Sunday, 6 October 2013

Harm reduction and its opponents

The arguments for and against harm reduction in the field of nicotine are much the same as those in the field of illegal drugs where governments have increasingly adopted needle exchanges, methadone programmes and safe consumption rooms to reduce drug-related mortality. In the field of drugs, harm reduction is widely considered to be a healthier and more humane approach than rigid prohibition. The biggest difference between harm reduction for narcotics and harm reduction for nicotine is that many more people die each year as a result of smoking than die as a result of drug use, albeit usually at an older age.

The other key difference is that narcotics are illegal whereas cigarettes are not. Accusations of institutional hypocrisy made against governments which facilitate the consumption of illicit drugs carry less weight in the case of tobacco harm reduction since cigarette smoking is legal. Advocates of e-cigarettes and snus cannot be accused of condoning smoking since both products are alternatives to smoking and the former does not even contain tobacco. At worst, they can be accused of condoning nicotine use, but nicotine does not cause disease and, as a drug, it is much closer to caffeine than to opiates. Tobacco harm reduction therefore forces campaigners to ask themselves if it disease they are fighting or if addictive pleasures and corporate profits are a greater concern.

The economist Thomas Sowell divides people into those who have the ‘tragic vision’ and those who have the ‘vision of the anointed’. The latter believe that the problems of mankind are created by institutions and that, through legislation, solutions can be found - in this instance, total worldwide abstinence. The former see mankind as inherently flawed and believe that there are rarely ‘solutions’, only trade-offs. There are those who believe that legislation, denormalisation and NRT can reduce the prevalence of tobacco use to less than 0.5 percent of the population within twenty years. Others look at the failure of similar efforts to suppress alcohol and drugs in the past and view the neo-prohibitionist approach as utopian, unrealistic and ultimately damaging to health.

Back of the envelope calculations of how many premature deaths could be prevented by a shift to alternative nicotine products are easy to produce. ‘If all the smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes,’ writes John Britton of the Royal College of Physicians’ Tobacco Advisory Group, ‘we would save 5 million deaths in people who are alive today. It’s a massive potential public health prize.’ This assumes that every smoker will be happy to shift to the electronic devices, an unrealistic scenario, but significant health gains can be predicted whatever the level of uptake.

In a private letter written in 1984 when harm reduction was out of fashion and total abstinence was the order of the day, the renowned epidemiologist Richard Peto pondered the question of ‘how many cancer deaths would be likely to be caused each year if one-third of the British population become habitual tobacco suckers.’ This was a reference to snus, which was becoming the subject of controversy in Britain as a result of the Skoal Bandits furore. Peto acknowledged that the health risks associated with snus, if any, were unknown and would take many years to identify. He cautioned that ‘no matter what epidemiological studies you mount, you probably won’t get even a preliminary answer this century, so as a practical basis for action I suggest you assume that the adoption of Skoal Bandit-like products by a quarter or a half of the British population will cause about 1000 cancer deaths a year. In contrast, tobacco smoking currently causes about 100,000 British deaths a year!’ Peto based his prediction of a thousand cancer deaths on the assumption that snus had a similar risk profile to the kind of loose oral snuff used earlier in the century in the USA. It took many years before the epidemiological evidence showed no association between Swedish snus and mouth cancer. He was, however, correct in his basic assumptions which he outlined as follows:

‘- The risks are not zero - The risks can probably be reduced by immediately commissionable laboratory research; - The risks are much, much less than those of cigarette use.’ (Peto, 1984)

Writing about Skoal Bandits in the Lancet the following year, the addiction specialist Michael Russell came to a similar conclusion:

‘Our results suggest that this new product could help people trying to give up smoking. It might be cheaper than nicotine chewing gum and would not require a prescription. If all smokers in Britain switched to sachets about 50,000 premature deaths per year might eventually be saved at an annual cost of less than 1,000 deaths from mouth cancer.’ 

Speaking to Virginia Berridge in 1995, Russell recalled that such messages fell on stony ground in the 1980s. ‘I gave a talk fifteen years ago at a respectable conference in Edinburgh - if you could get people to switch to snuff you could prevent lung cancer and bronchitis - all for a small risk. People don’t like it if you raise these issues.’ Such arguments ‘carried little weight with a public health lobby which still regarded safer smoking (in whatever form) as a discredited strategy and abstention as the only aim,’ writes Berridge (Marketing Health, 2007: 271). ‘The scientific message might have been right, but it was coming from the wrong messengers at the wrong time.'

In the USA, the oral pathologist Brad Rodu was roundly condemned by anti-smoking campaigners when he published his book For Smokers Only: How Smokeless Tobacco Can Save Your Life (1995). Like Peto, he based his calculations on the risk profiles of the most carcinogenic smokeless products but nevertheless concluded that ‘if all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from smoking-related cancers, heart problems, and lung disease.’ (Rodu, 1995: 131) Despite the book’s title clearly indicating that Rodu was not condoning the use of smokeless tobacco by nonsmokers, he was accused of being ‘irresponsible’ and ‘naïve’ by public health activists who have ostracised him in the years since (For Your Own Good, Sullum: 78-80).

Arguments against safer products

Opposition to harm reduction is by no means universal in public health circles. A number of organisations, including the American Association of Public Health Physicians, Action on Smoking and Health, the American Council on Science and Health and the Royal College of Physicians have recommended that snus be re-legalised and e-cigarettes be encouraged. For others, however, stated concerns include the possibility that alternative nicotine products act as a ‘gateway’ to cigarette smoking, that some people will use less harmful products as well as cigarettes, and that snus and e-cigarettes allow smokers to ‘get around’ smoking bans.

Taking the objectives of modern public health at face value, one can consider the following theoretical process by which a less harmful product could negatively affect population health. It is possible that individuals who would not have taken up smoking because they think it is too dangerous might take up the less harmful product. If Product A is half as hazardous as Product B and the entire market shifts from B to A, then net harm will fall by half. If, however, Product A attracts so many new customers that the entire market doubles, the net effect would be zero. And if the market increases threefold, net harm would increase by 50 per cent.

How likely is it that a shift to safer nicotine products will increase net harm? Further research will quantify exactly how much safer e-cigarettes and snus are in comparison to conventional cigarettes, but there is little doubt that they are at least 90 per cent less hazardous and are probably in the region of 98-99.9 per cent less hazardous (Rodu, 2011; Cahn and Siegel, 2011). If so, the risk posed by these products is of a similar order to that of eating red meat, drinking alcohol in moderation, driving a car, sun-bathing or any of the other run-of-the-mill lifestyle choice.

Approximately twenty per cent of the UK population currently use nicotine, of whom the vast majority smoke cigarettes. The nicotine market cannot, therefore, increase by more than fivefold (100 per cent). If snus and e-cigarettes are 95 per cent less hazardous than cigarettes (a very conservative estimate), then there would have to be a more than twentyfold increase in the size of the nicotine market for net harm to rise above the current level. This is a mathematical impossibility.

Alternatively, it is possible that individuals might take up the less harmful nicotine product and then move on to cigarettes - the ‘gateway’ effect. There is, however, very little evidence that reduced harm products appeal to nonsmokers in the first place. In the case of e-cigarettes, ASH notes that ‘there is little evidence of use by those who have never smoked.’ Based on survey data, ASH found that ‘regular use of e-cigarettes is extremely rare’ amongst children. Only one per cent of 16-18 year olds - and zero per cent of 11-15 year olds - use an e-cigarette more than once a week and this tiny minority is made up of smokers and ex-smokers. ASH found no regular users of e-cigarettes amongst non-smoking teenagers:

‘Among young people who have never smoked 1% have “tried e- cigarettes once or twice”, 0% report continued e-cigarette use and 0% expect to try an e-cigarette soon... Frequent (more than weekly) use of e-cigarettes was confined almost entirely to ex-smokers and daily smokers.’ Far from acting as a gateway to smoking, all the evidence indicates that e-cigarettes are a gateway from smoking. Switching from vaping to smoking would require a conscious decision to take up a habit that is ten times more expensive and one hundred times worse for your health. The prohibition or over-regulation of these devices will close off a hypothetical gateway from e-cigarettes to tobacco, but it will also close off a very real gateway for people who want to go from tobacco to e-cigarettes, and that is the path most travelled.

Some have complained that e-cigarettes ‘normalise’ smoking. ‘We are especially concerned that e-cigarettes might reinforce the smoking habit as they are designed to closely mimic smoking actions’, says the British Medical Association. For this reason, the BMA has called for the smoking ban to be expanded to include e-cigarettes despite it being almost inconceivable that ‘passive vaping’ could pose any risk to bystanders. On the campus of the University of California, San Francisco, it is against the rules to carry, let alone use, an e-cigarette, even outdoors.

For all the talk of ‘denormalising’ tobacco use, smoking prevalence in most countries exceeds twenty per cent of the adult population. Smoking may not be universal, but it can hardly be described as abnormal or unusual. In 2010, cigarettes and rolling tobacco made up 94.9 per cent of the EU’s nicotine market. E-cigarettes and NRT held just 0.4 per cent each while smokeless tobacco held 0.6 per cent (Matrix Insight, 2012: 20). Whilst there is evidence that the ‘denormalisation’ approach can lead to lower smoking rates (Hammond et al., 2006), it remains doubtful whether e-cigarettes ‘normalise’ smoking in any meaningful way. As a device that has spread rapidly by word-of-mouth in recent years, it would be more accurate to say that e-cigarettes normalise harm reduction and smoking cessation. Moreover, there are social costs incurred by the denormalisation/stigmatisation approach which can be avoided by the more liberal harm reduction approach (Bayer and Stuber, 2006).

Once bitten, twice shy?

A further objection sometimes raised is that harm reduction has been tried before and failed. Low tar cigarettes and filter tips are now widely portrayed as tobacco industry ruses to trick consumers and delay tougher regulation. This ‘once bitten, twice shy’ argument requires some rewriting of history. Lowering tar yields and investigating the ‘safer cigarette’ had the support of many public health scientists, including some of those who first identified the link between cigarette smoking and disease, as well as successive Surgeon Generals and several Ministers for Health. The Federal Trade Commission recommended that tar yields be printed on cigarette packs in 1969 (Sullum: 69) and many governments officially advised smokers to switch to low tar brands in the 1980s and 1990s.

Moreover, the harm reduction efforts were not complete failures. There is ample evidence that the unfiltered high-tar cigarettes of the 1950s posed more of a health hazard than the filtered low-tar cigarettes of later decades (Hammond et al., 1976; Tang et al., 1995; Blizzard and Dwyer, 2001; Harris et al., 2004). The European Union has progressively lowered the maximum permissible levels of tar and nicotine in cigarettes, presumably because it believes lower yields to be less dangerous. Although the ‘safer smoking’ initiative of the twentieth century was a more collaborative effort between the tobacco industry and government than is often recognised, the industry was guilty of keeping its misgivings about ‘light’ cigarettes to itself and it clearly failed to produce a ‘tolerable risk’ cigarette. None of this has any bearing on the safety or efficacy of snus and e-cigarettes, however. ‘Once bitten, twice shy’ is fallacious reasoning.

Arguments made against tobacco harm reduction on health grounds are not compelling. Opposition to e-cigarettes and snus can only be properly understood in the context of the public health lobby’s longstanding goals of eradicating recreational nicotine use and destroying the tobacco industry. An underlying objection of anti-smoking campaigners to these products is that cigarette companies could survive and thrive by selling them. Several tobacco firms have started selling snus and Lorillard became the first tobacco company to acquire an e-cigarette firm in April 2012. British American Tobacco has created a startup company called Nicoventures to create products for ‘smokers who may not want to quit smoking but who want a safer alternative to cigarettes’ while Philip Morris has patented a nicotine aerosol product (Matrix Insight, 2012: 52) Many anti-smoking veterans would find it intolerable if ‘Big Tobacco’ became a player in harm reduction since they have long since cast the industry as a consummate enemy with whom they are engaged in a war of annihilation.

Meanwhile the pharmaceutical industry has an incentive to lobby against non-medicinal nicotine products and national governments have a financial incentive to perpetuate the smoking of highly-taxed cigarettes. The novelist Lionel Shriver, who kicked her smoking habit thanks to e-cigarettes, blames opposition to the devices on ‘kneejerk cultural prejudice, puritanical vindictiveness, corporate collusion, and the unconscionable greed of tax authorities that won’t be able to heap the same punitive, confiscatory, opportunistic duties on a product that doesn’t hurt anyone.’

Resistance to e-cigarettes - which contain no tobacco and are, for the most part, not made by ‘Big Tobacco’ - is consistent with the puritanism and prejudice Shriver alludes to. Moral indignation towards pleasure-giving ‘vices’ may well be a motivation for some of those working in the tobacco control industry. Bell and Keane (2012) note that objections to e-cigarettes have a moral dimension and that ‘it is not clear that further research into e-cigarettes will substantially alter current opinion. This is because their dangers stem not merely from the constituents of the products themselves, but the ideological challenge they pose to the binary categorisation of nicotine into not only remedial and harmful forms, but morally “good” and “bad” ones.’

As smokeless products, e-cigarettes and snus do not violate the anti-smoking lobby’s vision of a ‘smoke-free society’ - indeed, they are likely to bring it closer to fruition - but recreational nicotine use of this sort remains morally suspect to some of its members and was never part of the plan. The question now is whether ‘it is better to aim for complete exclusion or prohibition of nicotine use, or to accept the place of nicotine in society but to regulate to make nicotine products safe.’ (Britton et al., 2001: 14-15) It remains to be seen whether that plan is flexible enough to adapt to changing circumstances or if the abstinence-only ideology is too big a juggernaut to be turned around.

From Free Market Solutions in Health: The Case of Nicotine


Barman said...

Excellent post!

Thank you...

docjd said...

Thank you for this well thought-out piece.

John-T said...

Great article thanks for sharing this very informative info...

John-T said...

Great article thanks for sharing this very informative info...

John-T said...

Great article thanks for sharing this very informative info...

Ian said...

I would guess that most students at UCSF are using their e-cigarettes to vaporize hash oil rather than nicotine - this may be more the root of the ban