THE E-CIGARETTE WARS

Over the last ten years, the use of nicotine vaporizers (a product category also referred to as “e-cigarettes” or “electronic nicotine delivery systems”²) in the US has proliferated within a highly contested environment. In 2009, the Food and Drug Administration (FDA) blocked entry of these devices into the US on the grounds that they were unapproved drug-device combination products. After e-cigarette makers were granted an injunction against the agency’s ban, the FDA proposed new regulations extending its authority over nicotine vaporizers and other nicotine products that were not initially contemplated under the Tobacco Control Act. Although the FDA announced its intent to regulate in April of 2011, the regulations were only finalized in May of 2016, following protracted public comment periods that yielded little agreement in the battles between the pro-vaping and anti-vaping camps. At present, the new regulations are the subject of several lawsuits (Center for Tobacco Products 2016; Deyton and Woodcock 2011; Kirshner 2011; Swanson 2016).

Conflict over the meanings and consequences of e-cigarette use is reflected in disparate approaches to e-cigarette access both nationally and internationally. For example, while the FDA’s new regulations seek to curb e-cigarette access, the UK’s National Health Service (NHS) has moved toward promoting e-cigarettes for smoking cessation and harm reduction (Food and Drug Administration and Health and Human Services 2016; NHS Choices 2015). Meanwhile within the US, controversy over tobacco harm reduction and e-cigarette safety has led to the creation of groups such as the Consumer Advocates for Smoke-free Alternatives Association (CASAA), which promotes e-cigarette access in the face of public health campaigns aimed at curbing e-cigarette use. CASAA and other vaping advocates have criticized mainstream health organizations including the American Lung Association and the American Cancer Society Cancer Action Network for portraying nicotine vaporizers as a health threat virtually indistinguishable from combustible cigarettes, but have also recognized pro-vaping stances from organizations such as the American Association of Public Health Physicians (Nitzkin 2009; Noll-Marsh 2013b)

In California, which has long been a breeding ground for influential tobacco control policies, the divide over e-cigarettes is especially stark. Several milestones in changing social norms related to tobacco use have origins in California’s tobacco control movement, including laws that restrict smoking in public spaces, the publication of incriminating tobacco industry documents that had been hidden from the public, and the subsequent crafting of the Tobacco Master Settlement Agreement negotiated between US tobacco companies and attorneys general nationwide. Rooted in 1970s activism targeting “Big Tobacco,” California’s anti-tobacco movement is embedded in a dramatic history of “tobacco wars” waged by activists against a powerful and unscrupulous industry (Americans for Nonsmokers’ Rights 2016; Buckley 2012; Davis 1992; Francey and Chapman 2000; Glantz and Balbach 2000).

In particular, support for anti-vaping perspectives in the California anti-tobacco movement (Davis 1992) may be shaped by the legacy of public health support for “light” or low yield cigarettes as a harm reduction strategy. Federal Trade Commission (FTC) labeling of cigarette tar levels, begun in 1966 with support from public health officials, did not cease until 2008, as it became increasingly clear that light cigarettes did not substantially reduce tobacco-related harm. Meanwhile, internal industry documents revealed that tobacco companies had knowingly misled the public about light cigarettes for decades (L. T. Kozlowski and Abrams 2016; L. Kozlowski and Pillitteri 2001; Shiffman et al. 2001). Among some present day tobacco control activists, commitment to a tobacco “endgame” abolishing recreational tobacco products and an aversion to tobacco harm reduction measures may be an inheritance of this recent past. From this point of view, tobacco harm reduction is a disingenuous label for industry attempts to keep people using deadly products (Brownell and Warner 2009; Glantz and Balbach 2000; Hurt and Robertson 1998; Rabin 1992).

Nevertheless, California’s reputation as a center for technological and cultural innovation has also made it a fertile setting for the ongoing development of e-cigarette technologies and practices, with the support of California’s ubiquitous start-up and DIY/hacker ethos. Orange County, for example, is known for manufacturing e-liquid flavors and has been heralded as the “Silicon Valley of vaping, “ while the Bay Area is home to a series C vaporizer start-up known for its innovative e-cigarette designs, as well as DIY vaping and e-liquid enthusiasts (Vaknine 2015; Williams 2015). In an unrestricted, pre-regulation e-cigarette marketplace, the West Coast has emerged as a hotbed for the vaping industry (Groskopf 2016).

DAVID OR GOLIATH

As the regulatory environment evolves, it is unclear whether the challenge to public health officialdom posed by e-cigarettes will persist, or emerge as a fleeting Mardi Gras – one soon constrained by Lenten restrictions on a “vice” that had previously escaped bureaucratic control. Regardless, e-cigarette use has flourished during a period of suspended constraints, outside the reach of regulators and public health advocates who seek to restrict e-cigarettes in much the same way as conventional cigarettes. During this period in which e-cigarettes have broken away from the “usual rut” of the tobacco marketplace (Bakhtin and Emerson 1993), pro-vaping advocacy has also inverted conventional narratives about the health hazards of nicotine use, the dangers of smokeless tobacco, and who is the righteous underdog of the tobacco wars4. While the anti-tobacco movement sees itself as an array of nonprofits doing battle with Big Tobacco, the pro-vaping side sees itself as a collection of ordinary citizens and small businesses battling a public health funding apparatus that they believe protects the pharmaceutical industry’s investment in Nicotine Replacement Therapy (NRT) products such as nicotine patches, nicotine gum and nicotine inhalers, as well as Big Tobacco’s monopoly on recreational tobacco products. Each side, therefore, sees itself as David to its adversary’s Goliath.

It was no surprise then when members of the online e-cigarette forum we approached did not greet us, the representatives of Goliath, with open arms. After negotiating approval and guidelines between both our Institutional Review Board (IRB) and a forum moderator, we introduced ourselves as researchers on the site’s welcome channel as requested of all new user accounts. The response we received to our introductory post was so overwhelmingly negative that we decided not to post our proposed thread with group discussion questions directly related to our study at all. Our experiment failed. And yet, as we listened to participants’ concerns and answered their questions about our motives, we became engaged in extended dialogue with several forum members and one moderator, both on our initial thread and through the site’s private messaging system. (Although nearly all of the forum members initially regarded us with suspicion, those we spoke to via backchannel seemed more open to dialogue, perhaps attributable to the intimacy of one-on-one conversation or an element of social pressure on the thread.)

Forum members inverted our typical practices through their vociferous opposition to our proposed research. In a reversal of the dynamic we often participate in as qualitative researchers, the thread’s participants essentially interviewed us, on their own turf. First and foremost, they sought to establish whose side we were on. E-cigarette research, they noted, typically has a “political stance.” On one side, they suggested, were those who believed that vaporizers can be useful as a less harmful alternative to combustible cigarettes and/or as a cessation tool. On this side, a forum member noted, researchers were “trying to prove what vapers already know.” On the other side, forum participants observed, were those who believed that e-cigarettes should not or cannot be used to reduce harm or for smoking cessation. On that side, forum members suggested, researchers exaggerated and misrepresented the potential harms of e-cigarette use. Much like Becker, forum participants’ comments suggested that “the question is not whether we should take sides, since we inevitably will, but rather whose side we are on” (Becker 1967)

Since our study received public health funding, we were perceived as having arrived at predetermined conclusions. No matter what forum members said to us, they feared, we would “twist [their] words.” As one forum participant explained:

After being burned several times by researchers…most of the user base is likely going to be extremely hostile toward anyone claiming to be researching vaping, so you probably won’t get a lot of volunteers.³

In addition, forum members regarded us as complicit in what they considered to be bad acts on the part of public health institutions. Among these bad acts was the California Department of Public Health’s mass media campaign “Still Blowing Smoke,” which forum members pointed to as a vehicle for misleading messages about e-cigarettes. Still Blowing Smoke is presented as a campaign against “the e-cig industry,” as shown in the campaign image below (Figure 1), reinforcing a hierarchy of credibility in which less credible information about vaping is attributed to industry.

Figure 1. “There’s a lot the e-cig industry isn’t telling us about vaping” (“Still Blowing Smoke” 2016)

In this campaign, the health department is looking out for the general public by protecting “us” from e-cigarette companies. Other messaging from Still Blowing Smoke suggests that, for example, e-cigarettes may pose equivalent or even greater risks than combustible cigarettes (“E-cig vapor can contain even more particles than tobacco smoke” (“Health” 2016). In addition, the campaign equates the e-cigarette industry with Big Tobacco, as shown in Figure 2.

Figure 2. “It’s no surprise that Big Tobacco would be all over e-cigarettes” (“Still Blowing Smoke” 2016)

However, the forum members we spoke to saw their support for vaping as opposition to Big Tobacco. Vaping advocates have suggested that some of the restrictions forwarded by anti-vaping advocates will benefit Big Tobacco and disadvantage the smaller companies that initially dominated the e-cigarette market in the US. Thus messaging like that found in Still Blowing Smoke can read as support for Big Tobacco masquerading as opposition, whether wittingly or unwittingly. As a result, public health campaigns that take this approach are often parodied online. Still Blowing Smoke, for example, has a counter-campaign devoted to it called “Not Blowing Smoke” that challenges the original campaign’s credibility, as shown in the image below (Figure 3) from the counter-campaign’s website (“Not Blowing Smoke” 2016).

Figure 3. “There’s a lot that California public health isn’t telling us about vaping” (“Not Blowing Smoke” 2016)

Since vapers associated us, as California public health researchers, with the “California public health” institutions referred to in the Not Blowing Smoke campaign as shown in Figure 3, they did not find us credible. From this perspective, California public health is a superordinate group of “of?cial and professional authorities in charge of some important institution” (Becker 1967) atop a hierarchy of credibility that relegates “us” – a general public seeking information about vaping – to a subordinate position. The Not Blowing Smoke campaign inverts this hierarchy by suggesting that public health institutions are not credible on the subject of vaping, and that vaping is qualitatively different from combustible cigarettes, i.e., vaping is “not blowing smoke.” As shown in Figure 4, Now Blowing Smoke frames “public health funding” as generating misinformation about vaping because researchers fear “losing their revenue from the harmful effects of… combustible tobacco products” (“Not Blowing Smoke” 2016).

Figure 4. “Vaping is only a hazard to public health funding” (“NOT Blowing Smoke” 2016)