Tobacco Harm Reduction: Applying the Evidence to Policy
The nature of the 24-hour news cycle and our short collective attention span means that the media does not always present a holistic and balanced assessment of complex problems. In the case of alternative nicotine delivery systems, where every day a new report adds to the conversation, it can be difficult to keep up with the evidence. The R Street Institute’s recent Tobacco Harm Reduction: Evidence Update, summarized by RealClearPublicAffairs, provides greater context to the debate about tobacco control. It is worthwhile to consider how this updated evidence can translate to policy and what effects may result from embracing tobacco harm reduction as part of the tobacco control strategy.
First, policymakers need to recognize that tobacco control is not a zero-sum game. With the advent of alternative nicotine delivery products tobacco control can include outcomes beyond quitting combustible or smokeless tobacco products. By using an alternative nicotine delivery product, a person can now quit smoking while still being nicotine dependent. In the case of substances like nicotine and opioids, where alternative consumption methods can limit adverse health effects, policies that attempt to minimize the most harmful use patterns and associated behaviors (e.g. medication-assisted therapy or syringe exchange programs) are more pragmatic than aiming for complete elimination of use. Given the continued persistence of tobacco use despite decades of public campaigns against it, it is evident that eliminating smoking and eliminating nicotine use are two different goals.
Policymakers need to remember that not all nicotine delivery systems are created equal, and nicotine itself is almost never what kills users. People dependent on nicotine can choose from a number of products to meet their needs, some more harmful than others. Harm reduction policy recognizes that there is no one-size-fits-all solution to risky behaviors, and that abstinence may not be the goal for all individuals. Instead, harm reduction policies allow individuals access to products with different levels of risk. Policymakers then should strive to enact policies that discourage use of the most harmful products while making less harmful sources of nicotine more appealing for people who, for one reason or another, find themselves unable or unwilling to quit using nicotine.
This, of course, presents the conundrum of how to prevent people, especially young people, who do not use nicotine from beginning to use these less harmful—but not harmless—products. Striking the right balance between protecting non-nicotine users and keeping options available for nicotine users is a difficult task, but when applied to other policy areas, regulators have already demonstrated that achieving balance between competing interests is possible. Consider patent or employment law, which must balance encouraging business with ensuring fair treatment for workers and consumers. Across the country, a number of policies have been proposed and adopted to address this problem. However, most of them do little to discourage youth use while greatly decreasing options and access for established nicotine users. Bans and restrictions on quantities or physical location of sale, while intended to decrease youth initiation, have limited effects and fail to address the root causes of substance use initiation among minors.
Social influence is one of the strongest predictors of risk behavior among young people. That is to say, young people are likely to do what their friends and family members do. There is no single policy intervention that will remove this risk factor. But policies that make obtaining age-restricted products from social contacts more difficult and those that create significant penalties for merchants who violate minimum age of purchase laws are powerful tools. For example, increasing the minimum age of purchase for tobacco products to 21 is a policy solution that reduces the likelihood that a teenager will have social contacts who can legally buy tobacco products, which decreases availability and therefore peer exposure to the behavior. Of course, minimum age of purchase laws are only effective if merchants know they will be enforced.
Perhaps the most important thing to remember when considering tobacco control initiatives is that policies that impact only alternative nicotine delivery systems and exclude the most harmful ways to consume nicotine—combustible tobacco products—are shortsighted. The Tobacco Control Act, signed in 2009, prevents the FDA from banning or requiring the total elimination of nicotine from combustible and smokeless tobacco products. However, it does not prevent states from prohibiting or restricting the sale and distribution of tobacco products. The current push to ban or severely restrict sales of alternative nicotine delivery products while leaving cigarettes untouched is the antithesis of harm reduction policy and discourages adult tobacco users from trying or switching to less harmful products.
History tells us complete prohibition of addictive substances has harmful consequences: Consider marijuana or alcohol. However, history also provides lessons in using policy to minimize harmful effects for users and non-users. As public health professionals and policymakers, it is our job to encourage individuals to make choices that protect their health and the health of their communities. While a world free of tobacco related illness and death is a worthy and important goal, harm reduction strategies, combined with other tobacco control tactics, provide a pragmatic path forward that does not leave behind current smokers.
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