18 June 2013

Tobacco harm reduction, it’s not just about harm reduction

It has recently occurred to me that perhaps the terminology that I and other pioneers of tobacco harm reduction developed is starting to be a drag on our efforts.  I refer specifically to our defining phrase, “tobacco harm reduction”.

When my colleagues at the University of Alberta and I launched our website in 2005, it was not entirely clear what to call it.  We settled on “TobaccoHarmReduction.org”, but there were other candidates at the time.  That term already existed, though was not in widespread use.  The widespread adoption of that term over the ensuing decade validated our choice (though this might be somewhat circular since our use of the term presumably contributed to the validation). 

The term is now locked-in as the description of everything related to efforts to promote low-risk tobacco/nicotine products, including all efforts at education and defending people’s rights to access to these products.  That “everything”, however, is perhaps unfortunate, because it tends to over-medicalize the entire effort, focusing all attention on the reduction (i.e., the value of alternatives as compared to cigarettes).  The tendency to treat the decision to use low-risk tobacco products as purely as a “cure” for the “disease” of smoking was most recently exemplified by the MHRA decision to classify e-cigarettes as medicines, though the tendency is hardly new.  (I had already drafted most of this post long before that came out.)  

It is more politically correct to focus on low-risk tobacco products as purely a cure for smoking, but sometimes politically correct is not optimal for the long-run, or merely for being fully correct.  I try to hedge a bit when I define THR in my writings, with something neutral like “the substitution of low-risk tobacco/nicotine products for cigarettes”.  This does not actually say that the only reason for using the is because otherwise someone would smoke.  However, it is intended to be close enough to pass for that in the eyes of those who demand such a view, suggesting that efforts related to THR are all about getting people off of smoking, and so probably does not provide any benefit with respect to the issues presented here.

It is clearly true that for many people, this is exactly what e-cigarettes and other THR products are – a cure for their smoking habit that they could not find another acceptable path away from.  I trust it is obvious that I am not trying to downplay that at all.  I do a lot of work focused on exactly that angle (e.g., CASAA’s effort to collectstories from people who successfully used THR to stop smoking -- please give us your story if you are one of them).

But suggesting that low-risk tobacco products are merely a cure for smoking narrows the discussion, hurts the cause, and unintentionally fuels the opposition.  Recognizing that low-risk tobacco products are more like coffee than they are like cigarettes, and a lot more than they are like medicines, is crucial for a sensible policy discussion and advocacy.  Breaking the grip of the narrow-minded “public health” types over the discourse cannot be done by adopting their rhetoric.  These products can be enormously welfare enhancing compared to either smoking or abstinence (I have written more about this in my paper about the basic economics, which I finally released – I will write more about the content of that analysis soon, but you can check it out now).

Of course, not everyone who has positive things to say about low-risk tobacco products agrees that it is right to think this way.  Many prominent THR supporters come from a medical or public health background, and still fall into those fields’ unfortunate tendency to ignore any human preference other than health.  To them, THR really is only about the “R”.  They often explicitly state that abstinence is always “better” (without defining their basis for that normative claim), which leads conclusions like "we should restrict education about low-risk products so that they only attract smokers who would not otherwise quit smoking" (setting aside the fact that such targeting is impossible, and recognizing that they may well understand this, they still would prefer to do it if it were possible).

This thinking – whether it comes from those who support THR, oppose it, or are reasonably neutral – invites comparisons to methods for abstinence promotion and implicitly denies that substitution has advantages over abstinence.  This results in the typical discussions about how THR is a more effective method for quitting smoking (for those who are not inclined to just quit) than the alternative methods.  I certainly engage in plenty of those discussions, and I believe it is true.  But focusing entirely on this gives comfort to those who would prefer smokers not have access to a pleasant way to reduce their risks (why would anyone prefer that? read here).  It makes it easy for them to make up claims that THR is not really proven to be more effective for many smokers, and that there are officially “approved” alternatives which therefore must be better, and such.  Those claims are generally full of utter lies, of course, but they is effective at tricking casual observers into doubting the value of THR – so long as THR is only about not smoking.

But since low-risk tobacco products occupy basically the same consumer niche as coffee, I would argue that this is not the battle we should be fighting.  It should be possible to move one step above that fight and argue that low-risk products are better than abstinence for many people.  I am not talking about the constructed and often-invoked (but, in reality, empty) category of those who “cannot” quit smoking.  A focus on that category suggests that THR advocates are conceding that that abstinence is best for everyone in theory, and are merely arguing that a second-best solution is needed for some people.  This, in turn, invites the retorts that “better” cessation methods eliminate the need for this second-best and that low-risk tobacco products really are medicines.  After all, if the only reason we should allow people to buy and use e-cigarettes is because otherwise they would continue their smoking habit, which their personal history shows they are unlikely to stop anytime soon, then why not make them available only by prescription to long-term smokers?  (One answer might be “because under that rule, the only products available would be as unappealing as NRT is”, which is a valid worry, but is a rather different point; a market could be created that is still makes high-quality and innovative products, but is open only to those with diagnosed “cannot quit smoking” syndrome.)

So if this is not just about those who need low-risk tobacco products to “cure” their smoking because nothing else will, who is it about?

To some extent it is about those who experience identifiable health benefits from nicotine, or perhaps other aspects of tobacco use, those who find it to be a good treatment for various psychological conditions and a few physical conditions.  That group that represents one my major motivations for working on this topic.  Efforts by “public health” people to deny such people access to low-risk tobacco, insisting on quit-or-die to those who would suffer terribly from tobacco abstinence (both now, in the world of e-cigarettes, but also for a decade before that when it was demonstrated that smokeless tobacco was a low-risk alternative), is cruelty that is arguably genuinely evil.  It is indefensible from the perspective of any accepted modern ethical system, and exists merely as religious persecution of people who are “different”, with all that implies. 

But it is not just that group either.  This is also about the welfare of everyone that likes or might like the experience of using low-risk tobacco products enough to accept the risk that they might cause a very small reduction in life-expectancy (or they might be beneficial for health on net – we do not know for sure).

Many such individuals are, of course, the aforementioned groups of those who “cannot” quit – i.e., do not quit despite every legal effort being taken to make them suffer for their choice – and those who get serious psychological or other health benefits from smoking (these categories probably refer to mostly the same group of people).  There are many such people who will smoke if there were no other satisfying option, and so this their harm is indeed being reduced if low-risk products are made satisfying and available.  But they will also benefit from the products as compared to abstinence.  If they would choose smoking over abstinence but choose the low-risk product over smoking, then they are almost certainly getting great benefit from using the low-risk product rather than being abstinent.

But for those who are or will be abstinent rather than smoking, possible use of low-risk products is not about the harm reduction.  There is no harm to reduce.  Since this includes everyone who could be bludgeoned into abstinence using other methods, failure to consider the welfare of this group is what gives comfort to the enemy.  In the extremists' rhetoric, everyone will soon be in this category (never mind that this is some combination of mistaking a hope for a plan and out-and-out lying on their part – they still make the claim), and so in their imaginary world there is no harm to reduce.  Arguing that “tobacco-free 2025” is an absurd fantasy is simply not effective – it ought to be because the idea is utterly crazy, but somehow it is not.  I am tending toward the conclusion that only by pointing out that this fantasy future is inferior to a world of minimally-harmful or non-harmful tobacco use, rather than merely arguing that the fantasy is not happening, is it possible to gain the upper hand.

If it is just about harm reduction, then their solution of discovering some magic bullet that will eliminate all harm by eliminating all use is indeed a superior option.  Never mind that a hope is not a plan and there is no legitimate expectation; experience makes clear that the anti-tobacco extremists can make such claims without being subject to any scrutiny from the government or the press, or from most of the public.  But they also might find a slightly more honest argument looking at “clinical” interventions (i.e., treating e-cigarettes or other low-risk products as if they were medicines and, in a medical-like setting, trying to push them on average smokers to try to get them to quit) and finding that – when you do not focus on the right group, smokers who want an alternative – relatively few can be pushed to switch.  As evidence about such artificial and inappropriate efforts to push or cajole random smokers into switching trickles in, it shows that this does not work much better than any other aggressive approach.  If (and only if) these products are medicines, then such evidence indeed represents a failure.

But what if we were to focus on the fact that any risks are minor – down in the range of everyday hazards – and there are net benefits to be had?  In other words, this is a choice that is not very similar to cigarettes, and is more like coffee, soda, snacking, travel, sports, and computer games, all of which have their health costs, but substantial and widely-appreciated benefits.  Moreover, as a choice and not a clinical intervention, any observed failure of trying to clinically force products on currently uninterested smokers is is not damning.  That is simply not the role of the products among free living adult consumers.

Yes, there is some such effort now.  But it is not very concerted, and it is overshadowed by the harm-reduction-only rhetoric (which, again, is unfortunately partially locked-in due to terminology).  Yes, that effort would have to struggle against decades of fairly successful demonization of people who use tobacco products.  But that is the point.  Even if people understand that low-risk tobacco use creates about 99% less risk than smoking, it is still creates 50% or perhaps even 99% of the scorn.  This will clearly no longer be the case after low-risk tobacco product use becomes the norm and those who have been brainwashed by anti-tobacco rhetoric slowly come to their sense (or die off).  But that is a long time, and in the meantime there will be needless loss of welfare, both among smokers who are discouraged from quitting and those who benefit from tobacco/nicotine who are discouraged from using anything.  Perhaps the process can be accelerated.

One challenge is that there will be pushback from some people who support THR, but only as HR.  For them, the term is exactly right.  This seems to include most of the medics who have been won over to THR, and includes a few of those who are considered strong public backers of THR.  These are good people trying to make the world better; they genuinely care about health (they want to improve health rather than merely make people behave “correctly”) and they are pragmatic (they favor something that works over mere hopes).  But ultimately, a lot of them are still anti-tobacco extremists – that is, they ultimately hold the extreme anti-tobacco view of preferring a world in which there were no tobacco use, regardless of whether the benefits of use might exceed the costs for many people.  Many of them long refused and still refuse to embrace smokeless tobacco as a THR product (even though it is the proven low-risk product and probably lower risk than e-cigarettes) and endorse e-cigarettes only because they can take refuge in the rather tortured rationalization that “they are not really tobacco”.  While far from being like the “public health” people who actually care more about destroying tobacco companies than they do about improving people’s health, there are plenty of e-cigarette advocates who ultimately still hate all free-chosen tobacco/nicotine use and only like the product that they can think of as being like a medicine.

It is my assessment that attempts to defend access to and promote awareness of low-risk tobacco products – even if motivated primarily or entirely by trying to reduce harm for current smokers – would benefit substantially if there was more attention devoted to arguing that low-risk tobacco products are little different from everyday consumption choices (except in the minds of an zealous minority who think that there is something evil about this plant).  Many of the popular protests about the MHRA announcement focused on the point about e-cigarettes being a consumer choice, not a medicine.  But that may not push quite far enough.  They are not just a choice, but a fairly unexceptional choice – with the added benefit that if a smoker chooses to use them to “cure” their smoking, they can.


  1. Absolutely with you on this Carl. Though I suspect it will take getting the consensus to the point of nicotine being considered harmless enough to be actually called harmless before the designation of beneficial has a fighting chance.

    Many of us are absurdly proud of the fact that there are so few new users (never having smoked) of ecigs. If they really are as safe as we claim they are then new users are a non issue.

    1. Excellent point. When I write more about this, I will be sure to incorporate it. If you got a chance to look at that economics paper, you will see that I point out that it is inevitable that there will be new users, and also that these new users must be people who are getting net benefit. But it never occurred to me to take that one step further and criticize that pride.

      (Hmm. What do you think of this -- not saying I believe this, just throwing out a hypothesis: Perhaps the reason that ecigs do not seem to appeal to new users, while smokeless tobacco does, is that they really are not as appealing except for those looking for a "cure" for smoking. In which case they really are somewhat medicinal. Even is so, that is likely to change as the products get better.)

    2. As far as new users the explanation would differ depending on age. If you were 30 and had never drunk coffee or alcohol would you bother? Unless you join your friends on a regular basis and they all caffeinate or inbibe would you feel compelled to add a behavior that you never felt was lacking?

      As to adolescents I have always argued that it is the very safety of ecigs that make them unappealing. As a teenager I tried smoking precisely because it was considered dangerous.

      I predict the new users will come from adults who try them out of curiosity and then find the effect of nicotine useful.

      And to return to why so few new users...I have always felt that one of the strongest benefits of drug use is the shared behavior community aspect. And though there are remarkably dynamic vaping communities the product itself does not replicate the sharing and giving aspect of cigarette smoking. You cannot give someone a smoke, share a light, ask for a light from a person as an icebreaker - e-cigarettes lack that connection (even with snus you can offer around the tin).

  2. I've come to pretty well the same conclusion - these are consumer products for the consumption of a legal recreational drug. They need to be 'safe enough' but consumer will decide if they are 'good enough'. The language of harm reduction is a mislabeling - a highly desirable consequence rather than a primary purpose. Harm reduction frequently comes with the qualification that this is a compromise: "whilst it would be better to quit completely, these products can reduce harm to those who cannot or will not quit". The implicit assumption is that zero nicotine use is the goal. But that does not hold if nicotine provides benefits to the user. I am not a nicotine user, but I would not say zero consumption of caffeine or alcohol are optimum for me - I like a coffee in the morning a glass or two of red wine in the evening. Why should it be different for nicotine? The misunderstanding stems from the deep instinctive conflation of the drug and the harm in most of the public health community, even amongst those who know the difference. One of the greatest conceits in tobacco control is the belief that nicotine provides no benefits and that users are simply 'hooked'. As you've rightly said elsewhere, it's all much more rational than that - a weighing of the costs and benefits of continuing or discontinuing use. These pay-offs change radically if you are prepared to accept there are benefits with nicotine use and costs with stopping. Neal Benowitz, one of the world's foremost nicotine scientists, puts it thus:

    "Nicotine induces pleasure and reduces stress and anxiety. Smokers use it to modulate levels of arousal and to control mood. Smoking improves concentration, reaction time, and performance of certain tasks. Relief from withdrawal symptoms is probably the primary reason for this enhanced performance and heightened mood. Cessation of smoking causes the emergence of withdrawal symptoms: irritability, depressed mood, restlessness, and anxiety. The intensity of these mood disturbances is similar to that found in psychiatric outpatients. Anhedonia — the feeling that there is little pleasure in life — can also occur with withdrawal from nicotine, and from other drugs of abuse. The basis of nicotine addiction is a combination of positive reinforcements, including enhancement of mood and avoidance of withdrawal symptoms (Fig. 3).The following popper user interface control may not be accessible."

    That's not really an advertisement for everyone taking it up, but quite a strong rationale for continuing once established as a user. This is the main reason to believe that e-cigarettes will ultimately prevail - even if regulators slow down progress and limit the opportunities, leave millions harmed in their wake.

    1. <...with the qualification that this is a compromise: "whilst it would be better to quit completely, these products can reduce harm to those who cannot or will not quit".>
      Just a random thought -- I wonder if I can pull off using "whilst". What a great word. I already insist on using the sensible British styles of putting the punctuation after the close-quote when it is not part of the quotation (much to the annoyance of a few of my colleagues) and using plural verbs for groups of people, so maybe I will give it a try!

      I would argue that even that intelligent anti-tobacco party-line on nicotine (as exemplified by Benowitz) is unsupported and certainly over-generalized. How could anyone know that the benefits are caused substantially (let alone primarily) by relief from withdrawal symptoms? One apparent answer is to let abstinence continue long enough that anything that can sensibly be called a withdrawal symptom is gone, and then see if someone gets the benefits again from using again. And we know that in many such cases, the answer is "yes they do", putting the lie to the party-line claim.

      The party-line response to that (among those few in the anti-tobacco party who actually think and read, and thus ever respond to anything) tends to be some claim about use creating a permanent change that necessitates further use to get back to what would have been baseline. But if you talk to many users, they will testify that the benefits they get are the same ones that they got when they first started using, so this is apparently wrong also. The party-line basically just reports an input assumption as a conclusion: "Assume that nicotine/tobacco has no real benefits; observe that people testify that they are getting benefits; but since there are no real benefits, these must be just relief from withdrawal or long-term harm that nicotine can relieve; since all the supposed benefits are just relief from withdrawal, etc., then it must be that there are no real benefits, proving our original point!"

      Of course, It is quite possible that for some people, the withdrawal symptoms are the only thing keeping them using. In such cases, abstinence would be better. But what passes for research is so clearly wrong about so much (including what I noted above and more) that it is impossible to take it seriously. The party-line is that this is *everyone*, when it is clearly not. So even trying to conclude, from that same research, that it is *anyone* seems rather tenuous.

    2. I agree with you... the distinction between reward and release is quite hazy. I don't think it is that different to other lifestyle drugs. How often do you hear "I can't function in the morning until I've had a decent cup of coffee"? Benowitz is careful to acknowledge positive reinforcements as well as relief from withdrawal - and doesn't give primacy to one or the other. For people already using nicotine, the distinction doesn't matter that much anyway. It would be a problem only if there was continual increase in tolerance and ever greater doses need for the effects - but I don't think that is the case. Or if the use of the drug itself was disruptive to normal living - but nicotine is not an intoxicant.

      (BTW - it's a great posting).

    3. Thanks.

      Following down the tangent: I have not yet written about this, but I have experimented with nicotine use to try to better understand the experience. (And I use the word "experimented" properly -- not in the derogatory sense that basically means "played with" that appears in discussions of youth "experimenting" with drugs.) The clear upside of this is that it gives much better data about what is entirely a subjective experience. The clear limit is that it can only produce data about a single body and mind, and so extrapolation is limited; however, it still serves as an existence proof and provides some deeper insight into the experience.

      Results: Significant increased tolerance observed, but it seems to plateau and to reverse with non-use. This is more mildly disappointing than anything else -- it requires more product to get the same (very positive) effects. No withdrawal symptoms occurred. With decades of experience in a steady adult state, it seems pretty clear that a lack of dosing just returns me to baseline. Nothing that seems like it should be called "addiction" observed. After acquiring an appreciation for the positive effect, I obviously want to get that effect, but I cannot find anything about this that is different from, say, discovering a park I like to visit and wanting to return to it. No disruption to normal living observe (obviously).

  3. Great post, Carl. One point that I would like to underscore is that the "benefits" are not simply the medicalized benefits like improved cognitive performance, but, perhaps more importantly, the consumer/market benefits of things like flavor and enjoyment that can only be quantified as improved quality of life. Some people enjoy most/all the benefits of a good cup of coffee to start their day, even when that cuppa is decaffeinated. Likewise, many e-cigarette users are quite satisfied with 0-nicotine vaping, and it is quite a stretch to regulate something as a medicine when it continues to serve its primary purpose even when there is no "active" ingredient.

    The similarity to coffee is not simply the chemical similarities between caffeine and nicotine (and that it they can be used without either), but even in the mechanism itself. Because e-cigarettes vaporize liquids, they only get about as HOT as a cup of coffee. Flavor and "presentation" (ie. what the actual cup/vaporizer look like) become far more important, and the actual strength or physiologic effects are secondary factors that aren't even necessary for all users.

    Focusing too much on the "harm reduction" aspect, or even the "tobacco" aspect also misses many of the biggest risks or harms related to smoking: Fire. Even Anti Nicotine & Tobacco Zealots will admit to using the catchphrase "the only safe cigarette is one you don't light on fire". Without the fire, there is no "tar"--tar is just the industry term for the sticky conglomerate of partially burnt tobacco alkaloids; but not only that, but other things such as fire hazards and lingering odors are all direct results of the process of combustion. It doesn't really even matter WHAT you light on fire and inhale the smoke 100's of times per day, it is the fact that you are lighting something on fire and creating smoke that presents nearly all of the measurable risks that cannot even be reasonably be compared to products that aren't. Comparing smoking to vaping isn't as close a relationship as apples to oranges, it is comparing military-grade assault weapons to laser tag. Might one "renormalize" the other? Uh, the very question is missing the entire point.

  4. I don't agree with Benowitz for the same reason that CVP outlines; and in addition, account needs to be taken of the fact nicotine is a normal dietary ingredient that a percentage of the population may need to supplement. There are many interesting subjects for research here: for example, are there some populations globally that do not ingest nicotine in the diet and have no dietary substitute; how do their cognitive function scores equate, on average; and so on. In the past, all clinical trials showed that every person tested was positive for (dietary) nicotine; perhaps this will no longer hold true, as diets get worse. Indeed it might be part of the problem (some people may need nicotine).

    I expect the CDC will continue to try and conceal their test of 800 people that demonstrated everyone tests positive for nicotine until such time as they can show that many people don't. What they won't test, at that time (I'll bet), is comparative cognitive function between nic-pos and nic-neg subjects.

  5. I wonder if you chaps are over-complicating the matter? Here's the simple version.

    A few years ago, ecigs appeared. Few people used them. The charlatans, who took over Tobacco Control a couple of decades ago, decided that ecigs were 'small beer' of no significance. They declared ecigs NOT to be 'smoking cessation devices/aids' and insisted that they should not be so described.
    Recently, the use of ecigs has burgeoned. The charlatans have therefore decided that ecigs ARE 'smoking cessation devices/ aids' and have got their wordsmiths to issue statement after statement describing them as such in order to drill that 'fact' into the public mind. Since ecigs ARE now 'smoking cessation devices'aids', they must be medicalized. What better way than to have them declared to be medicines? Charlatans in charge of a monopoly? What easier way is there to make tons of money?
    Can you remove the charlatans? Could you get together hundreds of scientists (or better still, thousands) and have them sign a declaration that shs science is junk? Could you produce a list of people working in tobacco control who have come from advertising, the media, marketing, big pharm and such?
    It surprises me how difficult people in and around tobacco control find it to say the word 'pleasure'. If people who gain pleasure from smoking tobacco decide to try to stop smoking tobacco and switch to ecigs, they will only succeed in giving up the pleasure of smoking tobacco if the pleasure of an ecig is sufficient. That is a good enough reason for the authorities not to interfere in the ongoing development of ecigs.
    A couple of decades ago, I gave up smoking purely as a act of will. I did not touch a cigarette for 12 months. When I decided to start again, that first cigarette was WONDERFUL!

  6. Very interesting post.

    Some of this analysis has hazily occurred to me, particularly as I've been drafting letters to representatives about the MHRA decision and the EU TPD. I find it easiest to stick to the THR approach - it's hard enough to explain even this without going on for pages and pages, such is the sticking power of the "mainstream" views and misconceptions. But I have had vague notions that in sticking to the THR arguments I'm actually leaving some loopholes open.

    I'm reluctant to go down the full "harmless enjoyment of a consumer product" route, for fear of alienating the people I'm trying to inform.

    One curious effect I've noticed in myself is that the idiocies disseminated by the ANTZs actually affect my own feelings about my own nicotine use (through e-cigarettes) - in a way they wouldn't intend! Perhaps, if I was just left in peace, I might gradually cut down my nicotine consumption. (But, perhaps not). As it is, the insults to my intelligence I hear in the name of tobacco control are all too liable to make me harden my position: I feel like going on enjoying nicotine, and shouting loudly that it's not a THR product, I'm not intending to give up - no, it's a damn DRUG, and I'm damn well ENJOYING it! Just to annoy and frustrate the ANTZs.

    May seem like a childish reaction. But perhaps I'm not the only one who reacts like this? In the spirit of the recent study claiming that 9/11 caused additional "terrorism-related smoking", perhaps a study could be commissioned on additional smoking caused by irritation at obviously false anti-tobacco propaganda?

    1. Thanks for the reply. Several very interesting points.

      I agree that much of the time -- probably most of the time we are making arguments -- it is good to stick with the pure HR arguments. But you seem to have come to the same approach as me, of trying to leave loopholes to at least feel a little better about doing that. Unfortunately as I noted, my own way of doing that is probably far too subtle and so really only exists in my own mind.

      I like the observation about backlash to the ANTZ. In some sense, it is almost identity politics. I personally don't think my thoughtful decision to use low-risk tobacco products is actively influenced by backlash, but one can never be too certain of such things. But I do know for sure that I am pleased to be part of the small group who has figured out that this is a good choice to make. Kind of an "early adopter" thing. I expect that in two decades, at least a quarter of the population that would not smoke if that were the only choice will be regular nicotine users.

      This circles back to some of the theme of this post. The ANTZ find that such a horrifying thought that they would kill lots of smokers in order to delay it happening (for delaying it is all they can do). Anyone who cares about people's welfare or about ethical rules, on the other hand, would see that choice as beneficial, or at least nothing anyone should be interfering with.


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