Rethinking Nicotine with Clive Bates

The sad news that Dr Colin Mendelsohn is retiring from harm reduction advocacy is a bitter blow for anyone who believes in seemingly arcane concepts like truth, decency, and critical thinking. Coupled with the fact that global health bodies are getting stranger and more conniving by the day, voices like Clive Bates have never been more vital.

I’ve been a massive fan of Bates’ work and no-nonsense style for years, so I was delighted when he agreed to a quick chat about rethinking nicotine. Sharp, erudite, and super funny, he’s tailor-made for taking apart the pompous and corrupt world of tobacco control, which he does regularly on his brilliant blog, The Counterfactual.

The interview has so many unique thoughts and insights that there is no time to waste. Let’s get into it.

Tobacco harm reduction can be very dry. But what I love the most about your blog is that it’s so funny. Was that always your plan, or is it just because things are so absurd in the space?

I try to write things that people want to read, and often, one of the ways of doing that is to write in a style that makes people chuckle and helps points to land. Basically, not everything deserves frivolity. Some things are very serious and technical, but usually, you can find an ironic turn of phrase or metaphor to help people understand things that way rather than with dry, technocratic language.

It often gets lost in all the discussions about health and regulations, but nicotine has been part of human culture and history for a long time. Is that something that should factor into legislation?

Nicotine has been a recreational stimulant for thousands of years. People have been using it for its effects for maybe 6000 years or more. The idea that it’s just the creation of the tobacco industry and it’s only used because of predatory marketing is incorrect.

People have been using it throughout history. It’s remarked upon by King James and so on. So, it’s not a new thing. And people generally use things that they get something from. Now, you can say that people don’t get anything from it; they only get addicted, and then it’s only about relief from withdrawal or cravings or whatever, but I think there’s much more to it than that.

Interestingly, I think the research on the reasons why people use nicotine has been suppressed. This is because of the danger of appearing to justify it, and that is one short step from justifying smoking, which no one wants to do because it’s so harmful.

So, we have allowed the two things to be conflated and have been a little bit blind to the reasons why people use nicotine because of our desperation to encourage people to stop smoking on health grounds.

Do you think there are any good pathways to untangle nicotine from the harms of smoking?

I think until 2010, it was possible to conflate nicotine use and smoking. People saw it as just one big thing. Smoking, nicotine, passive smoking, predatory marketing, the tobacco industry, exposure to second-hand smoke; you could say you were against all of the above and basically get away with it.

Now, the interesting thing is that since 2010, those things have been deconflated. Nicotine use is no longer only associated with smoking. You can vape; you can use pouches; it’s always been the case that you could use snus. And, of course, the proof of concept for nicotine without smoke is based on the experience of snus for over 50 years in Scandinavian countries.

What the tobacco control community tried to do with snus was make out it was no less dangerous than smoking. They would say that smokeless tobacco is not a safe alternative to smoking, which is factually correct but profoundly misleading.

All that stuff is now coming to an end because we can examine the implications of nicotine use separately from the implications of smoking, and that presents a much more complicated and nuanced picture because the effects of nicotine use as a drug are not very serious.

What are some of the upsides of nicotine that go unreported?

Compared to alcohol, for example, nicotine is a relatively innocuous drug that people get stabilising effects from. It can relieve stress and anxiety, make people feel calmer, and It may improve the cognitive performance of some people.

You’re looking at a drug that is not particularly harmful and probably has some benefits when you consider the merits of the drug in isolation from the delivery system. However, when we talk about nicotine use in its safer forms, people are still opposing it because they’re opposed to people using nicotine.

So, we’ve gone from wanting a smoke-free world to wanting a nicotine-free world without ever pausing to think whether the second of those objectives is legitimate in terms of harms and benefits and whether it justifies state intervention to do that.

I don’t think we’ve asked enough questions about what this all looks like. Nicotine, delivered without much harm, is perhaps something that should occupy the same mental space as caffeine, which is also a habit-forming substance that contains a recreational stimulant.

Which begs the question, should we be thinking of nicotine without much harm more in the same way that we think about coffee or moderate (but not serious) alcohol consumption?

It’s an interesting comparison because the caffeine industry has a chequered history that people seem to have forgotten while being fixated on the tobacco industry tactics of the 20th century. I wonder if there is room for people to allow these companies to reform.

There is a very marked difference between the tobacco industry pre-2000 and the tobacco industry post-2000. I’m sure it’s associated with the super litigation in the United States, the Tobacco Master Settlement Agreement that defanged these companies, and then the rising tide of litigation that would have put most companies out of business and put their executives in jail.

So, they’re like, “Hang on, we cannot live with this kind of legal liability. It’s time to stop this stuff about lying to the public and misleading everybody. We don’t want to be a successful company with all our executives in jail, thank you very much.”

I think there’s been a marked change from that time onwards; they kind of withdrew from the aggressive public relations approach they take in most of the world.

That changed again in 2010 when they could see the alternatives that would take them out of the deep pit they were in. People see them as merchants of death, everybody despises them, and nobody wants their kids to admit that their dad works for a tobacco company at school.

So, now they are saying, “Let’s rethink our business model so that we are providers of recreational nicotine.”

Now, we have a platform of technologies to do that in a way that doesn’t involve laying waste to millions of people every year, which are vaping products, heated tobacco products, oral nicotine products and smokeless tobacco.

That’s not a bad basis for transforming an extremely harmful business into a relatively but not entirely harmless one with much lower risks and harms.

Do you think most tobacco companies will eventually take this path?

One big mistake people make is seeing Big Tobacco as a monolith. It isn’t. The companies have different approaches to reform, even inside their subsidiaries. Public companies like Philip Morris, BAT, and JTI have a different approach to the state-owned tobacco monopolies like the China National Tobacco Corporation, The Indian Tobacco Company, and the monopoly in Thailand.

You can’t think of the tobacco industry as one thing. They all see these issues differently and see contrasting advantages and risks in the transformation of the industry.

The multinationals generally think that if they get ahead, they will be where the consumer is and positioned to take market share from the non-transforming incumbents. But of course, there’s much more competition in that market from the Chinese manufacturers and, increasingly, from illicit trade.

It’s impossible to talk about smoking without acknowledging the black market and illicit trade. Do you think governments are inadvertently helping illicit trade with shortsighted policies?

There is a principle in the World Health Organization Guidance on Article 5.3 of the Framework Convention on Tobacco Control (FCTC) that states that there is a fundamental and irreconcilable difference between the interests of the tobacco industry and the interest of public health.

So, if you accept that principle, then anything you do to harm the tobacco industry is in the interest of public health. That’s the mindset that we’re dealing with.

The problem with that is that you end up excluding legal manufacturers and hand over the market to an illicit supply chain that doesn’t involve the legal manufacturers — or at least doesn’t involve the legal manufacturers in the country. So, there is a danger that the efforts to tackle tobacco end up turning the whole market illicit.

Yes, they tackle Big Tobacco but don’t address the supply chain, market, or demand for these new products. At the same time, they end up protecting the incumbent companies who don’t want to make these changes, which is a textbook case of the Bootlegger and the Baptist alliance.

Is there any particular region where this effect is most visible?

India is a good example. The big Indian tobacco company is called ITC. They’ve been doing very well because the government made vaping products and heated tobacco products (which ITC does not sell) illegal.

That’s not to say those products aren’t available in India because they are, but it’s via the black market. They’re available, but they’re not marketed by professional, well-regulated tobacco companies. The Indian government has just handed that market over to chaotic, informal, essential criminal markets, and that’s all that it’s achieved.

The effect of that is two things. One, you get an illicit market in the banned products. Two, you essentially get regulatory protection for the incumbent provider, which is ITC.

And fewer jobs and less tax.

Well, yes, and you get other bad things, too. A lot of this is done in the name of protecting children. But when you do that, what you find is that children become retailers in the illicit supply chain. These products are not being sold in shops and big stores; they’re being sold in playgrounds and passed on for kids to sell.

Not only do you not solve the problem of them using these products, but you actually involve a substantial subset of them in selling these products.

Which maybe would make them not prioritise education

Yeah, that’s right, because instead, you give them a livelihood from an early stage as mini criminals.

What about the UK government? How do you think we’re doing over there?

Well, up until this year (2023 at the time), I would have said they have been doing very well. They have been, and they still are, in many ways.

They have a very positive attitude to vaping. They see it as a way of getting people to stop smoking. They understand the value of people being able to do that through their own consumer choice and with their own money, to choose to make their lives better without having to be sort of bludgeoned into it with ever more onerous laws.

We’ve got very high taxes in Britain, bans on smoking in all public and workplaces indoors, plain packaging, graphic warnings, large health warnings, and retail restrictions. We’ve pretty well thrown a lot of what’s available at the problem, and we still have one in one in maybe seven or eight adults smoking.

Everybody knows how dangerous it is, but that’s still a lot of smoking, so they’re looking for more imaginative ways now.

Why do you think these numbers are so high despite so much state intervention?

The desire to use nicotine is much more resilient and robust than any particular way of taking it. That’s the key insight here. So you can move from a high-risk to a low-risk way of taking nicotine much more easily than you can move from a high-risk to an abstinent position with nicotine.

It’s a much easier transition for people to make if they don’t have to give up nicotine completely, and that’s why I think the second phase of harm reduction is to think about the people who just want to use nicotine and haven’t smoked in the first place. Do we only see these vaping products as something for smokers to reduce their risk, because that’s the harm reduction proposition?

What about people who want to use nicotine? I said at a conference the other day that when you say things like vaping is only for people who already smoke to reduce their risk, that’s a bit like saying drinking is only for people who already drink.

That doesn’t make any sense if you think there is an underlying demand for drugs, and this is where the rethinking nicotine argument comes from. Because if you don’t think there is any reason to use nicotine, or you don’t think it has its own demand function other than tobacco companies created it, then you’re going to be misleading yourself.

What should we think about the public demand for nicotine?

I normally talk in terms of the three groups of benefits associated with nicotine use. They may be perceived rather than real, but they are nevertheless felt by the users. The first is hedonistic, so it creates a dopamine release for people, and that’s pleasurable. It’s essentially the same thing that happens in sex. You get sensory effects, tastes and hits on the throats. And then you get a behavioural ritual and social effects from it.

A second category is what I call functional benefits: cognitive improvements, better concentration, and better short-term memory. Then you have relief from stress and anxiety and some mood control, alongside functional benefits around appetite and weight loss and so on.

And then the final category, which I call therapeutic, is neuroprotective benefits. So protection against Parkinson’s disease, or anti-inflammatory benefits, like control of ulcerative colitis, or regulating, where people get relief of the symptoms of ADHD or possibly psychosis.

So you’ve got this range of benefits: hedonistic, functional and therapeutic and they, to me, at least give you a way of thinking about what the demand function for nicotine is going forward because if any of those are beneficial to users you know, then there will be a demand for this drug in the future, just as there is a demand for alcohol, caffeine, cannabinoids, and so on.

Once you’ve established that there’s going to be a demand for these products, your efforts to get a nicotine-free society are about as likely as efforts to get an alcohol, caffeine or cannabis-free society.

So, for me, the challenge of rethinking nicotine is to accept that there will be a demand for the recreational stimulant nicotine in perpetuity and then to configure a market that is based on products that have tolerable (not zero) risks that we find acceptable in society.

From there, we would have to say we don’t find smoking risks acceptable, and that’s why we have so much state intervention. But there are lots of risks in society where we don’t have state intervention. Horse riding, for example. It’s very risky, but we don’t we don’t regulate, control or ban horse riding, even though people can get terrible spinal injuries from it.

There is a kind of a student politics among some of the tobacco control people that is embarrassingly over-simplistic. What’s going on there?

I agree there’s a massive strain of anti-capitalism, and I think you’re right to pick up on that.

The tobacco control community is a control industry. Its playbook is essentially full of punishments, coercion, stigma, and restrictions enforced by an interventionist state. That’s basically what’s in the playbook. Medicalisation is another way of doing that by treating people as patients rather than free agents with choice.

Now, if you come along with the harm reduction proposition, you’ve got a completely countercultural playbook, which is the free choice of consumers interacting with innovative companies in a lightly regulated market to switch from high-risk to low-risk behaviours on their own initiative, in their own interests and with their own money.

The state barely needs to be involved in that, and you’re certainly going with the grain of consumer choice and the free will of the consumers involved rather than using an apparatus of control to sort of punish consumers and then stop punishing them when they make the desired behaviour change.

So, I think that explains to me a lot of opposition to this from the tobacco control community, which, by the way, only exists because of harm. We don’t have caffeine control, and even though it’s immensely harmful, we don’t have much alcohol control.

But the edifice of institutions, organisations, people, careers, and grants that are set up in tobacco control to deal with the harms of smoking is profoundly threatened, I think, by nicotine without much harm because it basically undermines their rationale.

This is again part of the rethinking nicotine argument where you have to consider what it means to them if you have a drug that’s available with minimal harm.

There is an old Upton Sinclair quote that, for me, really gets to the heart of the tobacco control community: ‘It is difficult to get a man to understand something, when his salary depends on his not understanding it.’

It’s almost a conflict of interest that is so large that no one can see it; it’s visible from space, but no one can see it on Earth. It’s like your whole livelihood, your university department, your grants, your conferences,  your prestige; everything depends on you being engaged in tackling harm. What if there’s no harm? You’re done.

Last question: Who do you think is the sanest or some of the sanest voices in?

OK, I would say, Colin Mendelsohn, massive, massive respect, and I would always listen to Karl Fagerstrom and Karl Erik Lund.

As for academics in the UK, I think there are some absolutely brilliant people, like Ann McNeil, Jamie Brown, and Sharon Cox. There are really too many to mention. I would say Peter Hajek, Martin Jarvis, Lynne Dawkins, and all of that group of academics in the UK are brilliant. These people are leading the charge, and then there are the much younger ones like Sarah Jackson, Harry Tatton-Birch, and Leonie Brose, who are doing great work.

In the United States, you have Abigail Friedman and Michael Pesko. I’m a big, big fan. I don’t always agree with them, but Ken Warner and Mike Cummings are using their seniority well to leverage opinion behind more rational policy and science.

I must also mention Jamie Hartmann-Boyce at the Cochrane Review. Outstanding work she’s doing there. I mean, there are too many to name.

One of the interesting things here is when you actually set it out, there is a very large number of sane voices in this field. But they don’t have the gigantic amplification that Bloomberg, the FDA, the CDC, the Truth Initiative, and all these people with millions and millions of dollars have to spend on shouting their messages out incredibly loud.

I think there’s like a big substrate of very credible, thoughtful academics in the community, and then a lot of frothy, loud, shouty academics who have got money and very strong opinions. They’ve got activist inclinations, and we hear far too much from them, often without any specialisation at all.

You know, they’re just some kind of throat surgeon or something who’s got a big opinion, and they don’t know anything about policy or understand anything about the young people they’re supposedly trying to save or understand anything about why people use these products, and what they would do instead if they didn’t.

Stay savage, Clive. We need you more than ever.