Nicotine Is a Great Fucking Drug, Part 2: It's All in the Delivery

There’s an analogy here. 

This post, the second in a series, is in response to a remarkable New York Times article called, “A Lesser Warning? Maybe,” about the efforts of Swedish Match (SM) to get the U.S. Food & Drug Administration (FDA) to approve a warning label for SM’s snus tobacco product that states it is less harmful than cigarettes, a move toward social harm reduction I am thoroughly in favor of.

For millennia, indigenous people in South America have chewed coca leaf preparations. To this day, its use is widespread—and legal—in many parts of South America. Coca leaf contains small  amounts (well under 1%) of the psychoactive substance that, in its highly refined state, we know as cocaine.

But chewing coca leaves is a very different proposition from using cocaine. First of all, while snorting it can deliver the full potency of cocaine within 15 minutes, chewed coca takes much, much longer—as much as three hours—to deliver the full effect of its much lower potency.

Second, the effects are much different. Coca leaf provides a mild stimulant buzz, and has analgesic and appetite suppressant effects. I’ve read speculation that it was a key factor enabling indigenous people in the Andes to survive a life of hard toil and poor nutrition while breathing the thin air of a high altitude environment. Supposedly (I’m relying on Wikipedia here), when a longtime user stops chewing coca, he doesn’t even go through withdrawal symptoms.

On the other hand, cocaine almost instantly delivers a strong brain buzz, and, as is widely known, turns people into amoral gibbering idiots. And it is notoriously addictive, while at the same time creating a tolerance in users that forces them to use more and more to achieve the same effect.

Finally, by my rough calculations, it takes 1000 grams (1 kilo) of coca leaf to make 1 gram of cocaine.

So, coca leaf versus cocaine. A relatively benign application of a naturally occurring stimulant, versus a perverse, life-wrecking unnaturally concentrated use of the same substance.

Where am I going with this?

Cigarettes are to tobacco as cocaine is to coca leaves.

Though, granted, tobacco in its more naturally consumed forms was already more toxic than coca leaves. Though tobacco use was widespread for centuries before cigarettes, people knew that it made some users unhealthy, and even killed them. Still, over those many generations, the vast majority of tobacco users achieved moderate effects from moderate use, at minimal risk.

Then cigarettes changed everything for the worse. They did this mainly by combining two factors: first, they provided a faster, stronger jolt of nicotine than any other popular form of tobacco; and, second, they greatly concentrated the most harmful and addictive aspects of smoking tobacco.

Prior to cigarettes, most tobacco smokers didn’t inhale tobacco smoke; nicotine was absorbed through the mucous membranes in the mouth (as it is with smokeless tobacco). That changed with cigarettes.

Aside from non-lethal doses of nicotine, cigarette smokers inhale the deadly byproducts of tobacco combustion, which contribute to human mortality in a variety of ways. Furthermore, to increase the appeal and sales of cigarettes, tobacco companies used processes and additives that reduced the harshness, but not the lethality, of tobacco smoke. So users could smoke more cigarettes and get more nicotine—while also exposing themselves to much, much more toxicity and risk.

Like cocaine, cigarettes are a perversion of a naturally occurring psychoactive compound that had been used for centuries by millions of humans. In the case of tobacco, while health risks were not unknown, users balanced those relatively low risks with the enjoyment they got from nicotine.

Now, as exemplified by the Swedish Match effort described in the Times article, some are arguing that it’s time to stop trying to prevent humans who want nicotine from getting it. Rather, they say, it’s time to recognize that people who want it will get it no matter what, and that the best way to counter the horrible individual and societal effects of smoking is to privilege less harmful methods of tobacco delivery.

Swedish Match wants the right to say on their packaging that their snus smokeless tobacco product is less harmful than cigarette smoking, which it undoubtedly is. The testing that has been done to date (which pretty much everyone admits is not sufficient) seems to show that it is much less harmful than American-style smokeless tobacco.

But here’s something else I learned from the Times article. We’ve all heard how dangerous American smokeless tobacco is, about how it greatly increases the risk of oral cancers. What we haven’t heard (or at least I hadn’t), is that the risk of oral cancer from using smokeless tobacco is half of that from smoking cigarettes.

That’s right. Cigarette smokers get oral cancer at twice the rate smokeless tobacco users do. Want to immediately cut the incidence of oral cancer in the U.S. in half? Create strong incentives for smokers to start dipping snuff. Yes, they will be twice as likely as non-tobacco users to develop oral cancer, but they will be half as likely as cigarette smokers. Not to mention they will completely eliminate the risks associated with inhaling the other, non-cancer causing lethal byproducts of combustion, like those that cause emphysema and cardio-obstructive pulmonary disease, by which cigarettes kill more people than cancer.

Now back to snus. Snus is made in a way that actually reduces nitrosamines, the heavily carcinogenic compounds in tobacco. So it’s even less risky than smokeless tobacco. (By the way, I’m not advocating the use of American-style smokeless tobacco. First, it’s a disgusting habit that’s really tough to kick. Second, it carries other risks, like damage to the teeth and gums. Third, as discussed, there are less harmful alternatives.)

Finally, there are e-cigarettes. E-cigarettes dispense with tobacco entirely. Instead, they vaporize small amounts of pure nicotine suspended in common liquid food additives that most of us consume every day. Again, the research on the negative health effects of e-cigarettes is preliminary. What are the long-term health effects of inhaling tiny amounts of glycerin vapor? We don’t know. But based on present knowledge, e-cigarettes almost certainly carry much, much less lower risk than any form of tobacco, even snus.

For many (not all) people, nicotine is a great fucking drug. Decades of experience have proven societies that concentrate their efforts on getting people to stop using it in any form are on a fool’s errand.

And, as I hope I’ve shown, there are much, much less harmful ways that people can consume nicotine. Still, many in the public health community argue that reducing the harm of tobacco is, in itself, harmful.

I’ll explain why they are full of shit in the final installment.