If there’s one crystal clear conclusion that comes out of the last half-century or so of public health research, it’s this: smoking cigarettes is both addictive and exceptionally unhealthy. People, especially adolescents, should not start smoking and anyone who does would be well advised to quit. For these reasons, from its very beginning, R Street has looked at ways we might limit the damage that smoking causes to personal and public health. In fact, our second paper ever  dealt with tobacco harm reduction issues and reviewed the research on tobacco and insurance.
Our interest in reducing the harm from tobacco also started our wider harm reduction policy focus and project. This work, headed by Dr. Carrie Wade , MPH, looks at harm reduction across the board, with a particular focus on three areas: opioid use, sexual health and tobacco use. We’ve hosted events and published work in all of these areas.
With a very disturbing cluster of sickness and death—seemingly coming from people vaping illicit THC—we think it’s important to talk about where we stand on tobacco issues, in particular, and what we, as an institution, think about vaping. People who have followed our work should find nothing new in what follows, but we thought it would be useful to put it all in one place:
- Children and teens should never use any type of tobacco or nicotine: From the time we were founded in 2012, we’ve supported efforts to raise the minimum age to purchase cigarettes and vape products to 21. The peer-reviewed literature shows this will reduce social sources of cigarettes and delay the age of initiation. This is important because it has been consistently shown that the earlier someone starts smoking, the harder it is for them to quit.
- Smoking should be denormalized: We’ve long encouraged extensions of indoor smoking bans in public places where they do not exist, and we’ve called for restrictions on vaping in schools and other places where younger people congregate. This is important not only because it reduces the risks of secondhand smoke exposure but also because it denormalizes smoking and thus creates social cues that discourage the behavior.
- Nicotine-containing products exist on a continuum of risk: The incidence of health problems between nicotine products varies a great deal. In all the studies that we know of, long-term habitual use of cigarettes produces worse health outcomes than any other tobacco or nicotine product. Smokers die younger than non-smokers by a significant margin. Long-term data in the scientific literature indicates other products, such as Swedish-style snus or cessation aids like the nicotine patch, gum or lozenge, are safer than cigarettes. And, the newest major category of products, e-cigarettes, seem to have many characteristics in common with products we know are safer: much lower concentrations of and exposure to hazardous and potentially hazardous constituents, and improved short-term health outcomes for those who switch. Furthermore, since they imitate the ritual of cigarette smoking and satisfy users in the same way, they may be a way to help smokers who won’t or can’t quit with traditional methods. As such, we think the market is worth encouraging and exploring in order to help adult smokers. Because vape products are new, however, it’s almost impossible to say that they are safe for long-term use and there’s a real possibility that such use could have health consequences that we don’t know about. We put this in the same category as our support for needle exchanges for injection drug users: it improves the safety of a dangerous behavior rather than completely eliminating its risk.
- Prevention and cessation programs work for all sorts of dangerous behavior—but not for everybody: Prevention programs have gotten us far in decreasing prevalence of smoking and will certainly result in major decreases in smoking-related illnesses as our population ages. But, we have a long way to go to reach many populations. People begin engaging in a variety of risky behaviors because they see a utility (e.g., pleasure, profit, convenience, escape or other fulfillment) in them. For this reason, simply telling people to abstain when it comes to all risky behaviors that are popular has never worked on a large scale over a large population. Indeed, it’s often counter-productive, something we see most clearly when it comes to sex education. While we’re aware that promoting options that are safer without being safe does present moral hazards, our libertarian principles and the overwhelming bulk of the data indicate that giving people safer alternatives and free choice will save and improve lives.
- The vaping-related illnesses we have seen present a serious problem that deserves a serious response: The preponderance of the evidence shows that the recent spate of vaping-related illnesses and deaths stems from illicit THC-containing e-liquids. Furthermore, none of these illnesses have been linked to legally FDA-registered nicotine-containing products. However, we should not be complacent in thinking such an epidemic couldn’t happen with e-cigarettes. It could. This calls for measured responses that ensure that safe products remain available and adulterated products are rare. FDA-enforced manufacturing standards, a temporary ban on THC-containing vapes in states where they are legal and significant investigations of the current problems could stem the tide of illness and death from contaminated vapes. In any event, the proper response should be a measured one: doing nothing is a bad idea but so is the Massachusetts’ Governor’s decision to temporarily suspend all sales of vapor products in his state.
Our positions on tobacco, nicotine and vaping are similar to the ones we take on other issues: they are pragmatic, responsible, data-informed and grounded in a philosophy of liberty.
- “second paper ever”: https://www.rstreet.org/2012/07/11/how-should-insurers-treat-tobacco-use-a-review-of-the-research-2/
- “ Dr. Carrie Wade”: https://www.rstreet.org/team/carrie-wade/