Yet another articulate description by Al Gor of a core problem in responses today by tobacco control to tobacco harm reduction: tobacco exceptionalism. It made me think about a time I had an appointment with a patient who had been on methadone as treatment for his problems when using street heroin. I felt I was the meat in the sandwich enforcing Department of Health ‘guidelines’ which I found preposterous but couldn’t ignore. The patient told me about the real world effects of these guidelines on his life. So I asked him why he still continued on methadone given a situation where the guidelines made his life a misery. He replied: “doctor, the last time I had a conversation like this with a clinician I accepted being talked into coming off methadone treatment. I knew what was going to happen, things I very much didn’t want to happen but nevertheless they happened. I went back on to street heroin. It cost me my marriage, my job, I lost my house and my savings. It has taken me a long time to get these things back again. I’m now too old to try that again. If I’m forced off methadone I know exactly what I’ll do. And I won’t hesitate.” That conversation moved me enormously. After that I never again tried to persuade a reluctant patient to come off methadone. A lot of the experience of drug treatment applies to smoking cessation work. If an ex-smoker wants to stay on smoke-free nicotine forever because they are worried about relapsing to smoking or because they enjoy nicotine, or a bit of both, what business is it of mine?
Thanks, Alex, that’s a powerful story, and it captures the issue perfectly. The real-world consequences of rigid, ideology-driven guidelines are often invisible to those who write them, but they’re painfully clear to patients living with the fallout.
Completely agree with your broad point that there's a huge double standard in how nicotine is treated vs. other substances.
But I wanted to comment on your statement that "Nobody argues that the existence of alcohol-free beer undermines abstinence." I am starting to see this argument made legitimately, unfortunately. It's as if some people *are* seeing the contradiction in nicotine vs. alcohol, but they are taking the wrong corrective action!
Instead of loosening their stance on noncombustible nicotine, they are tightening their stance on alcohol. I am peer-reviewing a paper right now that makes the same flawed "gateway" argument but with non-alcoholic drinks having an implied gateway to drinking. Chris Snowdon has written about this in more detail: https://snowdon.substack.com/p/anti-alcohol-academics-smoked-out
That’s a really important correction and I’m glad you raised it.
You’re right the “nobody argues ” line is becoming less true, and that shift actually strengthens the core critique rather than weakening it.
What you’re describing is exactly what it looks like when people start to notice the inconsistency around nicotine but resolve the discomfort in the worst possible way. Instead of questioning nicotine exceptionalism, they export it. They extend abstinence absolutism outward until everything that delivers pleasure, relief, or altered states must be morally quarantined.
So yes you’re absolutely right to flag this. The contradiction is being noticed. But instead of resolving it by loosening unjustified hostility toward non-combustible nicotine, some are choosing to tighten the screws everywhere else.
Thanks for this. I have some factual quibbles (including ones that AS reported and AW implicitly noted), but I very much like the overall vibe of it. That is where I am especially struck by the parallels to current US fascism or any number of other cult-like behaviors. Do some noun substitution and you get a different story about a cult that arbitrarily pretends to care deeply about some things, while treating analogous things completely differently, all the while doing nothing to improve upon any of them, because the tribal outrage is the goal, not a statement of a problem to be solved.
This brings up a possible retooling of this story based on people, not subject matter. A factual disagreement I will note, because it is more than a quibble, is that nicotine is not uniquely exceptional. As Chris Snowdon has widely documented, the same people (often literally the same humans, though also just the same tribe) who are at war with nicotine consumers (for it is the consumers that are the targets of the war, not the molecule) bring the same treatment to alcohol, particular foodways, and other choices. Same people, same script modulo some noun substitutions.
I would argue that the departure from harm reduction principles is not a divide within people, but between groups of people. The tribal moralizers simply ignore harm reduction norms related to criminalized drugs and to sexual activity because they have no traction there. Harm reduction is supported by "public health" (i.e., the minority in the field to bother to care about those matters) but not by the public health establishment; they don't oppose harm reduction because they don't want to take on that fight, not because support it. If they could seize the discourse in that area (as their ilk did for decades in the US), I suspect the war on the consumers would become evident there too. Watch for it to happen with cannabis as the niche further opens up to condemn decriminalized use.
Carl, thank you. This is a really valuable perspective.
What you’ve done is to shift the lens. Rather than seeing nicotine as uniquely exceptional, you’re suggesting that what we’re really observing is the consistent behaviour of a particular moral-regulatory tribe within public health. The substance changes; the script doesn’t. In that framing, the inconsistency isn’t primarily within individuals who believe in harm reduction in one area but abandon it in another. It’s between groups. A harm-reduction minority prioritises outcomes, proportionality, and lived reality.
Nicotine may be the clearest current example, partly because of tobacco’s history and the institutional identity built around fighting it, but it’s not uniquely exceptional. It may simply be the most developed proof of concept.
Your reframing sharpens the core question: is public health about reducing harm in the world as it exists, or about enforcing moral conformity to an idealised version of it?
Yes, that's it. I will add further detail that there are people who are primarily focused on harm reduction for criminalized drugs, sex work, and such that are outside of the card-carrying public health establishment (even though they are doing real public health work). This is not much different from the fact that there are traffic engineers who would never be considered part of "public health" who are doing important public health work. There are a few within card-carrying public health who are advocates for drug harm reduction, but they are just a few and are not really noticed by the institutions.
The other side of this, which you note, is more telling. Those few in institutional public health who care about other areas of harm reduction do not get systematic pushback from within the institutions, as anyone who dares to support THR does. (They do get some flack from political types sitting just outside of the public health institutions.) I don't have an explanation for this contrast that I am terribly comfortable with. Probably the most convincing story is that the bad guys are infuriated by the observation that an individual person and a legal corporation would dare enter into a transaction that they (the self-appointed guardians of public health) disapprove of. If the supplier in that transaction is breaking the law, however (black markets, sex work) then it is all good because the actors are *victims* not free people who disagree.
I keep coming back to this, but I think there is good reason for that: It is basically the same as pseudo-Christian right-wingers being furious about someone's autonomous and open decision to have a legal abortion or declare what gender they are, but don't care the people who are secretly raping children. It is the fact that people are unapologetically making choices they have declared to be unacceptable, rather than doing something obviously worse but having the good manners to hide it, that bothers them far more than the actual actions on the ground.
Reminds of these group of local citizens that was chosen by my local with a purposely to give ideas and find things that needed to be fixed, improved and in that way beuitfy and generally improve every day living in my council area.
In beginning they met regularly and had some really good ideas and some suggestions were actually implemented by the council.
Bur with time their ideas and now demands became more and more pointless, expensive and straight out ridiculous.
The council quietly sidelined them, and then dismissed.
These "concerned citizens" could not accept that not important anymore, so they kept having their meetings privately and now started writing letters to the council, till eventually they figured out that they have become irrelevant.
Same here, laws, policies, media,...irrelevant. The only thing that that actually counts is "offer and demand" , the market will sort it self out.
The market choses if they are going to smoke or vape.
Until someone proves otherwise, this is blamblam envelopes of death, ngo too gutless to deny, who/un fucking bought cunts. BT n bp spreading their despicable finger.
thx for your replies.Should you wear it a day long,and next day a fresh one?Or how does it work?I live in Germany,have no clue, thats why I am asking for the brand,because I hear there are diffrent Brands with ingredients.
Yet another articulate description by Al Gor of a core problem in responses today by tobacco control to tobacco harm reduction: tobacco exceptionalism. It made me think about a time I had an appointment with a patient who had been on methadone as treatment for his problems when using street heroin. I felt I was the meat in the sandwich enforcing Department of Health ‘guidelines’ which I found preposterous but couldn’t ignore. The patient told me about the real world effects of these guidelines on his life. So I asked him why he still continued on methadone given a situation where the guidelines made his life a misery. He replied: “doctor, the last time I had a conversation like this with a clinician I accepted being talked into coming off methadone treatment. I knew what was going to happen, things I very much didn’t want to happen but nevertheless they happened. I went back on to street heroin. It cost me my marriage, my job, I lost my house and my savings. It has taken me a long time to get these things back again. I’m now too old to try that again. If I’m forced off methadone I know exactly what I’ll do. And I won’t hesitate.” That conversation moved me enormously. After that I never again tried to persuade a reluctant patient to come off methadone. A lot of the experience of drug treatment applies to smoking cessation work. If an ex-smoker wants to stay on smoke-free nicotine forever because they are worried about relapsing to smoking or because they enjoy nicotine, or a bit of both, what business is it of mine?
Dr Alex Wodak AM
Thanks, Alex, that’s a powerful story, and it captures the issue perfectly. The real-world consequences of rigid, ideology-driven guidelines are often invisible to those who write them, but they’re painfully clear to patients living with the fallout.
Completely agree with your broad point that there's a huge double standard in how nicotine is treated vs. other substances.
But I wanted to comment on your statement that "Nobody argues that the existence of alcohol-free beer undermines abstinence." I am starting to see this argument made legitimately, unfortunately. It's as if some people *are* seeing the contradiction in nicotine vs. alcohol, but they are taking the wrong corrective action!
Instead of loosening their stance on noncombustible nicotine, they are tightening their stance on alcohol. I am peer-reviewing a paper right now that makes the same flawed "gateway" argument but with non-alcoholic drinks having an implied gateway to drinking. Chris Snowdon has written about this in more detail: https://snowdon.substack.com/p/anti-alcohol-academics-smoked-out
That’s a really important correction and I’m glad you raised it.
You’re right the “nobody argues ” line is becoming less true, and that shift actually strengthens the core critique rather than weakening it.
What you’re describing is exactly what it looks like when people start to notice the inconsistency around nicotine but resolve the discomfort in the worst possible way. Instead of questioning nicotine exceptionalism, they export it. They extend abstinence absolutism outward until everything that delivers pleasure, relief, or altered states must be morally quarantined.
So yes you’re absolutely right to flag this. The contradiction is being noticed. But instead of resolving it by loosening unjustified hostility toward non-combustible nicotine, some are choosing to tighten the screws everywhere else.
Thanks for this. I have some factual quibbles (including ones that AS reported and AW implicitly noted), but I very much like the overall vibe of it. That is where I am especially struck by the parallels to current US fascism or any number of other cult-like behaviors. Do some noun substitution and you get a different story about a cult that arbitrarily pretends to care deeply about some things, while treating analogous things completely differently, all the while doing nothing to improve upon any of them, because the tribal outrage is the goal, not a statement of a problem to be solved.
This brings up a possible retooling of this story based on people, not subject matter. A factual disagreement I will note, because it is more than a quibble, is that nicotine is not uniquely exceptional. As Chris Snowdon has widely documented, the same people (often literally the same humans, though also just the same tribe) who are at war with nicotine consumers (for it is the consumers that are the targets of the war, not the molecule) bring the same treatment to alcohol, particular foodways, and other choices. Same people, same script modulo some noun substitutions.
I would argue that the departure from harm reduction principles is not a divide within people, but between groups of people. The tribal moralizers simply ignore harm reduction norms related to criminalized drugs and to sexual activity because they have no traction there. Harm reduction is supported by "public health" (i.e., the minority in the field to bother to care about those matters) but not by the public health establishment; they don't oppose harm reduction because they don't want to take on that fight, not because support it. If they could seize the discourse in that area (as their ilk did for decades in the US), I suspect the war on the consumers would become evident there too. Watch for it to happen with cannabis as the niche further opens up to condemn decriminalized use.
Carl, thank you. This is a really valuable perspective.
What you’ve done is to shift the lens. Rather than seeing nicotine as uniquely exceptional, you’re suggesting that what we’re really observing is the consistent behaviour of a particular moral-regulatory tribe within public health. The substance changes; the script doesn’t. In that framing, the inconsistency isn’t primarily within individuals who believe in harm reduction in one area but abandon it in another. It’s between groups. A harm-reduction minority prioritises outcomes, proportionality, and lived reality.
Nicotine may be the clearest current example, partly because of tobacco’s history and the institutional identity built around fighting it, but it’s not uniquely exceptional. It may simply be the most developed proof of concept.
Your reframing sharpens the core question: is public health about reducing harm in the world as it exists, or about enforcing moral conformity to an idealised version of it?
Yes, that's it. I will add further detail that there are people who are primarily focused on harm reduction for criminalized drugs, sex work, and such that are outside of the card-carrying public health establishment (even though they are doing real public health work). This is not much different from the fact that there are traffic engineers who would never be considered part of "public health" who are doing important public health work. There are a few within card-carrying public health who are advocates for drug harm reduction, but they are just a few and are not really noticed by the institutions.
The other side of this, which you note, is more telling. Those few in institutional public health who care about other areas of harm reduction do not get systematic pushback from within the institutions, as anyone who dares to support THR does. (They do get some flack from political types sitting just outside of the public health institutions.) I don't have an explanation for this contrast that I am terribly comfortable with. Probably the most convincing story is that the bad guys are infuriated by the observation that an individual person and a legal corporation would dare enter into a transaction that they (the self-appointed guardians of public health) disapprove of. If the supplier in that transaction is breaking the law, however (black markets, sex work) then it is all good because the actors are *victims* not free people who disagree.
I keep coming back to this, but I think there is good reason for that: It is basically the same as pseudo-Christian right-wingers being furious about someone's autonomous and open decision to have a legal abortion or declare what gender they are, but don't care the people who are secretly raping children. It is the fact that people are unapologetically making choices they have declared to be unacceptable, rather than doing something obviously worse but having the good manners to hide it, that bothers them far more than the actual actions on the ground.
Reminds of these group of local citizens that was chosen by my local with a purposely to give ideas and find things that needed to be fixed, improved and in that way beuitfy and generally improve every day living in my council area.
In beginning they met regularly and had some really good ideas and some suggestions were actually implemented by the council.
Bur with time their ideas and now demands became more and more pointless, expensive and straight out ridiculous.
The council quietly sidelined them, and then dismissed.
These "concerned citizens" could not accept that not important anymore, so they kept having their meetings privately and now started writing letters to the council, till eventually they figured out that they have become irrelevant.
Same here, laws, policies, media,...irrelevant. The only thing that that actually counts is "offer and demand" , the market will sort it self out.
The market choses if they are going to smoke or vape.
Until someone proves otherwise, this is blamblam envelopes of death, ngo too gutless to deny, who/un fucking bought cunts. BT n bp spreading their despicable finger.
Does sombody know wich nicotine stripps are used according Dr Ardis?
He recommends using 14mg or 7mg nicotine patches. From what I understand, he specifically prefers the TOLEVITA brand.
Note, I'm not providing medical advice.
I know you are not providing medical advice 🙏🏽
Hello Alan,
thx for your replies.Should you wear it a day long,and next day a fresh one?Or how does it work?I live in Germany,have no clue, thats why I am asking for the brand,because I hear there are diffrent Brands with ingredients.