On the global intensification of "vapor-free" policies (Part 1)
Part I: Historical background on passive smoking.
Dear readers
I apologize for the long delay on the continuation of my Substack. I passed through a 4 month period under pressing academic commitments. I am now back planing more posts on environmental vape aerosols and other issues.
In this post I open a two parts hiatus on my usual technical sequence of physical and chemical properties of vape aerosols.
In this post and in a follow up post I would like to address the sudden drive of anti-THR advocacy, public health academia, regulators and governments to extend to passive vaping all established restrictions and policies for passive smoking.
Recently the drive for these policies has intensified, with proposals to extend prohibitions of vaping and usage of heated tobacco products (HTPs) even to outdoor spaces.
This drive has now reached the UK, with proponents of these restrictive policies openly disregarding the current more pragmatic approach to regulate vaping in public spaces, an approach based on official communications from Public Health England, the Royal College of Physicians and the Office for Health Improvement and Disparities (OHID).
Reading guideline
The institutional attempt to extend all public smoke-free spaces to be also “vapor-free” did not emerge spontaneously in a vacuum, they are a natural continuation of previous policies. Therefore, to address this issue I present in this post
a summary of the historical background that lead to consider passive smoking as a key ingredient of tobacco control policies
an account on how the characteristics and the effects of “second hand smoke” became enforced in the period 2000-2010 as indisputable “quasi-sacralized” knowledge.
In the follow up post I will discuss how these developments evolved in the vaping era after 2011, focusing on how tobacco control orthodoxy has attempted to include prohibition to vape in all smoke-free areas, disregarding evidence showing the enormous difference between the environmental emissions. I will also show how “independent” research on passive vaping has supported this agenda through grossly biased publications.
Foreword
The approach of tobacco control orthodoxy to vaping in public spaces is consistent with its persistent tendency to ignore the risk continuum in recreational nicotine products. This is justified by an extreme form of the precautionary principle that denies or downplays available evidence on the products (often following “merchant of doubt” tactics correctly criticized when used historically by the tobacco industry). This extreme precautionary approach is not invoked with same emphasis in other legal drugs (alcohol, caffeine) or on other health issues.
The logic is crude and simple: if the risk continuum is so questionable for primary usage (inhalation), then it must be also questionable in passive exposure by non-users. Therefore, the inevitable conclusion is the pressing need to protect the public from the passive exposure, just as comprehensive smoke-free policies have protected non-smokers from “second hand” smoke.
The statements described above are not sustained by available scientific evidence, either regarding the direct exposure through inhalation or the environmental bystander exposure to the exhaled aerosol. This can be appreciated from the summary of the scientific peer reviewed evidence on these emissions that I have provided in the sequence of posts in this Substack, including summaries from my own research.
In particular, the description of the physical and chemical properties of the exhaled vaping aerosol in post 8, post 9 and post 10 completely disqualifies any pretense of following scientific evidence in applying to vaping and HTP aerosols the same policies applied as protection from environmental tobacco smoke (ETS).
The claim that protecting the health of bystanders is only possible through a full point blank usage prohibition of vaping in all public spaces is disproportionate. By denying evidence on the involved risks, this claim sounds like an institutional effort to stigmatize and de-legitimize the public usage of harm reduction products, a usage that the tobacco control orthodoxy disapproves.
Policies to regulate usage of e-cigarettes and HTP products in public spaces must be risk proportionate, specially aiming to limit an exposure that while not harmful is undesired, but allowing for legal and socially accepted venues open to public willing to accept voluntary exposure.
Regrettably, the fear oriented conflation of passive smoking and passive vaping presented as “health protection” has become successful, largely because of widespread public ignorance on these products, which are assumed by the broad public to be a sort of new form of smoking promoted by the industry, ignoring their origin and development as a consumer driven disruptive technology. Disinformation and scare headlines from the media together with public health miscommunication constantly reinforce this ignorance.
If health or governmental authorities would implement on (say) gender or race issues this type of aggressive fear based communication and point-blank prohibitions, blatantly ignoring scientific evidence, there would be a lot of public indignation and scandals.
In fact, mainstream media communicating health policies often follows scandalous double standards: widespread condemnation of aggressive fear based conspiratorial communication on vaccines, but the same media justifies equivalent disinformation on alternative nicotine products as “protection of youth”, also peddling the conspiratorial notion that these products are only Big Tobacco marketing to “addict children”.
Unfortunately, the political power and vast financial resources of the constellation opposing THR has made of vaping an easy punching bag, to be pummeled by scandal obsessed tabloids and assorted collections of opportunist demagogues and extremists in social networks, in public health academia and in government.
Public health authorities that equate THR products with combustible products are committing or condoning serious ethical misconduct that costs lives. So far they have faced no accountability.
Passive vaping is not passive smoking: but the issue is often sidelined.
Smoke-free spaces have been been (and still are) a very important issue with public health implications. However, e-cigarettes and HTPs do not emit “smoke”. Therefore, strictly speaking, spaces (indoor or outdoor) where nobody smokes but these devices are used are actually smoke-free spaces, as ‘smoke-free’ as all spaces in which combustible tobacco products are not smoked.
True, “smoke” as defined in physics and chemistry can also be emitted by other combustion sources (fossil fuel cooking, motor vehicles, industry chimneys), but in public health terminology the term “smoke” involves combustion from burning tobacco biomass.
As a consequence of the fundamental differences and risk levels between combustion and non-combustion processes, public health smoke-free regulations and policies must be reconsidered to deal with environmental agents (aerosols) that are chemically and physically very different from tobacco smoke.
However, what I call “tobacco control orthodoxy” (the majority mainstream of the tobacco control community), medical establishments, regulators and policy decision makers have avoided the necessary reconsideration of the smoke-free concept that fully incorporates evidence of environmental emissions of non-combustible products.
This needed policy reconsideration has been, either fully blocked by denial (or downplaying) of the scientific evidence on the difference in the emissions, or (at best) initially pursued hesitantly (“… safer than passive smoking but not safe enough”), with timid hesitancy surrendering in the end to the easy bureaucratic exit to simply apply to passive vaping the same historical policies against passive smoking.
Currently there is an intensification of the ongoing global attempt to prohibit vaping and HTP usage in all public spaces (even open outdoor spaces) where smoking is prohibited. This is a set of policies still justified in terms of health protection (emphasis on children), regardless of the fundamental differences in the environmental emissions and on the harm reduction benefits for smokers switching to non-combustible products.
In fact, the UK government has not (not yet) implemented on passive vaping the strict smoke-free guidelines and policies historically implemented to prevent passive smoking. However, even the UK government is gradually shifting its more pragmatic policy on passive vaping to align with the policies that equate vaping and smoking espoused by the tobacco control orthodoxy that prevails in most countries.
I have noticed that the “pro-THR” research community (a dissidence from the orthodox tobacco control orthodoxy) is mostly and more intensely involved in two very pressing issues: smoking cessation and a rational understanding of youth uptake of vaping, with the latter being what the orthodoxy (up to the WHO) now regards as the totemic phenomenon to justify a frontal opposition to THR, which has driven many initiatives towards banning of flavors.
The pro-THR community also regards nicotine pharmacology as an important topic, since safer nicotine consumption is the core issue of THR, though at least part of the attention is to address an aggressive narrative that often weaponizes nicotine “addiction” of children and young people in “war of drugs” framework, aiming at comprehensive flavor bans at all costs and despite unintended consequences (black markets and more smoking).
I have also noticed that the pro-THR community is largely indifferent to policies whose aim is to implement for vaping in public spaces the same restrictions applied to smoking. This is in my opinion a short-circuit in THR, since THR cannot be reduced to a product substitution, even when this substitution is supported by solid evidence on its safety in substitution of smoking.
Although the pro-THR community acknowledges that this product substitution also benefits those non-users surrounding the users of the new product, the issue remains of secondary importance for most, a loss of concern that aids the efforts of the orthodoxy to falsely regard passive vaping as too close in harms to passive smoking, thus arguing the need to apply same smoke-free policies to vaping.
The low level of concern on misrepresentation of environmental emissions is an unintended form of acquiescing the orthodoxy’s denial of the evidence, it contributes to orthodoxy’s denials on other THR issues. This low concern on unjustified restrictions of vaping in public spaces is acquiescing policies that are detrimental to vapers, that derive in their loss of personal welfare, social acceptance and fulfillment.
Here I understand welfare as an overreaching concept that includes health and longevity, but also includes social acceptability and sense of value of the new lifestyle. Arbitrary prohibitions to vape in all public spaces is a serious attempt against the welfare of those who vape or use HTPs to reduce harm from smoking.
Perhaps, the low level of concern of many pro-THR academics on this issue occurs because they have never used non-combustible products, which were not available decades ago when they (perhaps) still smoked. But for consumers, not being allowed to vape in public places that may include an open terrace or in a park or a windy beach, is an attempt against our personal welfare.
Historical background: the early years
To understand current issues, it is necessary to dwell into their historical background. I have the impression that in its early beginning 1960-1980 anti-tobacco groups (that later evolved into tobacco control) were altruist medics and advocates waging a David vs Goliath struggle against the powerful tobacco industries and the indifference of the political class.
To get a documented account of events in these times, people should read “Velvet Glove Iron Fist” by Chris Snowdon, or “Tobakkonachts” by the late Michael McFadden, or Robert Proctor’s “Golden Holocaust”. Therefore, I request readers to be patient with my incomplete account of events.
From the early epidemiology work of Richard Doll and Austin Bradford Hill, the reports from the Surgeon General and the Royal College of Physicians, the link between cigarette smoking and lung cancer acquired full scientific consensus already in the late 1970s, which arose the attention of the public and the medical establishment, not only in the US, but also in the anglosphere and then globally, leading to the FTCT, the first international treaty on a health issue, sponsored by the WHO and signed by 158 countries.
Already in the late 90’s early 2000s the public disrepute of the tobacco industry and legal challenges it faced were well in their way in the US, with important contribution by anti-smoking groups that had increased their scope and activity to become gradually a powerful special interest group, enjoying high bipartisan public approval and political clout in the US, a development that was spreading globally.
The US Federal Government implemented the Master Settlement Agreement to protect the industry from lawsuits in exchange for large payments to coffins of the states, allegedly to fund anti-smoking initiatives, though the money ended up being a cash box for many other purposes. These events are well described in Snowdon’s book mentioned before.
In 1975 close to 40% of Mexican males (myself included) smoked (only 3% of women). At the time the association “smoking = cancer” became viral, cigarettes were popularly nicknamed “cancer tacos”. The medical establishment and government officials voiced and widely spread this message. By the late 1990s less than 20% of males smoked, women slightly increased to 5%. This significant drop of smoking prevalence occurred without proper tobacco control legislation, without aggressive stigmatization of smokers. However, the smoking prevalence has remained roughly static between 15% and 19% from the early 2000s when Mexico followed the WHO-FTCT recommendations and enacted in 2009 a federal tobacco control law (strengthened in 2024).
The pattern I described on Mexico is roughly similar to patterns in other countries. Smoking prevalence rapidly decayed in the period (1960-1990), coinciding with widespread government information on the association with serious morbidity and mortality, but then typically since the early 2000s this decay continued but at a much slower pace.
Perhaps, the late stalling occurs when the population that remains smoking are perhaps the more dependent or socially deprived smokers. But judging from my own experience, this might be an overly simplified explanation. Smokers (specially young ones) in the late XX century kept smoking despite the accumulated evidence of health risks mostly because smoking was socially accepted, also they enjoyed it and felt reasonably healthy and there was no stigma in recognizing it was pleasurable. Most knew and had seen examples of disease and death, but they also knew that noticeable serious harm takes decades to occur.
The emergence of passive smoking
By the early 2000s millions of well motivated health conscious smokers had quit smoking, perhaps joined by other millions whose smoking was less dependent and more casual. However, the decay of smoking prevalence began to stall.
The fact that millions of smokers kept smoking despite the evidence had been a constant concern for the incipient tobacco control and anti-smoking advocates. A daring proposal to address this concern came in a WHO conference in 1975, when former British Chief Medical Officer Sir George Godber declared in a key note speech that to incentivize more smokers to quit:
“It would be essential to foster an atmosphere where it was perceived that active smokers would injure those around them, especially their family and any infants or young children”
This notion gradually produced reverberations. If serious health injury to non-smoking third parties could be scientifically validated, it would make sense to assume that much more smokers would quit, at least out of guilt. Godber’s speech provided a powerful incentive to invalidate the liberal principle stating that conscious adults are free to self-damage and assume the consequences, but only as long as their self harm does not affect third parties.
However, at the time (before the 1990s) there was only sufficient epidemiological evidence on active smoking, not on an environmental issue like passive smoking.
Also, an active campaign based on making smokers responsible for harming those passively smoking around them would involve significant restrictions on public spaces where smokers could socialize while smoking, restrictions that were at the time culturally and politically inconceivable (anti-smoking activists were only demanding smoke-free sections in public spaces).
Nevertheless, there were numerous attempts to study the association between passive smoking and lung cancer. The most comprehensive epidemiological study to verify this association showed that it was weak and inconclusive. This study was undertaken between 1960 and 1998 by epidemiologists Geoffrey Kabbat and James Enstrom. It was a prospective study involving couples in which only one spouse was a smoker: 118 094 adults in California
Conclusion “The results do not support a causal relation between environmental tobacco smoke and tobacco related mortality, although they do not rule out a small effect. The association between exposure to environmental tobacco smoke and coronary heart disease and lung cancer may be considerably weaker than generally believed,”
The study was initially funded by the American Cancer Society, which withdrew its funding at latter stages once it was evident that the association was weak and inconclusive, an unexpected outcome that was not useful to support policies that would aim at restricting smoking in public places in order to incentivize more smokers to quit.
Enstrom and Kabbat had to finsih the study with industry funding. Despite the pressure for rejecting the study by public health academics on the chief editor Davy Smith, the study was published by the BMJ.
Visceral reactions leading to a “regime of truth”
The Rapid Response section of the BMJ journal immediately displayed many responses (from academics and from laypeople) against the study by Enstrom and Kabat, mostly judgmental, angry and visceral statements, all of which can only be described as a concerted moral lynching of Enstrom and Kabbat, who were themselves committed anti-smokers and whose professional work had always been of top quality.
A few responses argued that there were no real smoke-free spaces during most of the time the study was conducted (1960-1998), a claim later shown to be false by Enstrom and Kabbat. Most responses did not express even a trace of technical criticism, they simply expressed angry judgemental dismissals, casting the study as an effort funded by the tobacco industry to derail tobacco control initiatives and to smear at ongoing independent research on passive smoking, a fallacious statement since other studies conducted at the time also showed weak associations.
At the time of the publication some prominent tobacco control academics conducted lobbying efforts in public health institutions to defame and discredit the study and its authors.
James Enstrom soon published a detailed point by point personal response invoking Lysenko pseudoscience:
Enstrom JE. Defending legitimate epidemiologic research: combating Lysenko pseudoscience. Epidemiol Perspect Innov. 2007 Oct 10;4:11. doi: 10.1186/1742-5573-4-11.
Who was Lysenko and why did Enstrom mention him? He was a prominent Soviet biologist who conducted a state sponsored smear campaign during 1940-1960 against Soviet researchers on genetics. His purpose was to implement a top State level initiative to eliminate genetics from Soviet biological research, as demanded by ideological dogma that regarded genetics as an anti-Marxist pseudoscience.
Enstrom’s reference to Lisenko is a good historical analogy, as it describes how academic groups and full institutions can become politically and ideologically energized to engage in a cascade mobilization to smear and dismiss research (even if good quality) whose outcomes are in conflict with dominant political and ideological agenda. It is useful to read Enstrom’s response, since a few of the public health academics fully involved in this moral lynching are still active today and continue acting as described by Enstrom.
This episode was analyzed by Sheldon Ungar and Denis Bray in a published article based on the revision of the rapid responses in BMJ and placing this in the context of suppression of scientific results that turn to be political inconvenient :
Conclusion. The results [of the paper] suggest that the public consensus about the negative effects of passive smoke is so strong that it has become part of a regime of truth that cannot be intelligibly questioned.
In the end the smearing and defamation of Enstrom and Kabat was successful, which practically terminated any rational discussion on the effects of passive smoking that did not comply with the basic core of tobacco control orthodoxy, as forcefully expressed by those conducting the smear. Hopefully, one day these two epidemiologists will be fully vindicated.
Bad science after the Enstrom and Kabat affair
The weak association found by Enstrom and Kabat between passive smoking vs lung cancer was finally vindicated in the extensive literature review by Lee et al
Lee, P. N., Fry, J. S., Forey, B. A., Hamling, J. S., & Thornton, A. J. (2016). Environmental tobacco smoke exposure and lung cancer: a systematic review. World Journal of Meta-Analysis, 4(2), 10-43.
CONCLUSION: Most, if not all, of the ETS/lung cancer association can be explained by confounding adjustment and misclassification correction. Any causal relationship is not convincingly demonstrated.
Its weak association with lung cancer is not in contradiction with the fact that ETS is in itself a hazardous pollutant, with solid available evidence of dose dependent gradual development of serious respiratory harm, mostly in prolonged indoor exposure and in frail individuals.
The difficulty to quantify ETS exposure with sufficient accuracy complicates the studies of its health effects, in particular studies relying on self-reported exposure accounts in questionnaires are very imprecise and speculative. This stands in sharp contrast with active smoking in which the number of smoked cigarettes is an accurate proxy for its exposure.
As a chemically and physically complex mixture of aerosols (which I described in posts 8, post 9 and post 10), ETS contains sufficient load of toxic compounds to justify extensive policies of indoor smoke-free public spaces, at least policies that only provide separate sections in public spaces for smokers (ie in airports).
However, open outdoor smoking bans lack any justification on health protection, with tobacco control orthodoxy (grudgingly) justifying these prohibitions as efforts to “denormalize” smoking motivated by the “common good” or “the children” (”...we don’t want children to see that smoking is ‘normal’ and socially accepted”).
The aftermath of the dismissal of Enstrom and Kabat triggered in the US (and then globally) a public health narrative that characterizes ETS almost as a metaphysical substance, a notion well captured by the statement “there is no safe level of exposure to ETS” by the US Surgeon General Richard Carmona in 2006, which is a politically motivated fallacy that could only be approximately fulfilled in the very long persistence of radioactive contamination in Chernobyl, the worse nuclear reaction disaster. Evidently, ETS is not even remotely comparable to radiation waste in Chernobyl and is not so ultra hazardous under all conditions as it is presented.
Anti-tobacco activists opposed smoking rooms in bars, restaurants and airports by arguing that ETS would penetrate and go through walls (like a spirit or a ghost) or would rise from balconies in buildings to reach children in an upper floor. These are all fallacies whose purpose was to generate disgust towards smoking, hoping to incentivize more smokers to quit.
If “second hand” was not sufficient, “third hand” smoke “THS” emerged as a scare topic in the 2000s. However, THR is not a ghost or a spirit, it is the product of surface to air interactions in indoor spaces, typically oxidizing reactions, between indoor pollutants (either gases or aerosols) and semi-volatile chemical residues of smoke (including base nicotine) deposited in walls. The byproducts are in general present in low concentrations that might remain very long times deposited in walls where smoking took place and even remain airborne.
While the tobacco control orthodoxy presented THS as another scary output to further escalate the chemical horror of tobacco smoke, the physico-chemical processes behind this phenomenon are not exclusive of tobacco smoke, they occur whenever the surface to air reactions are chemically possible, for example in walls of poorly ventilated kitchens, or when walls are washed with cleaning liquids or urine is sprayed on walls (cat urine is specially persistent). It is a generalized problem of indoor pollution that occurs even in spaces where nobody ever lighted a cigarette. .
Given the scary stories of “second hand” and “third hand” smoke, the early 2000s triggered a series of peer reviewed fraudulent studies that can only be described as pseudoscience. These studies were taken at face value to justify open outdoor smoking bans in parks, beaches, university campuses.
These extensive bans are the overreaching application in 2000-2010 at full US federal level of the notion expressed by British Chief Medical Officer Sir George Godber in a WHO conference in 1975, namely, fear of really serious harm from ETS in non-smokers would motivate sufficiently extensive bans on smoking to entice more smokers to quit.
If such fears of serious harm (cancer, heart disease) could not be sustained by solid evidence (shown by Enstrom and Kabat), then they can be fabricated. However, before the massive market entrance of e-cigarettes in 2011 these extensive bans did not cause a significant decrease of the rate of smoking prevalence in the US, which was steady since the late 1990s.
The most notorious fraudulent ETS study claimed that an outdoor smoking ban in Helena, Montana, produced a 60% reduction in heart infarctions in the local hospital. There was criticism (by Brad Rodu and colleagues) pointing out to a minute sample and to “convenient” random finding in the heart infarctions statistics. Still, criticism was ignored and the study claims were taken at face value by all public health institutions in the US. It received global media diffusion (NYT, BBC, WP) as proof that ETS causes heart disease at large scales.
The study had been cited 619 times when it was finally refuted in 2016 by statistician Vivian Ho working on a national sample. The leading author of the study was Prof. Stanton Glantz, from the University of California at San Francisco, one of the leading academics behind the smear on Enstrom and Kabat. Glantz never recognized the criticism for the Helena Montana hoax. He is now retired, but he is still a very influential opponent of THR, pursuing the same political witch hunts of “inconvenient” science outcomes, just as he did in the smear of Enstrom and Kabat.
Epilogue
Almost two decades have passed since the Helena Montana hoax and the moral lynching of Enstrom and Kabat. A balance is necessary.
There is no doubt that the tobacco control movement fully deserves to be commended for having raised widespread public (and government) awareness on the harms from smoking, also for having spread solid scientific information based mostly on epidemiological studies on primary smoking. Credit is also truly deserved for having faced a powerful and deceitful tobacco industry at the time.
However, tobacco control from the early 2000s has been ethically stained by its visceral and ideologically abusive reaction to the study of Enstrom and Kabat affair, leading to the mystification of harms from ETS as indisputable knowledge, which paved an intellectual environment that prompted the publication of the Helena Montana hoax and other similar scientific frauds to justify the enactment of smoking bans in wide open spaces.
The approach of tobacco control to ETS and passive smoking provides clear examples of institutional initiatives presented as “scientific” activity whose purpose is not to advance knowledge, but to provide expected research outcomes that agree and justify the needs of a previously decided regulatory policy. This is a political deformation of science, as it violates the fallibility and uncertainties inherent in the scientific method. The analogy with Lysenkoism is accurate and appropriate.
Unfortunately, questionable attitudes of the deformation of science in that period remain today, now targeting vaping and THR. The mode of operation of the current tobacco control orthodoxy that so intensely opposes THR (ideological rigidity, opacity, intolerance and disregard of “inconvenient” evidence) strongly resembles attitudes of tobacco control in the US towards ETA and passive smoking, that I described taking place during the early 2000s, for example the visceral reaction to the findings of Enstrom and Kabat and their defamation as industry shrills, as well as the careless political manipulation of the dangers and effects of passive smoking, whose purpose was not health protection but “denormalization” of a behavior, a feat that was achieved with scientific fraud like the Helena Montana hoax.
The problem I see today is the deployment of the same attitudes against passive vaping that were deployed in the 2000s against passive smoking, specifically to generate a fabricated fear on the exhaled aerosol, parallel to what was done in the 2000s with passive smoking, which then had a minimal justification given the inherent toxicity of tobacco smoke.
The strong push for “no-vaping” in all areas where smoking is banned (including parks and beaches) is too similar to the drive in the 2000s to use fraudulent studies on ETS (Helena Montana) to justify smoking bans in open extended outdoor spaces, bans that could not be justified as health protection, only as an attempt to eradicate a behavior even in situations in which it caused no harm.
The ongoing effort of “denormalization” of vaping by banning it together with smoking in all public places (even outdoors) and inside cars is not just a technical issue, it is a very serious attack against THR, as it relies on falsification of facts to deform the public perception (including smokers perception) on the relative safety of vaping.
All what happened in 2000s is now history. It could possibly be justified as doing what was necessary to do against smoking. I disagree with this brutal way of saying “the ends justify the means”, but would understand it as crude utilitarian necessity against something very harmful.
However, this utilitarian justification is no longer valid when applied to a context with vaping and THR. For the tobacco control orthodoxy “rejection of vaping and THR” are the “means” whose “end” is the elimination of non-pharmaceutic nicotine. In this case, the “means” would cause much more damage than the achievement of the “ends”. In fact, both “means” and “ends” in this case are harmful and must be rejected. There comes a point when the ends do not justify the means and when lies for the “common good” becomes a crime.
Harm reduction, as a pragmatic humane policy, is destined to fail if the products and behaviors of users switching from cigarettes are so stigmatized, so weaponized by a false induced fear of harm to others. To forcefully oppose this denormalization is an important battle, as important as promoting smoking cessation.
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