Related:
- Faye Flam's September 24, 2019 telephone interview with Peter M. Sandman that followed these two emails. (Note: Link launches an MP3 audio file (44.1MB, 48 min.) on this site.)
- Faye Flam's resulting October 6 article on the Bloomberg Opinion website.
- Faye Flam's earlier May 28 interview with Peter M. Sandman (half of which was on e-cigarette risk communication) and the June 3 Bloomberg Opinion article that resulted.
1. Is It Honest to Blame Lung Damage on “Vaping” Generically When the Villain is THC and Other Illegal Vapes? (September 11, 2019)
Regarding e-cigs and the recent spate of lung illnesses, a few quick points:
- It is fairly clear but not totally established that the sources (or at least the main sources) of these recently identified lung illnesses aren’t commercial e-cigs like Juuls, but rather various other items – especially black market THC cartridges and flavorings inserted by customers though they were not originally intended for inhalation.
- A health agency focused on harm reduction would want to say this, focusing its warnings on what it considered the main sources of the illnesses – looking to balance acknowledgments of uncertainty with clear recommendations based on the evidence so far. That’s hard to do well, but it is standard risk communication practice. In food poisoning outbreaks, for example, the authorities try to announce as quickly as possible what foods they consider the probable source of contamination, while reminding the public that their conclusions are preliminary and their recommendations may change as further evidence is assessed.
- That’s what FDA has done vis-à-vis these lung illnesses. It is what several state health departments have done. And it is what the New York State Department of Health did until Governor Cuomo forced it to knuckle under. (NYS Health Commissioner Zucker’s statement was unusually candid about that.)
- By contrast, CDC and a number of medical and public health organizations have seized on these recently identified lung illnesses as an opportunity to score additional points in their ongoing propaganda battle against e-cigarettes. Hence their primary recommendation to consumers has been to avoid vaping altogether until the cause of the illnesses is definitively determined. The recommendation to avoid black market THC and flavorings not meant for vaping has been much less emphasized.
- The CDC strategy is defensible if you think e-cigs are a huge public health threat. The lung illnesses have so far affected only a few hundred people in the U.S., compared to the millions who vape. Since the smaller problem is suddenly and briefly newsworthy, why not use it as a much-needed news peg for the bigger problem? But if you think the campaign against e-cigs is at least overstated and arguably misguided altogether, it follows that CDC has no excuse for distorting the public’s understanding of the newly discovered risk.
- As a communication expert, I have no professional expertise on which of these two postures toward e-cigs is correct. But as a nonprofessional who has paid fairly close attention to the evidence, I side with those who consider the anti-vaping campaign misguided.
- I won’t go into detail (again) about my views on the broader e-cig controversy. But in a nutshell, I think e-cigs are at least an order of magnitude less harmful to health than ordinary cigarettes. (Public health authorities in the U.K. guesstimate 95% less harmful.) And I think people, including teens, are far likelier to switch from smoking to vaping than from vaping to smoking. (I’m amazed how seldom news stories about the increase in teen vaping point out the parallel decrease in teen smoking.) If I’m right about those two things, it follows that the anti-vaping campaign is likely to do more public health harm than good.
- As a communication professional, moreover, I think I know why CDC and its allies are so opposed to e-cigarettes: outrage. The tobacco industry has killed millions of people. And it fooled public health professionals decades ago about filters, then about “light” cigarettes. Their justified hatred for the industry makes it difficult for them to think rationally about the beneficial and harmful effects of vaping. How different things might have been if Altria had not bought a major stake in Juul but instead, Bloomberg had made the purchase as part of his anti-smoking campaign!
- Back to the new issue: I keep waiting for some reporter to ask CDC whether it recommends that kids who are addicted to nicotine and currently rely on e-cigs to satisfy their addiction should switch to ordinary cigarettes instead until the source of these recently identified lung illnesses is definitively identified. Because of its anti-vaping campaign, CDC rarely acknowledges that e-cigs are much less dangerous than cigarettes – and to the best of my knowledge it has yet to acknowledge that e-cigs remain much less dangerous than cigarettes despite these recent lung illnesses. Any addicted teen vaper who pays attention to CDC’s current messaging would do one of two things, both of them unwise: either heed CDC and switch to smoking or ignore CDC and continue using bootleg THC and flavorings.
- I should point out one other overlap between the broader e-cig controversy and the current spate of lung illnesses. The campaign to discourage teen vaping has focused largely on outlawing flavorings attractive to teens. Insofar as flavorings disappear from vape shops, addicted teens will do one of three things: (a) Keep vaping without the flavorings; (b) Switch to cigarettes; or (c) Add their own flavorings – likely to be food products containing oils dangerous to inhale. None of the three is beneficial; (b) and (c) are harmful. I suspect (c) is likeliest. Similarly, non-vaping teens interested in experimenting with e-cigs will probably want flavorings; if flavorings designed for e-cigs are illegal, many will use flavorings not designed for e-cigs instead. Bottom line: The campaign against e-cig flavorings (meant to be inhaled) may well lead to a lot more cases of this newly identified lung illness.
2. Health Scares: When Is It Ethical for Public Health Officials to Try to Frighten the Public? (September 13, 2019)
By “health scares” I assume you mean illness outbreaks that are affecting very few people so they’re statistically unimportant, but they capture the public’s attention because they’re interesting/terrifying and therefore newsworthy. A few quick thoughts:
- In assessing a statistically unimportant but newsworthy health scare, the key question is whether it’s the tip of an iceberg or just a “fascinoma.” (In case you don’t know the term, “fascinoma” is medical slang for a weird, interesting-but-rare case.)
- It could be the tip of an iceberg in any of several ways. For example:
- Early cases of an infectious disease outbreak (measles, Ebola, etc.) than needs to be caught early lest it grow and get out of control.
- Early manifestations of something new that needs to be stopped – e.g. a bad batch of heroin that just started being sold on a city’s streets, or a dangerous fad that’s starting to catch on.
- New evidence suggesting that an ongoing health problem has previously been missed or misdiagnosed, or is more common or more serious than previously thought.
- It’s not always easy to tell whether the case at hand is the tip of an iceberg or not. When you’re not sure, it’s sound precautionary public health to take the risk seriously. Think about the early days of AIDS as a prime example of public health not jumping quickly enough on Kaposi’s sarcoma and other early signs of the pandemic to come.
- Also, of course, not all icebergs are equally big. Even if a handful of cases might well grow into a few hundred, is there any way they could grow into a few thousand, a few hundred thousand, or a few million?
- Reporters rarely ask their expert sources the iceberg question. But they should. It’s extremely relevant to the “vaping-related” lung illnesses that you initially wrote to me about. It’s also extremely relevant to another controversy I have been following carefully, the biannual outbreaks of “polio-like” Acute Flaccid Myelitis, probably caused by Enterovirus D-68. How many cases of these two might have been missed? Under what scenarios could these two grow bigger, and how big might they grow?
- For various reasons, some of them unrelated to public health, CDC and other such agencies sometimes imply the iceberg is bigger than they suspect and sometimes imply it’s smaller. Local transmission of Zika in the continental U.S.: They implied bigger. Vaccination-related health harm: They imply smaller. Both lists are endless.
- Leaving the iceberg question aside, what’s proper risk communication about a small cluster of illness that is near-certain to remain small? The most obvious recommendation: Tell your audience it is near-certain to remain small.
- I consider that obligation a moral imperative – even when it’s tempting to seize on the news peg offered by a small cluster to score messaging points against a bigger evil. I believe that’s what CDC is doing vis-à-vis these vaping-related lung illnesses. Even if I agreed that teenage vaping is a horrible evil that must be stopped, I’d still disapprove of pretending that these lung illnesses are a big deal vis-à-vis the vaping of commercial e-cigs – but I’d be ambivalent. Since I think the CDC posture toward e-cigs is bad public health in the first place, my disapproval is unambivalent.
- Despite my conviction that expert sources owe the public an honest estimate of the size of a risk, I nonetheless accept that small clusters of newsworthy illness are a teachable moment. I urge clients to go ahead and seize the teachable moment (assuming I agree with the “lesson” they are trying to teach) – but to do so honestly. “From a public health standpoint, this outbreak is tiny and likely to stay tiny. It’s a very uncommon downside of doing X. But doing X has so many other, bigger downsides! Here are three much more important reasons for people to avoid X….”
- A non-health example: I’m okay with officials using school shootings and other mass violence events as a teachable moment for gun control. But mass violence events are a tiny fraction of gun mortality and morbidity in the U.S. And giving people a false impression to the contrary is an irresponsible way to score points for gun control – all the more so since the measures thought to deter mass violence events and the measures likely to reduce gun deaths are quite different.
- Of course any time public health officials say a problem is statistically small, they should bend over backwards to point out that it’s huge for a few unlucky victims. Empathically acknowledging the devastation endured by victims has to come both before and after explaining that the risk to the rest of us is very small.
I think all of the above is pretty much common sense, and I’m not sure it makes for an interesting article. On the other hand, it probably won’t get you fired.
Copyright © 2019 by Peter M. Sandman
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