To the WHO Independent High-level Commission:

We write to you on behalf of the R Street Institute, a Washington-based nonprofit public policy research organization dedicated to free markets and real solutions. Since 2013, a major focus of R Street’s research has been the exploration of harm reduction strategies that could address the millions of deaths that occur annually from tobacco and drug use worldwide. But we must recognize that abstinence approaches to drug use can only take us so far and work best when complemented by harm reduction programs.

As such we ask that the World Health Organization put an emphasis on harm reduction approaches to tobacco, alcohol and other drugs in its goal to reduce deaths attributed to non-communicable diseases.

Specific details are outlined below:

1) We ask that “other drug use” be included in paragraph 3 of the Introduction and appropriate subsequent paragraphs.

  • Opioid use and other injection drug use affect 30 million people worldwide and harm reduction approaches can reduce the incidence of communicable diseases such as HIV/AIDS and HCV, overdose deaths, cardiovascular disease and infection.[1]
  • Drug use other than tobacco and alcohol use should be included in the leading causes of premature deaths. In 2017 the life expectancy dropped in the United States – it has been suggested that this is a direct result of the current opioid crisis.[2]
  • Other drug use is tightly linked to mental health conditions such as depression.

2) We ask that harm reduction approaches are not limited to opioid and other injection drug use and include tobacco harm reduction as well. Tobacco harm reduction through access of reduced risk products represents one of the most promising ways to reduce smoking and its associated diseases in recent history.

The draft report explicitly recommends implementation of comprehensive tobacco-control programs which should include access and promotion to reduced-risk products for those who smoke. This draft also points to the “vicious cycle” that link poverty and NCDs.

  • In the United States, smoking rates among the uninsured and Medicaid recipients are double that of those with private insurance.[3]
  • Center for Disease Control shows that e-cigarette users are more likely to attempt to quit than non e-cigarette users (65% vs. 40%) and users enjoy higher rates of long-term success (4% vs. 8%).[4]
  • Modeling estimates predict that if the trajectory of e-cigarette use continues at a population level, e-cigarettes have the potential to save between 1.6 million and 6.6 million lives through the end of the century.[5]

3) We ask that the WHO recommends increased funding for harm reduction programs. Increasing access and availability of harm reduction programs is often touted as one of the most cost-effective measures that governments can take to reduce the negative and costly consequences of drug use, including tobacco use.

  • In 2000, free condom distribution programs in Louisiana, saved an estimated $33 million dollars in health care costs.[6]
  • Syringe access programs cost between $3,000 and $50,000 to prevent one HIV seroconversion–far below the estimated $385,000 it costs to treat one diagnosis of HIV.[7]
  • Naloxone distribution costs $2,500 per one year of health gained–well below the $50,000 threshold that is traditionally considered for a medical intervention to be cost-effective.[8]
  • In 2008 Washington D.C. allocated $650,000 of municipal revenue to fund SAPs; it is estimated that within 2 years this policy change averted 120 new cases of HIV and predicted a cost savings of $44 million.[9]
  • It is estimated that if one percent of current smokers switched to reduced risk products, states would save $28 billion dollars in Medicaid costs over the next 25 years.[10]

Harm Reduction International promotes a shift in 10 percent of funding from drug control to harm reduction. It is estimated that this can cover the costs of prevention and end infectious disease in people who use drugs, strengthen the networks of underserved communities, and ensure healthcare for populations that lack it.[11]

As an addiction researcher at The Scripps Research Institute I led studies that examined neurophysiological changes that occur in the early and late stages of drug use and addiction. The Scripps Research Institute continues to produce groundbreaking insights into potential treatments of addiction including vaccines that target drugs and prevent entry into the brain, deep brain stimulation that mediates compulsive drug seeking, treatments that target the stress response system that perpetuates the cycle of addiction and targeted drug delivery that prevents the initiation of addiction. Unfortunately, as is often the case, these treatments are many years away from being available and will not help everyone. One of the insipid aspects of addiction is that treatments that are efficacious in the lab or clinical setting are rarely effective in real world settings. Therefore, real world solutions must be available to mitigate the harms that accompany risky behaviors and these solutions must be promoted as appropriate and effective.



Carrie Wade

Harm Reduction Policy Director


Damon L. Jacobs

Associate Fellow and Licensed Marriage and Family Therapist






[4] S. H. Zhu, Y. L. Zhuang, S. Wong, S. E. Cummins, G. J. Tedeschi, E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys. BMJ 358, j3262 (2017).

[5] D. T. B. Levy, R.; Lindblom, E.N.; Goniewicz, M.L.; Meza, R.; Holford, T.R.; Yuan, Z.; Luo, Y.; O’Connor, R.J.; Niaura, R.; Abram. D.B., Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control,  (2017).

[6] M. R. Charania et al., Efficacy of structural-level condom distribution interventions: a meta-analysis of U.S. and international studies, 1998-2007. AIDS Behav 15, 1283-1297 (2011).

[7] Cost Effectiveness of Syringe Access Programs-Fact Sheet 2010. Harm Reduction Coalition. 2010

[8] P. O. Coffin, S. D. Sullivan, Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med 158, 1-9 (2013).

[9] M. S. Ruiz, A. O’Rourke, S. T. Allen, Impact Evaluation of a Policy Intervention for HIV Prevention in Washington, DC. AIDS Behav 20, 22-28 (2016).

[10] Belzer R., Expected Savings To Medicaid From Substituting Electronic For Tobacco Cigarettes. R Street Policy Study, December 14, 2017.