E-cigarettes and the role of science in public health policy

E-cigarettes have become, without doubt, one of the public health issues du jour. Many countries and states have been quick to prohibit them, while others continue to debate the issue. The debate ostensibly revolves around the relative harms of e-cigarettes: Are they dangerous? Will they reduce the harms caused by smoking tobacco? Will children take them up? Questions which would typically be informed by the available evidence. However, there is a growing schism within the scientific community about what indeed the evidence does say. On the one hand, there is the view that the evidence, when taken altogether, overwhelmingly suggests that e-cigarettes are significantly less harmful than cigarettes and would reduce the harms caused by nicotine use. On the other hand, there is vocal group that doubt the veracity of the available evidence and are critical of e-cigarette availability in general. Indeed, this latter view has been adopted by the biggest journals in medicine, The Lancet, the BMJ, the New England Journal of Medicine, and JAMA, each of whom have published either research or editorials along this line.

The evidence around e-cigarettes was recently summarised and reviewed by Public Health England. The conclusion of the review was the e-cigarettes were 95% less harmful than smoking tobacco. So why might these journals take a position that is arguably contrary to the evidence? From a sociological perspective, epistemological conflicts in science are also political conflicts. Actions within the scientific field are directed to acquiring scientific authority, and that authority requires social recognition. However, e-cigarette policy is also a political issue, and as such actions in this area are also directed at gaining political capital. If the e-cigarette issue can be delimited to a purely scientific problem then scientific capital can be translated into political capital. One way of achieving this is to try to establish oneself as the authoritative scientific voice on such matters and to doubt the claims made by others.

We can also view the issue in a broader context. The traditional journal format is under threat from other models of scientific publishing, including blogs, open access publishers, pre-print archives, and post-publication peer review. Much of the debate around e-cigarettes has come from these new sources. Dominant producers in the scientific field must necessarily be conservative since it is the established structure of scientific field that grants these producers their dominant status. But this competition is the scientific field may have wider, pernicious consequences.

Typically, we try to formulate policies that maximise social welfare. But, as Acemoglu and Robinson point out, the policy that may maximise social welfare now, may not maximise welfare in the long run. Different policies today affect the political equilibrium tomorrow and thus the policies that are available to policy makers tomorrow. Prohibiting e-cigarettes today may be socially optimal if there were no reliable evidence on their harms or benefits and there were suspicions that they could cause public harm. But, it is very difficult politically to reverse prohibition policies, even if evidence were to later emerge that e-cigarettes were an effective harm reduction product. Thus, even if the journals were to doubt the evidence around e-cigarettes, then the best policy position would arguably be to remain agnostic and await further evidence. But, this would not be a position that would grant them socially recognised scientific capital.

Perhaps this e-cigarette debate is reflective of a broader shift in the way in which scientific evidence and those with scientific capital are engaged in public health policy decisions. Different forms of evidence beyond RCTs are being more widely accepted in biomedical research and methods of evidence synthesis are being developed. New forums are also becoming available for their dissemination. This, I would say, can only be a positive thing.

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