Do Less Harm: The vapid opposition to vaping
Brown argues the federal government should do just about everything it can to discourage anyone from taking up vaping, from regulating e-cigarette production to banning flavorings. That e-cigarettes are very likely safer than their combustible cigarette cousins – that using them doesn’t involve inhaling the witches’ brew of carcinogens contained in cigarette smoke and doesn’t expose bystanders to this same exhaust – doesn’t seem to disturb him. Nor does the fact that vaping may be a successful way for heavy smokers to wean themselves from a dangerous habit.
And his position is defensible: Even the most ardent advocates of e-cigarettes acknowledge they contain the same addictive nicotine as cigarettes. Since they’ve only been in use a few years, they may turn out to cause some yet unknown long-term harm. Applying the precautionary principle, Brown appears to think it’s better to err in favor of total abstinence from nicotine rather than explore e-cigarettes’ potential to replace smoking and thereby reduce harm.
What makes this a bit unusual coming from Brown is that the Ohio progressive is also the Senate’s leading proponent of needle-exchange programs for injection drug users. In that area, he’s a big proponent of the harm-reduction approach he disdains for tobacco. In February, he introduced a bill that would provide federal grants to give clean needles to heroin addicts, while offering new treatment options.
Like e-cigarettes, needle exchanges – vehemently opposed by most Republicans in Congress – do have benefits. A comprehensive 2004 World Health Organization review found “compelling evidence” that they prevent transmission of HIV and AIDS and the U.S. Institute of Medicine found them “highly cost-effective.” Programs that pair them with social services and public injection rooms – the most studied of which are located in Vancouver, British Columbia – produce promising results. But there are legitimate questions raised about this approach, since it provides implicit public sanction for behavior that can result in death.
Brown’s mixed case for harm reduction is hardly unique. The famously left-wing college town of Ithaca, New York, which is vying with San Francisco to open the first Vancouver-style injection center in the United States, was one of the first places to ban most public use of e-cigarettes. And conservatives, who often prove friendlier to the possibility of reduced-harm nicotine, are far more likely to raise objections to other forms of harm reduction. As governor of Indiana, Republican vice presidential nominee Mike Pence put the kibosh on harm-reducing needle-exchange programs while simultaneously cutting back funding for abstinence-only smoking cessation programs. (Needle-related disease transmission rose and Indiana’s smoking rates remained above average.)
Although evidence for harm reduction as a public-health approach is pretty good, it’s difficult to find anybody, on the left or right, who is consistent in advocating attempts to reduce harm. That’s a shame. Wider implementation of harm-reduction approaches and honest discussion of their downsides both depend on creating a movement of people who take a consistent view in favor of harm reduction.
Much federal policy regarding harm reduction is incoherent. When passing a Medicare “doc fix” in 2015, Congress voted to provide $75 million for “abstinence-only” sex education in schools and another $75 million for the Personal Responsibility Education Program that emphasizes safer sex harm reduction, in other words in order to reduce the risk of disease and pregnancy. People exposed to programs sponsored by both streams of federal funding will get messages that aren’t just mixed, but sometimes directly contrary. The bill passed, 92-8.
Other harm-reduction approaches remain far outside the political mainstream, despite evidence that they could work better than existing protocols. For example, the well-known Alcoholics Anonymous model – which suggests people with alcohol problems must never drink again and must surrender to a “higher power” to keep themselves sober – has nearly universal support as a “good thing.” But the biggest ever meta-analysis on the program’s effectiveness, conducted by the Cochrane Collaboration in 2006, suggests its success rate may be as low as 5 to 8 percent. Similar self-help programs that allow moderate drinking – Moderation Management being the best known – seem to do at least as well in helping people with drinking problems.
The Sinclair Method, a regimen that uses lifetime doses of the drugs naltrexone and nalmefene to reduce the desire to drink, but allows continued alcohol consumption by its adherents, may have a success rate in the neighborhood of 80 percent. No U.S. government agency appears to promote the Sinclair Method. Its most prominent advocate remains science fiction actress Claudia Christian, best known for the 1990s television series Babylon 5.
This isn’t to say that all harm-reduction approaches are worth implementing or even exploring. Experiments with providing heroin and other opioid prescriptions to confirmed addicts in the United Kingdom during the 1960s, 1970s, and 1980s correlated with rising crime rates and higher rates of drug use across society. Even if they do benefit society as a whole, injection centers probably wouldn’t be things many homes or businesses want nearby. One major study of the drugs used in the Sinclair Method, published in the New England Journal of Medicine, showed poor results. And even these criticisms set aside the objections some may have to condoning behavior that’s clearly harmful and violates deep-seated moral precepts.
Indeed, the public-health messaging behind harm reduction is almost always going to be mixed. While needle-exchange programs exist in at least 35 states, nobody in the United States has actually legalized hard drugs. Harm-reduction approaches will rarely offer the type of moral clarity that many think is important in persuading people to change behavior.
Nonetheless, the idea of “abstinence only” appears ineffective with regard to many destructive behaviors, and much of the evidence on harm reduction appears quite promising. Moving forward with promising harm-reduction solutions – and critiquing them – would be far easier if a political movement on either end of the spectrum would actually embrace the concept consistently.
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