The Prohibition-era of the 1920s and early ‘30s and the War on Drugs of the last 50 years show that outright prohibitions and bans on alcohol and drugs of all kinds fail to curtail use of the banned substance. Despite this historical evidence, many modern advocates are attempting to ban nicotine and tobacco products from sale and use - ostensibly to “save the children” from nicotine addiction. However, former leaders of the nation’s leading scientific organization dedicated to the study of nicotine and tobacco are attempting to remind us of history’s lessons: bans don’t work, but a measured, evidenced-based, harm-reduction strategy will.
In an article published just last month in The American Journal of Public Health, 15 past presidents of the Society for Research on Nicotine and Tobacco urge us to follow the science on tobacco harm reduction. Tobacco harm reduction is a strategy wherein we steer smokers away from more harmful combustible cigarettes and cigars toward less harmful nicotine alternatives, like vaping devices, SNUS, or patches. By helping people switch, often as a first step on the road to quitting entirely, we can immediately reduce the negative public health impacts associated with smoking.
A large and diverse group of public health officials have come out in support of e-cigarettes and other tobacco and nicotine products that are not burned (like cigarettes and cigars) as effective means to move smokers at the highest risk for serious disease and death from combustible products to less risky products. The UK’s eminent Royal College of Physicians estimates vaping is 95 percent less harmful than cigarette smoking. And a study published in the New England Journal of Medicine showed e-cigarettes were nearly twice as effective for smoking cessation as traditional nicotine-replacement therapy and cold-turkey attempts.
As the 15 past SRNT presidents note, this strategy helps us avoid the pitfalls of less complicated, more emotional appeals focused solely on the prohibition of tobacco products. History has taught us that not only do bans fail to prevent use, they also create a litany of additional problems that plague society: racial discrimination in enforcement, increasing financial incentives to move products to the black market, and even increased use of these products by youth who find easy access to illicit sellers not concerned with checking IDs. The article asks us to look no further than EVALI, the lung disease that occurred in 2019 that was erroneously attributed to nicotine e-cigarettes: within months of the identification of the outbreak, the CDC determined that it was caused by illegal marijuana e-liquids cut with Vitamin E acetate - a result of marijuana prohibition.
Armed with that knowledge of history, policymakers across the country have begun turning to the more successful approach of harm reduction in other public health crises, particularly the opioid epidemic. For example, earlier this year, Rhode Island created a two-year pilot program that would make the nation’s first opioid harm reduction centers (also known as overdose prevention sites or supervised injection facilities). And President Biden’s initial drug policy proposal is heavily focused on harm reduction policies, directly mentioning the phrase twelve times.
Unfortunately, harm reduction for smokers has not gotten the same traction. The same day the Rhode Island House passed the opioid harm reduction centers bill with flying colors, a committee of the same body heard public testimony on a bill prohibiting the sale of flavored tobacco products in Rhode Island; legislators comments against tobacco harm reduction revealed inadequate understanding of harm reduction in the tobacco context.
More than 34 million Americans smoke today, and cigarette smoking is the number one preventable cause of death in the United States, killing more than 480,000 Americans per year. These adult smokers need constructive approaches to improve their health going forward. Policymakers at the state and federal levels should look to the success of harm reduction policies in other public health crises and put away their blinders on tobacco and nicotine products to create a successful tobacco harm reduction strategy. The publication of the AJPH article lays out a roadmap to innovative thinking on tobacco and health for youth and adult smokers.
• Dr. Michael Madden is a family physician and former chief medical officer of a multistate Medicaid health plan. He advises RAI Services Company on tobacco harm reduction strategies.
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