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.