Being realistic about harm reduction

This story from the Daily Mail raises one or two questions:

Free morning-after pill fails to cut teenage pregnancies

The drive to give free morning-after pills to teenage girls has failed to cut underage pregnancies.

Schemes to offer over-the-counter emergency birth control to girls under 16 have simply encouraged youngsters to have more unprotected sex, damning research found.

In doing so they have fuelled a rise in sexually transmitted diseases.

The study in question looks sound enough and (according to its authors) its findings are in line with the majority of other research on the same topic. But the fact that this story has not been widely reported outside of the right-of-centre newspapers in Britain suggests that some people are not comfortable hearing such news.

I don't have a strong view on whether or not the morning-after pill should be given to under-age kids, but having the government hand out free contraception to the under-16s obviously sends out a signal that is at odds with sex being illegal for the under-16s. Likewise, giving free needles to heroin addicts. But that's how harm reduction works—we don't approve, but we recognise that it goes on and we try to reduce the risks.

The point of this post is not to pontificate on the rights or wrongs of needle exchanges and free contraception to teenagers, but only to point out something that any honest person working in harm reduction will tell you: if the government facilitates an activity, it will be seen to have at least tacit approval and that activity is likely to become more common. Social stigma is an effective means of controlling behaviour. We've seen it with drink-driving and we've seen it with smoking. If you remove that stigma and give a nod and a wink that something's okay—by, for example, handing out the morning-after pill in schools—you can expect to see more of it.

This is pretty basic behavioural economics and the apparently controversial study above does nothing but prove an obvious point—harm reduction policies increase uptake. But it isn't uptake that is the problem. Liberal opinion is less worried about people taking drugs and having sex than by the unintended consequences of these activities. I feel the same way. The problem with the free contraceptive scheme isn't so much that it is increasing the frequency of underage sex, but that it seems to be increasing frequency of visits to the STD clinic while not reducing the frequency of visits to the maternity ward. It is having an unintended—albeit predictable—consequence while failing to deal with the real problem. (Arguably, the wrong contraceptives are being dished out. Condoms would be a better way of preventing unwanted babies and unwanted diseases, but perhaps that would be putting too much power and responsibility in the hands of teenage boys.)

Harm reduction policies should be judged by the overall effect on public health. If it was about morality and behaviour, we wouldn't be attempting harm reduction in the first place.

So it is with tobacco harm reduction. If people were given access to less hazardous products such as snus or e-cigarettes—and if this was accompanied with honest information about how much safer they were than combustible tobacco products—we should recognise that this will inevitably lead to some people trying these products who would not otherwise be attracted to nicotine. Quite obviously, more people would use snus if it was legalised than if it wasn't. But the number of people using tobacco/nicotine isn't the issue, unless we have some moral objection to people using a mild addictive drug. The issue is whether enough people quit the very hazardous product in favour of the less hazardous product to make it worthwhile from a public health perspective.

In the case of tobacco, the hazardous product (cigarettes) is so harmful that very few smokers would have to switch to make a net saving in lives lost. Conversely, the less hazardous alternatives (snus/e-cigarettes) are so very much less harmful that a vast number of previously uninterested nonsmokers would have to be drawn towards them before this gain was cancelled out.

In terms of overall prevalence, it is likely that the total number of nicotine users would remain steady or rise, when compared to a scenario in which safer products were illegal and smoking was made less and less socially acceptable (although considering the failure of anti-tobacco to reduce smoking prevalence in recent years despite using every trick in the book, even that prediction may be suspect).

Whether or not you have a few more, a few less, or about the same number of people using nicotine products, if they are doing so using products which are 90%+ safer, the overall effect on public health can only be positive. If they are 90% safer, you would need more than ten previously uninterested people to start using these products for every smoker who uses them to quit. If they are 99% safer (and this is the more scientifically probable estimate), you would need more than 100 previously uninterested people to start using these products for every one smoker who uses them to quit.  Common sense tells us that this is simply not going to happen and only a delusional fruitcake could possibly think otherwise.

Coming up tomorrow: I discuss Stanton Glantz's belief that encouraging harm reduction would lead to more people smoking and more people dying of tobacco-related deaths.