The problem of misinformation is profound for public health, as highlighted by responses to COVID-19 and to tobacco harm reduction. “We need targeted strategic approaches to really start getting corrective information to the misinformed,” said Dr Gizelle Baker of Philip Morris International at a recent Global Tobacco and Nicotine Forum held in London. “Research is needed to find out how best to tackle fallacies.” Including among doctors.
Baker said that 10 years ago, she would have laughed at some of the ideas being spread today about COVID and about novel tobacco harm reduction products. “I would have thought it was a meme or a joke. Now you find out people on the other end believe it.”
Baker, who is vice president of global scientific engagement at PMI, stressed the importance of understanding how misinformation spreads, during a plenary panel on “Science Driving Policy” at the GTNF conference held from 21 to 23 September 2021.
Fellow panelists were Swedish researcher Dr Karl Fagerstrom; Dr Qingyuan Hu, head of the China National Tobacco Quality Supervision and Test Center; Dr David O’Reilly, research director of British American Tobacco (BAT); and Professor Brad Rodu of the school of medicine at the University of Louisville in the United States.
Facts versus beliefs
The extent of misunderstanding about cigarettes versus smoke-free tobacco products was revealed by a multinational, 29,000-person survey commissioned by PMI. It found that over 45% wrongly believed that smoke-free products are equally or more harmful than cigarettes.
Nearly 60% of people misunderstood what causes smoking-related disease. While about 19% of people correctly identified a cause as exposure to high level of toxicants and 22% correctly identified tar, 59% of people did not answer correctly, Baker revealed.
Almost half of people also misunderstood nicotine. While knowing that it was addictive and not risk-free, they did not know that nicotine was not the primary cause of smoking-related disease.
How does confusion affect behaviour? Baker said that 91% of smokers who have switched to smoke-free products and given up cigarettes, state that having access to accurate information was a main factor in making the switch.
Some 33% of smokers have not considered switching to smoke-free products because of lack of clarity or uncertainty over the differences between these products and cigarettes, while 63% of exclusive smokers would be more likely to switch to non-combustible products if they had clarity on the products and the science behind them.
Across all people in the survey, almost 80% agreed that smokers deserved to have access to products and information so that they could make informed decisions.
“What this shows is that we need to get the information right,” Baker said. “We have to get the information into hands in an understandable way, in a compelling way, so that smokers can make informed decisions.”
Dr David O’Reilly of BAT told the GTNF that confusion over the risk-reducing potential of new tobacco products was growing.
“A 2018 survey showed that 62% of respondents from six European countries felt e-cigarettes were more harmful than cigarettes. An increase from 58% in 2016,” he said. In the UK, data showed that the number of adults who inaccurately believed that vaping is equally or more harmful than smoking was around 25% in 2016, rising significantly to 37% in 2020.
“This despite a growing body of evidence from companies and public health bodies demonstrating the tobacco harm reduction potential of non-combustible tobacco and nicotine products.”
While e- cigarettes are not marketed for purposes of smoking cessation, O’Reilly said, Oxford University’s most recent Cochrane Review of 56 studies on nearly 13,000 adult smokers found more people stopped smoking for at least six months using nicotine e-cigarettes than using nicotine replacement therapy or non-nicotine e-cigarettes.
Policies must decouple nicotine from the harms caused by cigarette combustion. O’Reilly said. “They need to draw a clear distinction between combustible cigarettes and non-combustible products that contain nicotine.
“Tobacco harm reduction is one of the most important public health policies today. Without greater clarity and differentiation of nicotine with robust scientific evidence as its foundation, we will struggle more than we should to realise its full potential.”
Educated but misinformed
Gizelle Baker spoke of populations who are vulnerable to misinformation. As an epidemiologist, she has found the opposite of what she expected. Often it is assumed that vulnerable populations are people of lower socio-economic status.
But people must have access to misinformation to be vulnerable to it.
“When you write up something that looks very scientific, the vulnerable population may be people who are academically educated in universities and may be more susceptible to some of the misinformation than the people you'd normally think of. This changes the way you have to strategically target, to counter misinformation.”
David O’Reilly found it “profoundly worrying, but also profoundly interesting that misperceptions of the safety profile of nicotine are almost as great in the health care practitioner field as they are in the general public”.
Dr Delon Human – panel chair and president of Health Diplomats, a global health consulting group – said it was clearly time for physicians to heal themselves. Regarding nicotine:
“There is a remarkable lapse of medical education at undergraduate and postgraduate level, and in continuing medical education, when a molecule can be so misunderstood and miscommunicated. If this had been any other molecule, it would have been headline news.”
Challenges facing tobacco harm reduction
Baker is an epidemiologist and biostatistician by training who now researches the risks of non-combustible tobacco products, among other things. PMI produces a heat-not-burn tobacco product as part of its move away from cigarettes.
To succeed, she told the conference, tobacco harm reduction requires that adult smokers have access to accurate information on alternative, less harmful products that they can switch to. If people are told that a product is not reducing harm, when it is, and they thus do not switch to it, “that has a huge impact on population harm”.
False information can be easy to debunk. “But when you have contradictory information, conflicting findings, an ever-changing evidence pool coming out – anything that drives uncertainty – it leads to a consumer base that is completely confused,” Baker said.
How is it possible to understand what a product means for your health, when you cannot get two pieces of information that tell you the same thing?
Misinformation is nothing new, Baker pointed out. Whenever science has changed and new products have arisen, misinformation bubbles to the surface.
“But today is very different. We're in a digital era. We have information at our fingertips, and it is really hard to differentiate between what is science and what is opinion.”
Is it even known what the dynamics of misinformation are? “The one thing we do know is misinformation spreads in ways that information doesn't and information spreads in ways that misinformation doesn't,” Baker told the conference.
“We can't just put more and more information out there and hope that misinformation goes away.” Misinformation reaches people in different ways, and there are various ways to understand data. Psychological, social and emotional drivers need to be understood.
“Who sends people misinformation? If it's somebody you know who talks about a doctor they know, are you more likely to read that information than to pick up a journal article that tells you that's wrong? When you're talking about consumers, the answer to that question is yes.
“We have to be aware of the role and impact of cognitive biases, especially confirmation bias,” said Baker. We all know that smoking cigarettes causes disease and death. If somebody says an e-cigarette is bad, and it has got the word cigarette in the name: “Everybody's like, ‘Yeah, we know that’. It confirms what I already know. So it's much easier to spread.”
Do people who are spreading misinformation understand the impacts it has? “Unless we start to understand it, to quantify it, and to share it back with people, they may go on spreading stuff, not really considering the impact it's having on not only their health, but others too.”
How to develop effective strategies?
How to get corrective information into the public realm in a way that it can counter the flow of misinformation, is an important area for scientific research.
Baker gave an example from COVID-19 of harm that can be wreaked by misinformation. Public health bodies are quick to react when misinformation is damaging a message they are wanting disseminated. When misinformation spread about vaccines, for instance, many were quick to respond with hotlines and information campaigns.
This was not the case with masks, which have been fraught with misinformation. First, people were told masks did not protect against COVID; later they were told that they did and masks must be worn both indoors and outdoors.
“All of a sudden, people don't know what to make heads or tail of. Should I wear them? Should I not? Am I protecting people? Am I protecting myself? What am I doing with this mask on? It's really hard to correct misinformation once it is spread because you don't know exactly what piece of that information people have heard.”
Another example Baker gave was a journal article asserting that e-cigarettes were associated with myocardial infarction. “This got picked up big time in 2019, it made headlines everywhere. Consumers learned that switching to e-cigarettes may cause a heart attack.”
Following work by scientific bodies, the article was retracted. “It didn't correct the misinformation. It didn't get picked up big time. It left people thinking these products are dangerous. These products will cause heart attacks. They're just the same as cigarettes.” Professor Brad Rodu provided numerous other examples of questionable science published in reputable journals, and its impacts.
Baker told the conference that bad science should be tackled from many sides. From industry and independent scientists. “You need to fight it at the journal level with the editors.”
This problem is bigger than tobacco harm reduction. “The scientific community has to stand behind science. Otherwise, science gets diminished everywhere. The bad stuff that comes out on COVID has an impact on scientists in tobacco harm reduction or climate change.
“Bad science makes everybody think that science is whatever you want science to be, when science is a fact-based, evidence-based approach. Right?”
“With COVID, it became so clear how important it is having scientific facts at our fingertips. We need to leverage these moments, when all of society comes together in agreement,” said Baker. “We need to have some really targeted strategic approaches of how to really start to get corrective information to the misinformed.”
Dr Karl Fagerstrom, a global expert on tobacco harm reduction, described the success of snus – oral tobacco pouches – as an alternative to smoking in Sweden and Norway
The latest Euro Barometer showed that the prevalence of smoking in Sweden is now only 4% – one of the world’s lowest rates. As use of snus rose, use of cigarettes declined, and one result has been less tobacco-attributable mortality. The 2019 Global Burden of Disease survey reported that the European Average was 128 smoking related deaths per 100,000 people, while in Sweden the figure was 72 – the lowest in the region.
But snus provides a clear example of how science is not driving policy. Despite 40 years of evidence of reduced risk, snus remains prohibited across the European Union while considerably more harmful cigarettes are not.
Dr Qingyuan Hu argued for a more scientific tobacco control strategy. There are many research gaps to be filled, he said, and the tobacco industry needs to continue investing in scientific research.
“Technology openness and sharing may help to understand policy. There are policy gaps and lack of consistency in regulatory policies on nicotine, novel tobacco products and tobacco harm reduction across leading regulatory authorities.”
So is science driving policy?
Panel chair Dr Delon Human said it had become clear during the conference that there were three frustrations concerning policy.
COVID-19 has shown that science and policy can be accelerated to, for instance, facilitate the use of vaccines in order to prevent disease and save lives. “Isn't that the dictum we've been using for tobacco harm reduction all along?” Yet there have been few advances in tobacco harm reduction policies.
There is also frustration about the lack of sophistication of tobacco product regulation. While the idea of a continuum of risk is widely accepted – with cigarettes being at the the highest risk end followed by progressively less harmful tobacco products – this is not reflected in regulations, or product labelling or taxation.
Further, there is an “absolute consensus that evidence-based policy is the way to go. We're all in agreement that we need to do the right science in order to eventually have the right policy in place,” said Human. “There is palpable frustration that instead of evidence-based science or evidence-based policy, we are fighting a war against policy biased evidence-seeking.”
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