Nicotine Is a Great Fucking Drug, Part 3: Where's the Harm in Harm Reduction?

 

This post, the third and final installment 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.

I hereby nominate Hon Lik for the Nobel Prize in Medicine.

Hon who?

Hon Lik is the Chinese pharmacist generally credited as the inventor of the modern e-cigarette. Hon was a former smoker himself and his father died of emphysema caused by smoking.

Cigarette smoking, by far the most common form of nicotine consumption, imposes enormous costs on every society where it is present, which is most of the societies in the world. And when I say enormous costs, I mean real money. Huge healthcare resources are devoted to treating smoking-related illnesses. Not to mention the loss of productivity due to those illnesses. Not to mention the personal grief of everyone who loses a loved one to smoking-related disease.

If there was a worldwide movement (led by the World Health Organization, perhaps), to move nicotine users from traditional cigarettes to Hon’s e-cigarettes, enormous benefits would ensue, almost instantly. Such a move would deliver the single greatest positive impact to world health—ever. Because, again, the problem is not that billions of people are addicted to nicotine. The problem is that most of them get their nicotine from the most harmful nicotine delivery mode available—cigarettes.

Promoting an activity that carries less risk over a similar activity that carries more risk is called harm reduction. E-cigarettes and tobacco-based snus are considered modes of harm reduction for nicotine consumption because, while not adequately studied yet and not risk free, they are, with a near certainty, far less risky than cigarettes, and the relative risks are probably not even close.

Yet, there are plenty of health advocates who want to see these products banned (along with cigarettes and all tobacco other products), or want them to be sold with warnings as stringent as those on cigarettes, along with tax levies that equally discourage their use.

So, according to these public health advocates, what’s the harm in harm reduction? Their arguments will probably be familiar to you:

  1. Addiction = bad

  2. Any activity that is less harmful will get more people to try it than an equivalent activity that is more harmful

  3. Anything pleasurable that is less harmful will always be a “gateway” to something similarly pleasurable but more harmful

These three tired arguments potentially stand in the way of a solution to what for decades has been an intractable health problem, a problem that is still growing rapidly in the developing world. Let’s call bullshit on each of these in turn, shall we?

Addiction = bad. Really? Have you been to a Starbuck’s near a high school recently? You’ll see a lot of minors there who are addicted to caffeine. In fact, underage kids can and do buy energy drinks laced with loads of the stuff. And I’m not aware of any age restriction on the purchase of any form of caffeine, even caffeine pills like No-Doz.

Personally, my addiction to caffeine is way more acute than my addiction to nicotine. By that I mean when I don’t have coffee in the morning, by the afternoon I have a wicked headache. Honestly, more than any other reason, avoiding that headache is why I drink coffee every morning. And it is very easy for me to overdose on caffeine by drinking a littl too much coffee, making me feel terrible—itchy, twitchy and ready to pull my skin off. I don’t have these problem with nicotine.

This all just goes to say that we’re irrationally selective in applying the addiction = bad argument. Alcohol is the other primary example. We know for a certainty that a huge amount of alcoholic beverages are consumed by alcoholics (i.e., alcohol addicts), at a huge cost to our societies. We’ve accepted the use of many addictive substances for centuries. People love ‘em, and they are gonna have ‘em.

The reasons for this kind of hypocrisy are way too convoluted for me to explore here. Suffice it to say that while acknowledging that nicotine is wickedly addictive, we must also acknowledge that modes of delivery aside, other wickedly addictive psychoactive substances are far more dangerous in an of themselves, and far more readily tolerated. So saying nicotine is bad simply because it’s addictive holds no water.

Let’s de-bullshit the second argument, that any activity that is less harmful will get more people to try it than an equivalent activity that is more harmful. Now, I could poke logical holes in that argument. But I won’t. Instead, I’ll wave the white flag and say, OK, you got me. Let’s assume it’s 100% true that making nicotine products with vastly reduced risks equally as accessible as cigarettes will get more people to experiment with nicotine, and get more people addicted.

My response to that is, So what? If we don’t care that people get hooked on caffeine, why do we care that they get hooked on nicotine—a drug enjoyed by billions over centuries—provided they consume their nicotine in a way that carries the least amount of risk to themselves and our public health systems?

Well, that brings us to the third bullshit argument: Anything pleasurable that is less harmful will always be a “gateway” to something similarly pleasurable but more harmful.

This is bullshit for many reasons. It has been proven false with illicit recreational drugs. The vast majority of people who try marijuana never try hard drugs. The vast majority of people who become regular users of marijuana don’t become regular users of hard drugs. On its face, there is simply no logical or statistical support for this argument.

Secondly, why would someone who gets hooked on nicotine through snus or e-cigarettes have any motivation whatsoever to switch to conventional cigarettes? Having used all three products, I can attest that cigarettes are far more noxious than the other two, without conferring significant advantages over them. This rationale for the gateway argument chases its own tail.

Think about it. The anti harm reduction folks say that if we openly acknowledge that some nicotine products are less risky than others, more people will try nicotine via those less risky products. So, why, if they come to enjoy nicotine and develop a dependence on it via those less risky products, would they switch to the more risky mode of consumption that inhibited them from trying it in the first place? Does that make any sense? Anyone? I drink about 16 ounces of coffee every day. It does the job for me. I have never once been tempted to crush up and snort a couple of No-Doz.

However, there are policies that could make this “gateway” argument more true. And, ironically, these self-fulfilling policies are being advocated by the anti harm reduction, absolute nicotine prohibitionists. Those policies would impose stringent restrictions and levies on less harmful forms of nicotine that are equivalent to those imposed on cigarettes.

Get it? If you say they are all equally bad, you remove any inhibition to move from a less harmful kind to a more harmful kind. And if you tax less harmful and more harmful forms equivalently, you also remove or weaken any financial inhibition against moving to the more harmful form.

I sincerely believe that what policy makers worldwide should do is to privilege demonstrably less harmful forms of nicotine consumption over more harmful forms. Raise taxes on cigarettes sky high and allow snus and e-cigarettes to carry warning labels that stress that while they are addictive and not harmless, they are far less harmful than regular cigarettes.  

And while they are at it, they should give Hon Lik the Nobel Prize.

Thanks for reading. You may also want to read Why Anti-Smoking Groups Should Endorse Snus and E-Cigarettes, an article on Forbes.com by Sally Satel. It was published three days ago, but I only discovered it this morning, and I haven’t read it yet, because I didn’t want her arguments to color mine, though I assume many are similar. I plan on reading it now.