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When Pride Hinders Public Health
Clifford E. Douglas, J.D., Chief Executive Officer | September 15, 2024
| Publisher's note: This material was paid for (*) by Global Action to End Smoking and provided by Global Action to End Smoking. The views expressed by the author are their own. This material is not part of Health Affairs Forefront; it has not been subject to editorial review or revision by Health Affairs or Health Affairs Forefront except to avoid offensive, dangerous, or deceptive content and to conform with Health Affairs style conventions. |
Like most people, I’m uncomfortable having to say these three simple words: “I was wrong.”
But six years ago, while serving as the national vice president for tobacco control at the American Cancer Society, I found myself saying just that. I had led an intensive process of analysis featuring input from dozens of scientific experts that led me to realize I was incorrect about a core principle of my commitment to reducing the death and disease related to smoking.
With new evidence at our disposal, it became clear that reduced-risk nicotine products like e-cigarettes, nicotine pouches, the smokeless tobacco product called snus, and heated tobacco devices have a place in helping adults who smoke to stop, alongside traditional medicinal therapies. I have spent my 36-year career as an attorney and champion of public health promoting science-based policies and education and seeking accountability for tobacco industry misconduct in courts of law. I therefore first assumed these products were simply the next generation of harm. But through careful research and the advancement of scientific knowledge, it became clear to me that when these tools are used appropriately by individuals who smoke and are trying to quit, they can play a role in improving health.
This isn’t to say that I believe these products are right for everyone, nor that I am recommending them universally as a tool to stop using lethal combustible tobacco products. On the contrary, I believe that given the fact that we know these products are not benign, we must continue to study their long-term effects and examine all research on their health effects closely and objectively. Furthermore, they must be kept away from those who are underage and their use discouraged for adults who have never used nicotine.
However, given that global smoking rates remain stubbornly persistent, I believe that we have a duty to the more than 1 billion people who continue to smoke globally to provide them with as many tools to reduce their risk as possible. For the millions of people who smoke and cannot or will not otherwise stop smoking, the availability of such alternative sources of nicotine can be the difference between life and death. These products have already saved millions of lives, and the need for new tools to fight the smoking epidemic is urgent.
Overcoming long-held beliefs
My work at the American Cancer Society followed three decades of experience as a lawyer and public health expert working in tobacco control, including once having been at the receiving end of a brutal cross examination under oath at the hands of industry lawyers. I spent years represented the grieving families of fathers and mothers who had died of smoking, and succeeded in holding cigarette companies accountable for the illnesses and deaths of thousands of their misled customers.
Because my commitment is to public health, I assumed that any new product from tobacco companies had the potential to be just as harmful as cigarettes. But as I engaged with emerging data, I saw that my biases were misleading me. Eventually, my journey to understand the potential role of reduced-risk nicotine products led to the publication of The American Cancer Society Public Health Statement on Eliminating Combustible Tobacco Use in the United States.
I want to be clear that reduced-risk nicotine products are not a silver bullet. I am uncomfortable with the fact that those best positioned by the U.S Food and Drug Administration (FDA) to manufacture these products are those responsible for also making and promoting deadly cigarettes. I am also uneasy that in the current, poorly managed environment, youth can too easily access these products, most of which are now illicit due to failed regulatory strategy. While we may not be able to change the former, the latter is something that must be addressed by providing for a carefully regulated and robust marketplace of alternative, noncombustible sources of nicotine, along with much better enforcement of the minimum age law.
Still, if my public health colleagues objectively promoted these products for the tools they are–reduced-risk, and not risk-free–and regulatory authorities took needed action to prevent youth from accessing them, we now know that we could seriously increase quitting rates and decrease the number of deaths related to cigarettes.
Many leaders in the tobacco control field have similarly exercised scientific humility and similarly put the interests of people who smoke first based on the rapidly advancing science that guides us. But there are too few of us who have the resources to make a meaningful impact on the global smoking epidemic, especially when other prominent figures in the space cling to outdated misinformation.
This unwillingness to acknowledge uncomfortable change is very likely prolonging the epidemic of smoking-caused illness and death. But I nonetheless remain optimistic because it is never too late for others to evolve in recognition of what we now know is true.
Acknowledging past ignorance
Science itself is an exercise in humility. The entire discipline involves verifying—through careful experimentation—a previously conceived hypothesis. Progress in science also requires being willing to accept when the initial hypothesis is disproven or requires adjustment.
Disproving an idea in science can’t happen with a single study or experiment. Science depends upon a rigorous commitment to the truth, and results must be replicated in order to verify their validity.
It is therefore understandable that it has taken so long to develop the evidence that alternative nicotine products like e-cigarettes, snus, nicotine pouches, and heated tobacco products can be used effectively to assist some people on their journeys away from smoking.
Given the horrific history of the tobacco industry’s fraud on the public and health authorities, the skepticism felt by many must be respected. We should not trust the tobacco industry any more than we trust environmental polluters or others with bleak histories of wrongdoing. But we must verify whether and when these actors are taking appropriately regulated steps in the right direction.
Few of us alive today can remember the time, earlier in the last century, when cigarettes and their manufacturers were regarded as benign, or even recommended by doctors. As a result of advertising and marketing throughout the 20th century, smoking was widely accepted as the norm and even promoted by many leading scientific journals and medical experts.
Part of the passion that led to me and others dedicating ourselves to this corner of public health resulted from the outrage of realizing that the cigarette industry had maliciously duped millions of innocent human beings into believing their lies. Ultimately, many thousands of independent research papers reported
that there was a strong causal link between cigarette smoking and lung cancer, heart disease, and other pulmonary conditions. Eventually, this mounting evidence led to the Master Settlement Agreement of 1998, and later the 2006 federal court ruling that the industry had fraudulently hidden the truth.
And yet it took years for the idea that smoking was dangerous to become well accepted with medical authorities. The first evidence that smoking directly caused cancer was documented as early as 1950—a time when cigarettes were a part of soldiers’ daily rations. Yet even a decade later, many U.S. doctors believed there was enough evidence to officially convict cigarettes as the lethal products they were.
By the time I joined the fight for public health in the late-1980s, the science was straightforward: inhaling the smoke from combustible tobacco exposed individuals to nearly 70 carcinogens and more than 7,000 chemicals overall. Nicotine, especially in combination with other additives engineered into the modern cigarette, was highly addictive and kept people coming back for more. And the repeated exposure to all those dangerous chemicals caused the deaths of one out of two long-term users, making cigarette smoking the leading preventable cause of death globally.
The world rightly lost all trust in the tobacco industry. We were wrong to believe the fraudulent information they infamously peddled—at the cost of 100 million lives worldwide in the 20th century. It would also take the development of an impressive body of new scientific evidence by independent researchers to change the public health community’s minds about newer, far less harmful nicotine products.
Humility to move forward
We have reached that threshold. We have that evidence. While it will continue to grow for some time to come, it is already powerful. It is enough for major health authorities such as the FDA to have announced that such products, which are far down the continuum of risk of tobacco and nicotine products, can provide a significant reduction in risk for smokers who switch completely. Many individual studies along with large-scale meta-reviews have produced data demonstrating that reduced-risk products have a critical role to play as a complement to traditional—and too often less effective—nicotine replacement therapies.
There are, of course, studies highlighting that some of alternative nicotine products present health risks. Some of these studies are valid: These products are certainly not risk-free.
However, it must also be recognized that a number of the analyses that have allegedly found these products to be as dangerous as cigarettes, many of them produced by the same authors, have been shown to suffer from deeply flawed study designs or incomplete data reporting. Some have been retracted.
But in this polarized environment, it is difficult to challenge these papers and researchers because those who do are erroneously accused by the authors of siding with the tobacco industry—an allegation no one in public health wishes to face. While such divisive tactics are unfortunate and have no place in the field of public health, these attacks haven’t stopped rich debate playing out across scientific journals through learned responses and commentaries. I am very proud of my colleagues’ commitment to following and fighting for the science.
Meanwhile, the data around the global smoking epidemic have remained largely unchanged: Though smoking rates have decreased in the last several decades, the rate of decrease is slowing and in some places, particularly some of the current war zones, even increasing. Smoking also persists at much higher levels in marginalized communities and is most prevalent in low- and middle-income countries, where 80% of the people who smoke live. The traditional, medicinal cessation tools currently available have not worked nearly well enough to drive down smoking prevalence. This means that, strictly in service of saving more lives, we must be ready to deploy all tools that help people discontinue using cigarettes—including newer products.
My legal training and experience in the courtroom reinforced the priority of objectively learning and then maintaining an unwavering conviction about the facts. In the grand scheme of my career, the people who smoke are far more important than my human desire to have always been right. So I’ve evolved to become a public health advocate who embraces all forms of smoking cessation and harm minimization.
As I move forward, I fear that progress is being slowed by those who cannot or will not publicly acknowledge the truth. Misinformation and disinformation are tragically slowing our progress in ending the smoking epidemic. In some cases, it is not mere ignorance that has led some health authority figures to publicly maintain their opposition to reduced-risk products. Their objections appear to reflect a value system that prioritizes punishing tobacco companies while single-mindedly emphasizing the protection of our youth. As a lifelong adversary of Big Tobacco and as a father, I fully understand both of those motivations, but also believe that this unscientific posture reflects a deep resistance to admitting when one has got it wrong.
No one likes to admit to mistakes. But we must surmount that hurdle and prioritize accelerating the end of the smoking epidemic, which—in the absence of a major change in trajectory—has been projected to cause an unthinkable one billion deaths in the 21st century.
I will continue following the science in my collaborative quest to end smoking. I invite others to reinvigorate their commitment to data-driven humility as we move forward and better serve the public—who are at the heart of why we entered this field in the first place.
Clifford E. Douglas, J.D., is Chief Executive Officer of Global Action to End Smoking. Katherine Ellen Foley, M.A., Director of Media of Global Action to End Smoking contributed to this piece.
About Global Action to End Smoking Global Action to End Smoking is an independent, U.S. nonprofit 501(c)(3) grantmaking organization whose mission is to accelerate science-based efforts worldwide to end the smoking epidemic. It is dedicated to ending combustible tobacco use, which remains the leading preventable cause of death globally. Through September 2023, Global Action received charitable gifts from PMI Global Services Inc. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products. Global Action has earned the 2024 Platinum Seal of Transparency from Candid, a leading global source of information about nonprofit organizations, which recognizes Global Action’s exceptional dedication to transparency, accountability, and effectiveness to achieve its mission.
(*) I asked Health Affairs how much it costs to publish such "sponsored content". Here the answer I received: "Our sponsored posts are priced at 2 for $10,000 or 1 for $6,000. We also also a sponsored post series if you are looking to do 3 or more posts. The series included a landing page where all posts are housed as well as some additional promotion to drive traffic to the landing page."
This does not tell us how much was paid but it provides a range and in any case I think it was a useful investment for Cliff Douglas to have his position published that way as probably he has not been able to do otherwise, ie having access to an opinion piece for free.
I regret Global Action deems useful to refer to their "Platinum Seal of Transparency" from Candid as it is meaningless. I previously asked Candid what they required to award this "seal of transparency': it is given to any non profit that respects the law, ie, publishing their 990PF form. This does not demonstrate any extra effort to be transparent, it only means you respect your legal obligations that are very minimal.
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