I think you might find anaesthesiologist Ronald Dworkin’s essay at The American Interest thought-provoking. It begins by making an argument against the public health establishment’s opposition to vaping:
Companies like JUUL Labs have created an e-cigarette substitute for smokers to “vape.†Although the substitute contains nicotine, it lacks the carcinogens and carbon monoxide found in “real†cigarette smoke. Despite improvement over traditional cigarettes, many public health experts oppose vaping, thinking it represents more of a gateway to cigarettes than a liberation from them. Nor does the FDA allow e-cigarette makers to advertise their products as being safer than traditional cigarettes. This has caused the public to mistakenly view both products as equally bad.
E-cigarettes are like the nicotine patches in my patient story: While it is best for people to abstain from all cigarettes, better that they use a less dangerous form. The public health activists are like the surgical team that denied the man his patches: In their quest to bring perfect health, they sometimes end up causing worse health. The average American is like my patient: resentful toward those who tell him or her how to live.
and then turns to how public health, despite its scientific foundations, is inevitably ideological:
Individuals, like all real things, have resistance; they do not reliably conform to abstract principles or universal categories. Every nurse, social worker, psychologist, and doctor knows this limits science’s applicability. Because public health experts deal with whole populations, they are less likely to see how abstract scientific principles can fail. A public health expert might say, “We must fight cigarette addiction to improve health.†The phrase can be taken for truth because it evokes no precise image, and because the expert who utters it does so in good faith. But the policies the phrase inspires do not necessarily end cigarette addiction. Why? Because there is a divergence between words and things, between the scientific principle and the reality of individual human behavior. A simple phrase does not represent with sufficient exactitude the complexity of addictive behavior expressed by any one person—as most social workers, psychologists, nurses, and doctors can attest.
These two historical tendencies in public health combine to make the field both arrogant and ideological, relatively speaking.
Arrogant because public health experts do not watch their science fail on a daily basis. Because they work with large populations rather than with individual cases, public health experts often think with words—for example, the American Public Health Association’s (APHA) goals to “reduce global childhood mortality†and “support global food security.†Goals like these are easy for the thinker with words; the delay between error and the serious consequences of error—a very short timespan for an anesthesiologist—is too long for the public health expert to learn humility or even responsibility. After articulating a principle, the public health expert sees nothing go right or wrong for years, if ever, and so the value of the words can only be judged by their good intentions. When the entire planet becomes a platform for action, and the desired goals verge on being utopian, the issues themselves start to lack physicality. The public health expert is thus tempted to believe that everything has been done when only words have been spoken.
Read the whole thing.
There are aspects of the story which Dr. Dworkin touches on but does not explore. One is the will to power. Nietzsche thought it was the main driving force in human beings. It would be incredible if it were completely absent among public health activists.
The other aspect is that constraints on government spending also place constraints on this will to power. Remove those constraints and there is a real danger of loosening the constraints on that urge to power as well. If there were no constraints on government spending it would be necessary to invent them.
Dworkin is missing the point about vaping. The FDA has moved to ban flavored e-cigarettes that by any reasonable view are targeted towards youth or at the very least people who weren’t previously smokers and restrict retail outlets where youth could be targeted. The other underlying issue is the paucity of studies of the health effects of using nicotine in this way at these potency levels. All that presumably can be said is that it is safer than smoking.
“In just one year, rates of past-year vaping increased by about one-third in all grades, to 17.6 percent of 8th graders, 32.3 percent of 10th graders, and 37.3 percent of 12th graders.”
“These one-year jumps in vaping are mirrored by changes in the perception of availability; more 8th and 10th graders reported that vaping devices and e-liquids containing nicotine are easy or very easy to obtain in 2018 than in 2017.”
“While 22.1 percent of 8th graders reported thinking that it is harmful to regularly use e-cigarettes, 32.4 percent reported thinking that it is harmful to regularly vape an e-liquid containing nicotine. . . . [while in comparison, the figures are 18.0 percent and 27.7 percent for twelfthgraders].”
https://www.drugabuse.gov/publications/drugfacts/monitoring-future-survey-high-school-youth-trends
To reinforce what PD said, vaping has rocketed amount teens. Drum documents it at link, and then looks at it from another angle. Nicotine is roughly as addictive as heroin and has negative cardiovascular and GI effects. Less harmful than cigarettes, but from a public health POV why would we want more of this?
https://www.motherjones.com/kevin-drum/2018/12/the-juul-fad-is-far-bigger-than-i-ever-would-have-guessed/
” I knew that the Juul fad had practically taken over American high schools recently, but it turns out that Juul reported a monster revenue increase of nearly 800 percent between 2017 and 2018 (from $107 million to $942 million), and they control about 75 percent of the market. That’s enough all by itself to account for a huge single-year increase in vaping.”
Steve
The Drum link makes a point that I also thought about making. There has been a decline in teenage smoking since the 1990s. Vaping isn’t simply acting as a substitute for teen smoking as Dworking implies (*), its expanding nicotine usage beyond levels that predated the technology.
That said, I think the larger point is that public health is hard in an open economy. It’s not easy to strike a balance btw/ helping people with a dangerous smoking habit without running the risk of making a drug safer to new consumers.
(*) “while e-cigarette use has increased among young people, regular cigarette use has declined.”
There are other ways to address will to power than instituting limits which can just as easily be un-instituted, and leave the individual raging against the limits.