the bulk of it, and I’ve also written a sequence on this for the EA forum. SMA describes vaping as a “way the tobacco industry is dodging the rules,” puts scare quotes around “safer” when discussing (and dismissing) its health benefits to people who smoke, and their incubatees appear to be lobbying against regulation that would make it more available while ignoring the countervailing evidence when confronted with it publicly.
I don’t have any reason to think SMA has anything but good intentions in helping people achieve better outcomes (health-related or otherwise) for their lives, but from the tone of their communications it appears that they are conflating hurting the tobacco industry with helping people that suffer because of the defects of their products. The idea that an industry that created a problem that causes so much death and suffering may, if properly regulated and incentivized, also be part of the solution to that problem appears to be beyond their moral imagination (or ambition, one might say) even though this approach seems to me pretty standard in other causes EA is interested in, like working with farmers and the meat industry towards progress in animal welfare or with fossil fuel companies to mitigate climate change.
Hi Brad, thanks for reading and commenting. The School for Moral Ambition and its incubatees are the EA-associated organizations I mentioned above. They appear to be strongly opposed to promoting vaping to people who smoke (“Vaping: a healthy alternative to smoking” appears as an item in a “Big Tobacco Bullshit Bingo” card used in one of their trainings), have lobbied for restrictions on e-cigarette use in places where smoking is banned, and have spread misinformation on both the risks of vaping and the evidence for its usefulness in smoking cessation.
I think they have good intentions and may be doing helpful work with other tobacco control efforts, but when it comes to vaping and other noncombustibles, they appear to be contributing to the problem Hannah describes rather than trying to be part of the solution.
Our World in Data on the public health benefits of vaping
Sex, drugs, and effective altruism: what EA and harm reduction can learn from each other
Are doctors and tobacco users unaware of basic facts around harm reduction?
Great post. Do you know whether GiveWell (or any other org doing evaluation) accounts for the extent to which NGO’s are doing this when assembling recommendations? While being aware of ecosystem thinking seems important, having incentives for acting in accordance with it could be even more so.
I think there’s some complexity (and a lot of confusion) in the tobacco story as well. The industry did try to trick consumers and regulators in the 1970′s that light cigarettes were less harmful when they themselves had evidence that that wasn’t the case. And now, the opposite is happening as misinformation has resulted in majorities of doctors believing nicotine causes cancer and majorities of consumers believing vaping is as harmful or more harmful than smoking.
Is reduced risk tobacco the most effective way to stop smoking?
Great post, and rhymes with some of the challenges I’ve observed in my own area of interest, tobacco harm reduction, particularly this part:
As far as I can tell, the movement responded to this by calling it humanewashing, and pushed harder for the BCC. But if McDonald’s actually did do all the things they said they would, the impact on the broilers would likely be more impactful than the BCC.
A number of large tobacco companies have developed products they claim are significantly less harmful than cigarettes and can serve to transition smokers away from them. If this is true, it’s a boon for public health, but many organizations in the field, including the WHO from which many regulators in LMICs take their cue, support banning them altogether despite criticism from non-industry affiliated experts who see their potential in reducing death and disease from smoking.
I get the impression that pragmatists in drug policy and animal welfare have quite a bit to learn from each other in advocating for sensible policies that avoid letting the perfect be the enemy of the good.
Fascinating post! A quick technical tip—marking your post as a link post highlights the original and makes it easier for readers to get to your Substack and subscribe. (Also, looks like the ‘Thanks for reading! This post is public so feel free to share it.’ from the original didn’t get cleaned up when you pasted it into the forum—same thing happened to me my first time!)
Thanks for reading and commenting! As you mentioned, the back of the envelope math here implies that the restrictions and bans that have come into force and are being discussed in European countries in the past few years are likely to have a net DALY-reducing effect, especially since pouches produced using good quality control are some of the safest noncombustible products currently available. (If you’re interested in the specific safety details across brands and varieties, Nicoleaks is a great resource.)
European Tobacco Harm Reduction Advocates, the main advocacy org in the region, has been pretty persistent in communications to both the public and to legislative bodies outlining this argument. They also published a survey a couple of years ago indicating about a third of European smokers would try snus as an alternative if it were made available. Unfortunately, they were unable to prevent recent bans in Belgium, France, and The Netherlands.
I agree it’s worth investigating the potential impact of their work, although my initial instict is that work in low and middle income countries, which tend to have both higher smoking rates, heavier restrictions (like outright bans on vaping in Brazil, India, and Mexico), and less accurate information available to consumers, could be lower hanging fruit.
I also don’t know that these bans have been that unpopular, which is not surprising given how misinformed the public is about the risks, as I mention in the post. It’s possible that clearing up that confusion is a necessary condition for any targeting of policy to have a decent chance of success.
How safe is nicotine?
This is super interesting and rhymes a bit with my own efforts to connect the EA community with another one that also has overlap in values but a distinct culture (harm reduction). I took a lot from another earlier post on this topic as well: https://forum.effectivealtruism.org/posts/8Qdc5mPyrfjttLCZn/learning-from-non-eas-who-seek-to-do-good
It’s cool to see the members of the tantric retreat were open to learning from EA—are there any learnings you think this community in turn offers to EA?
Core claims of tobacco harm reduction advocates
Thanks for taking the time to read and comment, and sorry I didn’t see this earlier! You bring up a couple of really interesting points that I’ll try to respond to separately.
Gateway effects
There are a couple of reasons I’m unconvinced by the gateway hypothesis, i.e. that the observed correlation between non-combustible use and subsequent smoking implies that the growth of the former is causing an increase in the latter.
An alternative explanation is that lack of adjustment for confounders (‘common liabilities’ between vapers and smokers, like living with family that smokes, smoking peers, or a higher propensity for risk-taking) is what drives the majority of the observed correlation. The meta-analysis on vaping that you linked makes exactly this point: they reviewed 11 original studies on the association between vaping and subsequent smoking, and found that only two of them made comprehensive adjustments for key confounders, with one of these having other serious methodological errors, and the last one showing a small effect size. Thus their conclusion is that “while there is evidence of a relationship between vaping and subsequent smoking, there is much less conclusive evidence for a gateway effect.”
If the gateway effect were significant, I’d also expect this to eventually show up in population-level data. Of course, this may be masked by other factors that are causing drops in the smoking rate at the same time, but attempts to detect the first while controlling for the other in England and the US haven’t turned up much so far. I haven’t seen a lot of data on other countries.
Finally, and this is a more informal point, no clear and plausible causal mechanism comes to (my) mind for why someone who wouldn’t otherwise have become a regular smoker would become one after and due to use of a non-combustible product. If I enjoy snus, lozenges, or vaping, why would I switch to a more expensive product with a much worse health impact?
Bias
I agree that this is a field where an unusually high degree of skepticism of claims is warranted. Because of the amount of money and lives at stake, many of the people doing research have strong feelings and/or financial incentives related to the policy implications of their findings; or they enter the field specifically because of an opportunity for funding or a preexisting belief about the danger or opportunity presented by non-combustible products. As Andrew Gelman puts it, “Tobacco research is a mess, and it’s been a mess forever.”
That said, If we were to disregard the work of everyone with some sort of conflict of interest, I don’t think there’d be a lot left to read, so I generally try to take a trust-but-verify approach. For example, Carl Phillips has received tobacco industry funding, but the article I linked doesn’t present original data but a logical argument I can follow and identify holes in, and the factual claims can be checked against other sources. Becky Freeman is a strident advocate for increased regulation of both combustible and noncombustible tobacco and a protégé of Simon Chapman, who has repeatedly stretched the truth both with regard to the risks and benefits of snus and vaping. Tobacco Tactics, the organization whose articles you linked, receives funding from Michael Bloomberg, who has led global efforts to ban flavored vaping and made numerous exaggerated statements about vaping. I don’t think these biases should disqualify the evidence either of them present from being taken into account, as long as their factual claims are thoroughly checked.
Tobacco company strategy
I think PMI’s actions are pretty consistent with an established business responding to the emergence of a disruptive new product cannibalizing sales of its existing one. They initially worked to shut upstart competitors out of the new market through regulation in their support of the PMTA process. They’ve since acquired innovative competitors in the vaping space like Juul and are trying to purchase the largest snus producer. Non-combustible products accounted for 30% of their revenue in the first half of 2022, and this percentage has been growing for years. As this shift continues, it makes more and more sense for them to continue to lobby for broader accessibility.
In addition, I’d speculate that while companies like PMI don’t want to say so out loud, they recognize that the total addressable market for tobacco could grow substantially if health concerns are alleviated. Not that long ago, almost half of the adult US population used tobacco, and many of the people that stopped since then did so mainly because of those concerns, so the non-combustible market could be even bigger than the cigarette market ever was.
edit: typo
Thanks for reading and commenting! I’ve deliberately avoided the term “addictive” in this discussion, as usage of the term in both formal and informal discussions is so broad and loose that I’ve found it to be more confusing than illuminating. Phillips has a couple of wordy but informative discussions arguing that the word is more like the opposite of an applause light than a term that cleaves reality at its joints.
I’m not aware of much evidence that nicotine use is harder to control than caffeine use in the sense you describe. If anything, the fact that 80% of people in the US use caffeine dailyand only about 15-20% use nicotine seems to point in the opposite direction, although there are obviously many other factors affecting those numbers.
Also, I think the utility calculation on whether the promotion of THR is net positive and cost-effective is pretty robust to changes in the net effect on a potentially larger group of new non-combustible users, even if that net effect is negative. This is mostly because the health costs of combustible use are so high. In other words, as long as there’s a reasonable substitution effect (lots of smokers dropping smoking as they start using other products), it likely outweighs the net harm to non-smokers that start using non-combustibles.
It seems to me there’s a lot of available data to help make an informed guess of the likelihood of success of the kind of measure SMA advocates for.
Tobacco bans are almost as old as the global tobacco trade itself, and all of them have been eventually reversed. Some examples beyond that of Bhutan:
A 17th century ban on tobacco in Japan lasted less than a decade
In 1633, Murad IV banned all tobacco in the Ottoman Empire—the policy was reversed by his successor 10-15 years later
The longest ban in history was implemented in Muscovy Russia in 1634 and lasted just over fifty years until Peter the Great repealed it
A smoke-free generation law similar to what one SMA incubatee has argued for was passed in New Zealand in 2022 and repealed less than two years later
Jurisdictions where cigarettes are currently taxed higher than most of the market will bear, or where noncombustible products are banned, also offer some evidence about the feasibility of keeping smuggling down:
A study examining littered cigarette packs in New York City found less than 20% of them had tax stamps showing they were legally sold
Seizures of e-cigarettes in Brazil, where vaping is completely banned, have been growing since 2019 and reached 1.3 million units in 2023
El Colegio de México estimates about 5 million daily vapers in a country whose vape ban is in the constitution
Reuters estimates the size of the current illegal vape market in the USA at about $2.4 billion