THE e-cigarette debate highlights the futility and sometimes downright pomposity of the trendy new uber-simplistic concept of evidence-based health policy.
History reminds us of the “arcane intellectual speculation” of 17th century academics over how many angels could dance on the head of a pin. Although it was probably never a significant preoccupation, it serves as a metaphor of “tedious concern with irrelevant details”.
In the latest salvo in the e-cigarettes debate, one side consumed considerable column inches arguing that there are only 178 000 angels dancing on the end of the pin and not the preposterously large estimate that 250 000 angels are dancing on that pin as the other mob contends; sorry, that was the number of vapers in Australia, +/- occasional users and whether to count them. The debate raged in the comments section.
Why are we seeing these innocent statistics tortured beyond credulity? Doesn’t the United Nations have a convention against torture?
A generation of factoid-wielding partisans has forgotten the admonition, possibly falsely attributed to Benjamin Disraeli, that there are three types of lies: lies, damned lies and statistics. This quote can also be seen as an acknowledgment of system complexity.
Many of us feel a sense of our head spinning from the whirling statistics. We might feel it is all too hard and actively get turned off the whole issue and, therefore, view it with the same sense of relevance as the angels–pin debate. Which is a shame, because this debate is not irrelevant or arcane. Potentially, the wellbeing of millions of Australians over the coming decades will be affected by what happens.
It seems that there are not only duelling experts but duelling societies. One side quotes the “door stopper” report Public health consequences of e-cigarettes by the US National Academies of Sciences, Engineering, and Medicine. Proponents of e-cigarettes quote a report by Public Health England (PHE). Although an appeal to authority per se is a logical fallacy, these societies do add considerable weight to each side’s claims.
For example, PHE confidently asserts that: “Concern has been expressed that e-cigarette use will lead young people into smoking. But in the UK, research clearly shows that regular use of e-cigarettes among young people who have never smoked remains negligible, less than 1%, and youth smoking continues to decline at an encouraging rate. We need to keep closely monitoring these trends, but so far the data suggest that e-cigarettes are not acting as a route into regular smoking amongst young people”.
Conversely, the US National Academies report claims that: “There is substantial evidence that e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes”.
But even if it is “substantial” (which is debatable), what is the relevance of the evidence of “ever using conventional cigarettes”? A commonly cited study labelled teens as smokers if they even had “just one puff”. Really? Should any of us who have ever had even a “single puff” immediately travel to Victoria for voluntary euthanasia?
Similarly, the anti-e-cigarette lobbyists cite evidence that “eviscerates” the claim that vaping is at least 95% safer than smoking. Yet, PHE this year confidently reasserted that same claim based on (yes, you guessed it) the evidence.
With this complexity in mind, using the e-cigarette debate as an example, we need to question what “evidence-based” health policy really is. It has the allure of the scientific method and is an obvious copy of evidence-based medicine. Who could argue with evidence? Science is objective, surely there is no opinion in science? There are just facts. But what fidelity of information can an evidence-based system really provide? For such complex and ever-changing systems involved with health policy, it is wholly predictable that the answer would be “not much”.
Consider the following:
Laboratory-based research should be the very definition of a system that is able to be held constant except for one variable and, therefore, be reproducible. Yet, there has been a reproducibility crisis in even basic biological research.
At the other end of the spectrum, consider the inordinately increased complexity of the systems that underlie public health policy. Do whole societies stay exactly the same in order to be reproducible? All manner of societal and health changes occur across time. Not only can the smallest of definitions change “the evidence” but trying to predict and project what will occur decades into the future is representative of nothing more than pure speculation. Opinions and speculation are important in order to move forward and evolve. However, evidence-based health policy is a modern self-congratulatory phenomenon whereby the mutton of mere opinion is being dressed up as the lamb of science.
The knowledge problem was described over 70 years ago to detail the fundamental problem of system complexity, whereby there could never be enough knowledge for economic and social planners to understand, and therefore control, the inordinate ways a complex system could behave.
The evidence-base paradox describes the problem of using evidence as related to complex systems.
But the main lesson to learn is that the system is not symmetrical between any two opposing or shouting camps. Both the e-cigarette naysayers’ and proponents’ preferred authorities, the National Academies and PHE, agree that vaping e-cigarettes is not as harmful as the combustion of tobacco in conventional cigarettes.
We could obfuscate to the end of the Earth and neither camp is going to concede regarding whether e-cigarettes should or should not be legal.
The liberal order, in the true sense of liberalism, would suggest that unless there is an overwhelming threat, we need to give autonomous people the option of the almost certainly less harmful e-cigarettes instead of the much more harmful conventional cigarettes.
One major rationale of e-cigarette prohibitionists is that the safer (not completely safe) option of vaping will somehow “normalise” the unsafe option of smoking. By this logic, during the AIDS crisis of the 1980s, we should have banned the use of condoms for safer (but not completely safe) sex because it normalises unsafe sex without a condom. Indeed, it can be shown that condom use among teens has a massive association with unsafe sex without condoms, compared with teens who had never used condoms (because the majority weren’t having sex with or without a condom).
The irrational nature of that argument is surely clear to everyone.
Associate Professor Michael Keane is a specialist anaesthetist and part-time visiting medical officer at Monash Health, with research possitions at Swinburne University and Monash University.
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