Editorial Tob Control: first published as 10.1136/tobaccocontrol-2021-056529 on 22 February 2021. Downloaded from

ways of understanding situations in Finding ‘common ground’ on shifting order to gain deeper understanding of complexity. sands: on the conflicts For example, assumptions we may hold about the role, permanence and power of over product regulation markets may prevent us from imagining creative alternatives to markets as ways Ruth E Malone ‍ to manage societal problems. Libertarians may believe that markets solve problems better without state intervention, and Recently I have been sent several papers youth, created concerns that the prod- therefore the problem of NNNTPs is char- taking up the challenge of trying to resolve ucts could prove to be a ‘gateway’ to acterised as one of government interfer- the current clashes within public health smoking and thus undo made on ence or over-reach.­ They may be unable to about the proliferating range of newer and tobacco control. Yet, some smokers found visualise a world where products must be novel nicotine and tobacco products the products helped them stop smoking, shown to be beneficial (or at the least, not (NNNTPs). The conflicts are real and can and some scientists, based on studies harmful) in order to be introduced and be hostile, provoking distress among long-­ suggesting NNNTPs’ reduced toxicity widely marketed in the first place. tobacco control researchers, advo- compared with combustible cigarettes, Assumptions about the role, perma- cates and observers and exacerbating argued for their use in a harm reduction nence, and power of states may likewise already-existing­ philosophical schisms approach. Discussions quickly devolved prevent us from considering how corpo- within the tobacco control movement. to two : protecting children rate could or should be incen- Hence, there is call for finding common from attractively marketed, potentially tivised or disincentivised to engage in ground, settling on an approach and dangerous and addictive products versus creating genuine social goods rather than ceasing the attacks on public health encouraging smokers to choose products contributing to societal ills. Those who colleagues. Whether this is now (or has believed to be less harmful that might also believe in a stronger consumer protec- ever been) possible is somewhat doubtful, help them quit. tion role for governments may have little particularly on a global level, and far Tensions also always exist in public conception of or in considering beyond the scope of an editorial. health between incrementalists and those how to motivate corporate institutions to I offer just a few observations about advocating breakthrough systems change. change, because they see the problem as the situation in which we find ourselves In the case of NNNTPs, there is addi- one of state failure to protect the public. copyright. now as we fight on into the second decade tional contestation between proponents How the ‘problem’ is defined and the of the 21st century to end the tobacco and opponents as to which side is actually causal story we use to explain it matters, epidemic: how the conflicts illustrate advocating the breakthrough. Proponents as Deborah Stone and many other political existing tensions in public health discourse, of encouraging smokers to use NNNTPs scientists have pointed out.1 So we have a common assumptions that may limit the claim the class of products represents (not just two) of vigorously competing possibilities for partial resolution, and market innovation that can help get people narratives about the very of the some speculation as to why these conflicts to cease using harmful products, or at least products, their potential role in promoting are so intense at this historical moment. I to use them less often. Opponents argue overall public health, what to do about http://tobaccocontrol.bmj.com/ am appreciative of all the colleagues with that NNNTPs are not a breakthrough, them, and who should be involved in whom I have shared these discussions to but profoundly, even regressively incre- deciding that. date and of all those attempting to wrestle mental, because they create no serious Who, for example, is the ‘public’ with productively and authentically with these challenges to the existing structures that which public health policy should be challenges. And I am profoundly unappre- sustain the tobacco epidemic, may actually concerned? Is it current smokers, youth ciative of the tobacco industry’s efforts further entrench the power of the tobacco or everyone in society? From the public to wedge itself into the conversation and industry, and may keep people smoking health perspective, the important question exploit the existing disagreements for its who would otherwise have quit, as well as is not whether some people are better off benefit. attracting new users who would otherwise using the products instead of smoking, have escaped nicotine addiction. but whether the products contribute to

EXISTING TENSIONS IN PUBLIC HEALTH reducing or increasing overall tobacco on September 26, 2021 by guest. Protected DISCOURSE harm at the population level. If they Public health has long been subject to LIMITING ASSUMPTIONS increase net harm, they should be regu- tensions around how to balance coer- But even this discussion oversimplifies, by lated to minimise population exposure cive actions by governments to protect suggesting there are just two sides to the through reducing availability, accessibility well-­ against the impor- conflict. In , such dualist conceptions and attractiveness. If they reduce overall tance of individual , particu- of problems can both simplify and compli- harm, they should be regulated in such a larly for adults. In the case of NNNTPs, cate trying to seek resolution. The ‘both way as to minimise youth and non-smoker­ the introduction of multiple new prod- sides-ism’­ assumptions that seem natural uptake and encourage complete substitu- ucts with unknown risk profiles, some as we try to understand conflicting posi- tion among current smokers. of which were clearly being marketed to tions on policy issues can help us see where But interpreting the science about all this we diverge on recommended actions, but is also not so simple as some in the various may not help us see more clearly our own camps would have it, due to the enormous Correspondence to Professor Ruth E Malone, Social blind spots in terms of how we see the variation in the ways products are defined and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA; world. Qualitative researchers often try to and identified, variation in the products ruth.​ ​malone@ucsf.​ ​edu complicate or ‘trouble’ taken-for­ -­granted themselves, variation in substance delivery

Malone RE. Tob Control March 2021 Vol 30 No 2 119 Editorial Tob Control: first published as 10.1136/tobaccocontrol-2021-056529 on 22 February 2021. Downloaded from and patterns of use and variation in the of tobacco companies, whose cigarette dynamics that keep the tobacco epidemic ways they have been studied. Preconceived sales have dropped in wealthy countries going, the second ought to be and sometimes unconscious about as stronger tobacco control policies and that policy should focus on addressing the role of government, industry and indi- social trends reduced consumption. These quickly and definitively those products viduals may interpretive choices for companies, late to the party on NNNTPs that are unarguably the most dangerous each of us, even when examining the same but now vigorously embracing the of to health, first through full enactment of set of ‘’. As many have pointed out, harm reduction, foreground their devel- the policies called for in the FCTC, and from randomised clinical trials, opment of NNNTPs as the way to legit- extending those, to phasing them out of which do not capture real-world­ experi- imise their continued and for the market or strictly controlling them ences, cannot be used to extrapolate to some, to argue for their ‘shared goal’ with under a poisons scheme. entire populations. Even the best longi- public health of achieving a ‘smoke-free’­ It can be hard to find a place to stand tudinal studies likewise have limitations. (not tobacco-­free) . So, conflicts together on shifting sands. The prolifera- Weighting multiple types of evidence about NNNTPs must be considered within tion of new NNNTPs creates much insta- and deciding what questions to prioritise the context of long-­planned tobacco bility, with resources potentially diverted involve interpretive decisions that are company business objectives of weakening from work to advance basic tobacco control made within a larger context. tobacco control movement solidarity, policies to studying, sorting, arguing about gaining increased access to policymakers and addressing the wide range of products WHY THESE CONFLICTS AT THIS and controlling the about their that keep popping up like Whack-A-­ Mole.­ HISTORICAL MOMENT? products. This is why they continue to Further, different countries already take The world is amidst a pandemic unprec- work to interject themselves into activities very different approaches to NNNTPs. edented in our lifetimes, reshaping many promoted under the WHO Framework That is not a bad thing: we will learn from aspects of life for everyone. Emerging on Tobacco Control (FCTC), their . Can we at the very least global conversations, furthered via social particularly criticising Article 5.3, which find common ground by continuing to media, foreground and challenge institu- seeks to protect public health policy-­ marginalise the tobacco industry, while tional racism, white supremacy and patri- making from their commercial interests, envisioning an end to the primary cause of archy. Climate change has become a global and why their allies seek to pressure and the epidemic in each region and country? concern. In many of these conversations, undermine the WHO. 2 there is increasing focus on the commer- Roe suggests that in cases of appar- Twitter Ruth E Malone @MaloneRuth cial determinants of disease and the health ently intractable conflict, it can be useful Funding The author has not declared a specific grant

of whole systems. These conditions can to identify a larger ‘metanarrative’ that for this commentary from any funding agency in the copyright. enhance awareness of public health as a captures the problem definitions and public, commercial or not-­for-­profit sectors. societal good, even as they have in some causal relationships of all or most major Competing interests See https://​tobaccocontrol.bmj.​ ​ places created resistance. There is a global positions in the conflict. Without delin- com/pages/​ ​wp-content/­​ uploads/​ ​sites/49/​ ​2019/10/​ ​DOI-­​ sense that real change is possible, immi- eating here all those positions, I speculate Statement-Ruth-­​ Malone.­​ pdf​ nent and necessary. But what change? that the notion of the tobacco endgame Patient for publication Not required. The current propensity for conspiracy could constitute such a metanarrative. Provenance and peer review Not commissioned; theories to shape of many The endgame calls for positioning the internally peer reviewed. social problems has likewise figured work of public health in an overarching © Author(s) (or their employer(s)) 2021. No commercial http://tobaccocontrol.bmj.com/ heavily in narratives about NNNTPs, with historical context, seeing the tobacco re-­use. See and permissions. Published by BMJ. claims flying that individuals opposing epidemic as industrially produced. The widespread use of NNNTPs actually want endgame’s definitional focus on changing permanently the structural, political and smoking to continue in order to protect To cite Malone RE. Tob Control 2021;30:119–120. their own funding or to avoid admitting social dynamics that sustain the tobacco their was skewed, while others epidemic3 should be a goal for both Tob Control 2021;30:119–120. suggest that some proponents of NNNTPs NNNTP proponents and opponents. With doi:10.1136/tobaccocontrol-2021-056529 are colluding with tobacco companies, such a shared goal, it should not be at all ORCID iD duped by their allies or are accepting controversial to assert as the first principle Ruth E Malone http://orcid.​ ​org/0000-​ ​0002-3324-​ ​2183 funding from industry-­funded organisa- of decision-­making that companies with a tions working to advance their interests. stake in selling products—regardless of the REFERENCES on September 26, 2021 by guest. Protected Conspiracy claims aside, the conflicts nature of the products and how harmful 1 Stone DA. Causal stories and the formation of policy are not only shaped by basic disagreement or helpful they may be—should not be Agendas. Polit Sci Q 1989;104:281–300. over the interpretations of science and the influencing how those products are or are 2 Roe E. Narrative policy analysis: theory and practice. not regulated, given their obvious conflict Durham, NC: Duke University Press, 1998. proper role and regulation of NNNTPs 3 McDaniel PA, Smith EA, Malone RE. The tobacco in real-world­ contexts. They are clearly of interest. And—again, with a shared endgame: a qualitative review and synthesis. Tob also being influenced by the activities commitment to changing permanently the Control 2016;25:594–604.

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