The Corruption of Public Health

The tobacco industry faces an unprecedented threat. Since a new rival, the electronic cigarette, emerged in 2010, the smoking rate in America has plummeted, especially among young people. The e-cigarette delivers nicotine in vapor without the hundreds of toxins and dozens of carcinogens in cigarette smoke, eliminating at least 95 percent of the harm of smoking, according to England’s national health agency, which endorsed its use after extensive studies. The Royal College of Physicians, Britain’s most eminent medical authority, reached a similar conclusion and warned that it would be “unjust, irrational and immoral” for public officials to discourage smokers from switching to a safer form of nicotine.

In America, though, that’s just what they’re doing. The officials, along with the researchers they fund, have mounted a furious campaign against vaping. They claim to oppose cigarettes, which they recognize as the leading cause of preventable death, but their actions have served to encourage smokers to keep lighting up. In a bizarre historical twist, the public-health establishment is protecting the cigarette industry with the same infamous techniques that Big Tobacco formerly used. Just as tobacco apologists once argued that no conclusive scientific evidence showed that smoking was harmful, American public-health officials now insist that there’s no solid evidence that smoking is worse than vaping. No tobacco executive today would dare make such a ludicrous claim about cigarettes—he’d fear the resulting lawsuits—but government officials enjoy legal immunity that lets them engage in deadly deception, without paying the consequences.

The previous surgeon general and leaders of the Centers for Disease Control have led this public effort, covering up data showing vaping’s benefits and using their funding powers to pressure local health officials to ban the practice. The Food and Drug Administration has forbidden e-cigarette firms from mentioning any health advantages over cigarettes, and it adopted rules to outlaw virtually all existing vaping devices next year. The National Institutes of Health has supported activist researchers who’ve manipulated evidence to hype risks of vaping and falsely claim that it is causing an upsurge in smoking by young people.

The disinformation campaign has been a success—in fact, more successful than the tobacco industry’s past attempts to mislead the public. Even before the federal government had started warning about cigarettes, most people realized that smoking was bad for your health. But today, thanks to the government offensive and the cooperation of gullible journalists, much of the American public is confused about the relative dangers of smoking and vaping, surveys show. Less than 15 percent of Americans realize that vaping is much less risky than smoking, while nearly half mistakenly think that vaping is as harmful as, or more harmful than, smoking—meaning that millions of smokers have been dissuaded from making a switch that could prolong their lives. The public-health establishment has become a menace to public health.

How could a profession dedicated to health oppose the most promising method of saving smokers’ lives? The immediate answer involves progressive activists whom the Obama administration appointed to government health agencies; with the change of administrations, their departure gives Republicans a chance to undo the damage. But the vaping story is part of a much bigger and longer-running scandal. It is the most flagrant example of how a once-noble enterprise became corrupted by ideology and self-dealing.

In its heyday in the late nineteenth and early twentieth centuries, the public-health profession had a precise understanding of “public.” They combated epidemics of cholera and dysentery through improvements in public water and sewage systems. They enforced quarantines, introduced inoculations, educated the citizenry, and looked for new ways to stop the spread of smallpox, measles, typhus, yellow fever, malaria, and tuberculosis. By making the world safer and healthier through the dissemination of information and protecting people against infectious diseases, they provided what economists call public goods—just the kind of service that government is supposed to deliver.

By the 1960s, the profession had proved so effective in reducing the threat from these diseases that it confronted another problem—the March of Dimes syndrome. What does an institution do after its original mission has been accomplished? The March of Dimes, created to fight polio, did not declare victory and put itself out of business when the polio vaccine defeated the disease; instead, it expanded its mission to fighting other childhood ailments. The public-health establishment was even more ambitious. It redefined its mission to include just about any social problem or individual behavior that might pose health risks and provide a rationale for the government to intervene in people’s lives, as James T. Bennett and Thomas J. DiLorenzo chronicle in their history of the public-health movement, From Pathology to Politics.

“Since 1968,” they write, “a top priority—if not the top priority—of the public health establishment has been to promote the idea that more government control and intervention is the surest route to sounder health.” The main professional group, the American Public Health Association, has become an advocate of progressive causes: nationalized health care, income redistribution, a higher minimum wage, government-provided day care for children, gun control, and new taxes on and regulations of cigarettes, soda, and food. Now that the World Health Organization has redefined its mission to be the achievement of “physical, mental and social well-being,” the field has boomed with new jobs—not just for medical researchers but also for psychologists, sociologists, anthropologists, environmentalists, and assorted activists. The Centers for Disease Control, founded in the 1940s to deal with malaria, has expanded its mission to include “epidemics” of obesity, hypertension, binge drinking, physical inactivity, mental illness, domestic violence, suicide, and handgun fatalities.

The “tobacco epidemic,” as it’s now called, was one of the earliest targets, though the first efforts against it were traditional. When evidence of smoking’s dangers accumulated in the 1950s, the public-health field was still led by medical researchers who considered their duties to be scientific analysis and public education. The surgeon general’s famous report of 1964, compiled by an expert committee that reviewed more than 7,000 studies, forcefully summarized the dangers of smoking but left it to others to devise “appropriate remedial action.” Private groups lobbied for government intervention, like the warning labels on cigarette packs that Congress mandated the following year, but they stressed voluntary education and individual responsibility, not coercion. “We believe in the freedom of the individual in the matter of cigarette smoking,” the American Cancer Society president told Congress in 1964, explaining his group’s opposition to legislation that banned smoking. “To achieve our goal we rely on persuasion and public and professional education.”

Many smokers were persuaded to quit, but not enough to satisfy the progressives who came to dominate public health. They shared the passion for social engineering of the original Progressives, who had helped lead the movement to ban alcohol in the 1920s, and they adopted the same prohibitionist approach to tobacco. In Jacob Sullum’s history of the antismoking movement, For Your Own Good, he describes the profession’s new philosophy: “The public health perspective, which seeks collective prescriptions to reduce morbidity and mortality, does not take individual tastes and preferences into account. Having noted that smoking can lead to illness, public health specialists now identify smoking itself as a disease, something inherently undesirable that happens to unwilling victims.”

To rescue these victims, public-health officials sought a “smoke-free society.” They lobbied for bans on smoking in indoor public spaces, reasonably enough—why should taxpayers using public property be involuntarily subject to a nuisance that’s smelly and can irritate respiratory ailments? But the activists also successfully fought for state and local bans on smoking outdoors and in private restaurants, bars, and workplaces, an expansion of government power ostensibly justified by the deadly menace of secondhand smoke.

That claim, unlike the surgeon general’s landmark warning in 1964, wasn’t based on rigorous empirical analysis. Led by the Environmental Protection Agency and the CDC, the new generation of public-health activists cherry-picked studies and massaged data to support claims that secondhand smoke was causing thousands of cases of lung cancer annually and that banning it in some towns brought dramatic declines in the rate of heart attacks. Prominent researchers contested those claims at the time, leading a judge in 1998 to rule that the EPA had grossly manipulated “scientific procedure and scientific norms.”

Long-term studies have subsequently debunked the alarms, but antismoking activists remain unapologetically convinced that the ends justified the means. In 2013, when the Journal of the National Cancer Institute published an exceptionally rigorous study that tracked 76,000 women (including wives of smokers) and found no connection between secondhand smoke and lung cancer, the results were dismissed as irrelevant to public policy. The journal quoted one expert explaining that ending the health risk of secondhand smoke was never really the point of the bans: “The strongest reason to avoid passive cigarette smoke is to change societal behavior: to not live in a society where smoking is a norm.” Science should never get in the way of social engineering.

The new prohibitionists were also disturbed by some smokers’ switch to smokeless nicotine products like snuff and chewing tobacco. As surgeon general in 1986, C. Everett Koop denounced the “tragic mistake of replacing the ashtray with the spittoon.” Once the public-health establishment changed the goal to a “tobacco-free society,” it became taboo to point out how comparatively safe smokeless tobacco was. When Brad Rodu, an oral pathologist now at the University of Louisville, reviewed the literature in the 1990s and estimated that smokeless tobacco eliminated 98 percent of the harm from cigarettes, the American Dental Association as well as the National Cancer Institute denounced him, and the National Institutes of Health subjected him to a yearlong investigation.

But Rodu’s estimates were an understatement. Researchers reviewing the literature in 2009 concluded that smokeless tobacco was 99 percent safer than smoking. One little-used variety, dry snuff, correlated with a very slight increase in the risk of oral cancer, but people who chewed tobacco or used moist snuff had the same risk as nonsmokers. The benefits of smokeless tobacco have become clear in Sweden, where millions have switched from cigarettes to snus, a form of moist snuff more socially acceptable than chewing tobacco because it doesn’t involve spitting. (It’s absorbed from a small packet, similar to a tea bag, placed between the gum and cheek.)

Swedish men have the highest rate of smokeless tobacco use in Europe—and, not coincidentally, the lowest rates of smoking and smoking-related diseases. It’s estimated that 350,000 lives would be saved annually if the rest of Europe followed Sweden’s example. But instead of encouraging this trend, the European Union has banned snus everywhere except Sweden, preferring the same prohibitionist approach as America. “Treating all nicotine products as equally dangerous is not just factually incorrect,” Rodu says. “It’s dangerously unethical, whether it’s applied to smokeless tobacco or e-cigarettes.”

The abstinence-only strategy—also known as “quit or die”—has manifestly failed. Despite a half-century of antismoking campaigns, more than 15 percent of adults still smoke in the United States and in every European country, except Sweden. These people know of the dangers but persist because of another fact that prohibitionists refuse to accept: nicotine provides real benefits. Studies have repeatedly shown that it can quicken reaction time and improve memory, alertness, concentration, and mood. Researchers have tested it, with some success, to counter the effects of Alzheimer’s disease and other forms of cognitive impairment.

Depending on the setting, nicotine can be a stimulant or a relaxant. It has been linked to reduced anxiety and stress. It helps people control their weight, which is why smokers typically gain ten pounds in the year after quitting. Nicotine is, in some ways, similar to caffeine: both cause increases in blood pressure and heart rate, but those changes are transient and harmless. Long-term studies of Swedish users of snus have shown no increased risk of cancer, heart attacks, strokes, or any other illness linked to smoking. In fact, snus users have a substantially lower risk of Parkinson’s disease and multiple sclerosis. Those findings don’t prove that nicotine prevents the diseases—correlation isn’t causation—but researchers suspect that it could be protective because of its effect on the brain’s dopamine system. “Nicotine itself is not especially hazardous,” the Royal College of Physicians concluded. “If nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.” The British group has faulted public officials for imposing restrictions and high taxes on smokeless tobacco and e-cigarettes instead of working to make these safer substitutes more available.

This is the same sort of “harm-reduction” strategy that the American public-health establishment uses to justify its support for government-subsidized needle-exchange programs: if addicts insist on using heroin, then it’s humane to protect them from some of the dangers. So why deny similar help to nicotine addicts, whose drug of choice isn’t even dangerous? Why subject them—but not heroin addicts—to the abstinence-only strategy? This inconsistency can be explained partly by the Left’s preferences in virtue-signaling. Like fundamentalists who object to dancing because it looks like sex, they’re repulsed by vaping because it looks like smoking. A more cynical explanation is the difference in employment opportunities for public-health workers and bureaucrats. There’s no role for them when people get nicotine through snus or e-cigarettes, but they can get jobs running needle exchanges and antismoking campaigns. Prohibitionist activists have received long-running support from the Robert Wood Johnson Foundation, which helped create the Campaign for Tobacco-Free Kids (a leader of the anti-vaping movement) and has spent nearly $700 million toward its goal of a “tobacco-free society.”

There’s also a larger financial angle. The campaign against nicotine is being conducted by what economists call a Baptist-bootlegger coalition, named after the Baptist preachers who campaigned for blue laws and the bootleggers who wanted liquor stores closed on Sunday so that they could sell alcohol illegally. The Baptists provided politicians with a virtuous excuse for increasing the profits of the bootleggers. The bootleggers could kick back some of the proceeds by making donations to the Baptist churches and the politicians who passed the laws.

In the anti-nicotine campaign, the Baptists are the public-health officials and nonprofit groups that denounce e-cigarettes. The bootleggers are the industries profiting by suppressing competition from vaping. One is the pharmaceutical industry, which sells nicotine-replacement therapies like Chantix (a drug that stimulates nicotine receptors) and nicotine skin patches, gum, and lozenges. These products are neither popular nor effective (the success rate in quitting is just 7 percent), but the public-health establishment has endorsed them as the only acceptable alternative to cigarettes (and even then, only as a temporary aid on the way to abstinence).

Faced with a much more popular new competitor, pharmaceutical companies have responded by supporting restrictions and taxes on vaping devices (just as they have long lobbied for restrictions on the sale of smokeless tobacco). As Monica Showalter reported in the Observer, the firms have contributed substantially to Democrats leading the anti-vaping efforts in Congress, including Senators Ed Markey, Sherrod Brown, and Richard Blumenthal. The drug companies have also donated to groups that have come out against vaping—among them, the American Cancer Society, the American Heart Association, and the Campaign for Tobacco-Free Kids. The firms’ influence has been chronicled by Bill Godshall, the head of Smokefree Pennsylvania, one of the few antismoking groups to break with prohibitionist dogma. “For decades,” he says, “drug companies have been promoting their nicotine-replacement therapies by bankrolling researchers, activists and lobbyists to demonize smokeless tobacco and e-cigarettes.”

The other chief bootlegger is Big Tobacco. Altria (the parent company of Philip Morris) successfully urged the FDA to issue regulations governing e-cigarettes, a move welcomed by Wall Street analysts who track the cigarette industry. Tobacco companies benefit in the short term from regulations and taxes that discourage smokers from giving up cigarettes, and they benefit long-term by suppressing competition in the vaping business, which tobacco firms have entered by introducing their own brands of e-cigarettes. These are more expensive than the alternatives developed by the many small businesses whose products are sold online and in vape shops (and which R. J. Reynolds has lobbied to ban). These firms have popularized vaping with a rapid series of innovations—new customizable devices that make vaping much cheaper and more satisfying—but they’re the ones that federal regulation threatens the most. After the FDA’s rules take effect, introducing a vaping device will require an expensive approval process, beyond the means of small-time entrepreneurs—leaving the market to deep-pocketed firms like the tobacco giants.

Wittingly or not, public-health activists have labored away on behalf of Big Pharma and Big Tobacco. First, they persuaded the FDA to classify e-cigarettes as a “drug-delivery device” that couldn’t be marketed without doing costly clinical trials. When the courts blocked that move, the FDA misclassified e-cigarettes as a “tobacco product,” so that federal regulations would apply. The prohibitionists have persuaded localities to extend smoking bans in public and private places to include vaping, even though e-cigarettes emit vapor that causes none of the irritations or the dangers claimed for secondhand smoke. They’ve promoted heavy new taxes on e-cigarettes, a policy that harms public health by reducing the incentive for smokers to switch, but it’s been welcomed by state officials (like New York governor Andrew Cuomo) eager to replace the cigarette-tax revenue they’re losing as smoking declines.

Worst of all, the prohibitionists have deceived the public by hiding the benefits and exaggerating the risks of vaping. One ad from the CDC warned of an “e-cig apocalypse.” Federal officials and activists claim that vaping is “renormalizing” smoking among adults and acting as a “gateway” to cigarettes for teenagers. Yet there’s no evidence for either trend, as the Royal College of Physicians concluded last year, after an exhaustive review.

Virtually all adult vapers have a history of smoking and use e-cigarettes as an occasional substitute or as an aid to quitting. At least 2.5 million Americans now vaping have managed to quit smoking entirely, and the number of smokers has been declining much more quickly than it was before vaping became popular. Between 2011 and 2016, the prevalence of smoking fell by 16 percent among American adults, and by 49 percent among students in middle school and high school. The CDC has tried to hide this good news. A typical CDC press release, issued last year, carried the headline “No Decline in Overall Youth Tobacco Use Since 2011,” which would be alarming—if true. The agency could make this claim only by classifying vaping as a form of “tobacco use,” an especially absurd move, considering that most of these teens are using liquids without any nicotine.

Some teenagers do try nicotine e-cigarettes in addition to tobacco cigarettes, which isn’t surprising: some teens are prone to experimentation of any kind. The federal government has eagerly funded efforts to show that vaping leads to smoking, without getting the desired results. Last year, a much publicized study of 347 high school students purported to show that vaping is a “one-way bridge to smoking,” but the paper’s omission of relevant statistics aroused the suspicions of Michael Siegel, a professor at the Boston University School of Public Health critical of anti-vaping propaganda. When Siegel analyzed the original data, he found that the grand conclusion was based on just four students and that it wasn’t even known if those four had smoked more than one cigarette over the course of a year. The most important—and unreported—result in the data, Siegel noted, was that very few teenagers who tried an e-cigarette went on to become frequent users. Vaping wasn’t even a bridge to regular vaping, much less to smoking.

“Anti-tobacco researchers and groups,” Siegel says, “are having a difficult time accepting the fact that a behavior which looks like smoking and which involves nicotine could possibly have benefits for the public’s health. The easiest way to resolve that cognitive dissonance is to convince yourself that vaping is actually full of terrible risks. The facts clearly don’t fit the ideology, but it is a lot easier to change the facts than your ideology.”

If anything, vaping seems to provide an alternative to teenagers who would otherwise be trying cigarettes. Studies by Yale and Cornell researchers have found that local restrictions on the sale of vaping devices to minors have resulted in more teenagers smoking cigarettes. Yet the surgeon general published a report in December denouncing e-cigarettes, accompanied by a tip sheet advising parents to dodge the question when their children ask if vaping is safer than smoking.

Instead of honest risk comparisons, federal officials have hunted for scares to promote, like the contention that vaping produces dangerous levels of formaldehyde—based on a study that overheated the vapor so much that it would have been intolerable. Several years ago, the CDC and some academics warned of an inevitable epidemic of poisoning among children drinking their parents’ e-liquid, but that has failed to occur (not surprisingly, since e-liquid tastes terrible and is usually sold in childproof containers, making it much less dangerous than the cosmetics and other household products that account for most poisoning). The FDA has issued warnings about toxins and carcinogens in vapor without bothering to note that the amounts are a million times lower than the concentrations conceivably related to human health.

It’s true, as the prohibitionists constantly point out, that no one knows the long-term consequences of vaping. The short-term effects—chiefly mouth and throat irritation—don’t seem worrisome, but it’s possible that other problems will show up. Even so, there’s no question that vaping is much safer than smoking. There are thousands of chemicals in cigarette smoke but only a few in nicotine vapor. Studies in Britain and Poland have shown that when smokers start using e-cigarettes as either a partial or complete substitute for cigarettes, their bodies’ levels of toxins and carcinogens dramatically decline. Among those switching completely to vaping, the levels are as low as, or lower than, those among people using nicotine-replacement therapies like gum.

Those are not the kind of studies that make news, though. The press much prefers the prohibitionists’ scare stories. They’ve loved quoting former CDC director Thomas Frieden, who told the Los Angeles Times last year that e-cigarettes could do “more harm than good”—a phrase he repeated five times. He recited a list of discredited scares and cast himself and his fellow bureaucrats as brave warriors against the “tobacco industry.” That was utterly false, given the benefits that the industry reaps from his misguided crusade, but Frieden must have realized how good such corporate-bashing would sound to his progressive allies.

Frieden knows, from his own career, that proper ideology can be the key to success in today’s public-health profession. (See “Dr. Meddlesome,” Spring 2009.) As New York City’s health commissioner, Frieden burnished his progressive credentials by likening cigarette-company executives to mass murderers, calling for new taxes on soda, and leading a campaign to distribute millions of free condoms. He forced food chains to post calorie counts for their meals, though no prior evidence showed that doing so would affect eating habits, and subsequent studies found that the New York law had no impact (except for raising restaurateurs’ costs and providing work for bureaucrats). But Frieden was never a stickler about data. He helped get trans fats banned in restaurants and tried to pressure national food companies to reduce salt in their products, despite a lack of consensus among researchers that such measures would improve people’s health. And he botched the job of protecting New Yorkers from infectious disease. His department’s slow response in 2007 to the outbreak of swine flu worsened the epidemic, which infected more than 750,000 New Yorkers and killed 54.

Yet Frieden wound up as the Obama administration’s choice to run the CDC. Asked what his top priority would be, he answered, “Tobacco.” At the CDC, he continued his other crusades to change people’s habits, persisting in his efforts to impose a low-salt diet on the nation, even as clinical trials showed that the regimen failed to prolong people’s lives and might even shorten them. His colleagues and the media lavished praise on him until the 2014 Ebola crisis. The CDC’s response was so inept, and Frieden’s public statements so confusing, that the Obama administration had to shunt him aside and bring in an outsider to be the “Ebola czar.” There were calls for Frieden to resign, but he was allowed to remain until the end of the Obama administration. Why should the head of the Centers for Disease Control lose his job for not controlling a disease? He has so many bigger threats to deal with, like e-cigarettes.

Now that Republicans control the White House and Congress, they have a chance to combine sound science with smart politics on vaping. Grover Norquist, the influential Republican strategist who runs Americans for Tax Reform, has discovered that vapers are much different from smokers, whom he found impossible to mobilize against cigarette taxes. Vapers don’t feel guilty about their habit. They show up at rallies and volunteer in campaigns that have helped block e-cigarette taxes and defeat anti-vaping Democrats in local and state elections. “The Democrats have made an unforced error,” Norquist says. “They’ve poked a hornets’ nest. There are 10 million vapers in America, and that demographic will easily double in the next decade.”

Norquist wants the Republicans to use vaping as a wedge issue against Democrats, particularly among younger voters. Vapers are part of what he calls the Leave Us Alone Coalition, which includes gun owners, users of Uber and Airbnb, homeschoolers, and others with firsthand exposure to Democrats’ big-government policies. Vape shops, like gun shows, have become an informal network for spreading the word. “Vapers look in the mirror and feel virtuous,” Norquist says. “They’ve quit smoking, or at least cut back. They’re doing the right thing for themselves and their families, and now these contemptuous nanny-state jerks want to take away the products that are saving their lives. Believe me, this is a vote-moving issue.”

Wisconsin senator Ron Johnson was expected to lose his reelection bid last November, but he pulled off an upset with the help of vaper-led rallies, volunteer work, and donations. He and other Republicans have been working to forestall the FDA’s anti-vaping rules, but they’ve been stymied so far by Democrats’ united devotion to prohibitionism. The best immediate hope lies with the FDA’s new commissioner, Scott Gottlieb, a longtime critic of overregulation in public health. He could, as a group of researchers recently urged, modify the FDA rules so that most companies could go on selling products that meet basic safety standards. The best long- term approach would be a bill introduced by Duncan Hunter, a California congressman and former smoker who vaped during a hearing at the Capitol. Instead of having the FDA treat e-cigarettes as dangerous “tobacco products,” the agency would enforce manufacturing and certification standards for vaping batteries and liquids. Instead of promoting scares, the FDA would be required to do a systematic assessment of the relative risks of nicotine products. Hunter’s bill could be further improved by giving sellers of e-cigarettes and smokeless tobacco the right to advertise truthfully that their products are safer than cigarettes.

It won’t be easy restoring rationality to the vaping debate in America, but the Trump administration can at least halt the obfuscation and deception by the CDC, surgeon general, and FDA. Then the new leaders at these agencies and the National Institutes of Health can take on a more daunting task: prodding the public-health establishment to return to its original mission.

The establishment will resist, of course, but it’s a fight worth making, especially as Republicans hunt for budget cuts. The federal government has been doling out vast sums to bureaucrats and researchers more committed to empire-building and progressive activism than to public health or rigorous science. President Trump has already identified the best way to deal with them, and it happens to be a technique used during the public-health profession’s glory days, back when it focused on genuine public threats like yellow fever and malaria: drain the swamp.

Top Photo: At least 2.5 million vapers have managed to quit smoking entirely. (TIMOTHY FADEK/REDUX)