There is an old Platonic conceit that, since the advent of technocratic administration, has been blissfully forgotten: Prior to office, statesmen should develop an appreciation of the need for philosophic approaches to governance. The prescriptions we have grown so accustomed to, striking only in their formulaic sameness, as if our civil servants all graduated from the same GE training program, would have struck our ancient counterparts as insufficiently nuanced to deal with present social ills. Of course, another modern innovation is the “caring hand” of the free market, which, by some accounts, suffices to correct—or affirm—social dynamics, be they base or noble.
Each of these approaches—the caretaker approach of Big Government and the unfettered free-market approach favored by Big Industry—is incomplete; each fails society, usually by way of unintended consequences, which can sometimes cause widespread harm. Nowhere are these miscarriages more evident—or more destructive—than in the healthcare policy space, where (and all due apologies to Cass Sunstein) even paternalistic “nudges” can jeopardize the health and lives of large populations.
So let’s take a little time to reflect on the genuine difficulty faced by policymakers when deciding what government should and should not do in public health interventions, through the lens of one particular healthcare problem: smoking. We are not so much interested in solving this particular issue as we are in reorienting the way policymakers think about and address these kinds of problems in the future. Still, the example is a useful place to start.
Cigarette addiction is complex in ways not unlike many other policy quandaries. There exists, whether policymakers wish to acknowledge it or not, a fundamental tension between the liberty we are each granted to purchase and consume a legal product and the reality that the product we are ingesting is deadly and addictive. Recall Michael Bloomberg’s so-called Soda Ban, which would have limited soft drink sizes in New York City in an effort to curb harmful calorie consumption. Cigarettes, like soda or alcohol, are here to stay, and, within certain restrictions, we are free to consume them.
But cigarettes won’t be facing legal extinction anytime soon, so legislators find themselves at an impasse. How best to stamp out the scourge? Higher taxes? Flavor bans? Higher age requirements? More robust verification systems? Education and cessation campaigns? Class-action lawsuits? Smoking bans? E-cigarette bans? We can go on and on. What is important to see is that behind each of these “solutions” lies a belief that, given the correct adjustment, it is only a matter of time before we legislate a smoke-free world into existence.
To which we ask: “How’s that working out?” Smoking rates are declining, yes. For now. Will they fall much further? How long to wait before attempting another tweak to the system? Instead—and this involves the reorientation alluded to above—perhaps it would be best to take the world as it is and embrace a different approach to our smoking crisis: one that does not aim for the impossible but seeks rather to tailor solutions to individuals and communities, abstaining from one-size-fits-all prescriptions.
This approach is called harm reduction. It’s intended to decrease the negative consequences associated with risky or dangerous behaviors, automobile safety being an obvious example. Driving is inherently risky and seat belts and air bags make it safer. They don’t do anything to reduce the frequency of car crashes, but they do reduce their lethality. Perhaps we should apply this logic to other behaviors, even if we don’t like or agree with them?
Just as policymakers would be well-advised to take the world as it is, public health functions best when it takes people as they are. This is one of the main pillars of harm reduction—that people are, whether the government likes it or not, in charge of their destiny, and thus will simply decide what is “right” for them, irrespective of external forces. Harm reduction uses our natural egoism by working with, instead of against, habits or prejudices. It recognizes there is no one-size-fits-all, abstinence-only solution that works for everybody, and that the stigma associated with risky behaviors are a major barrier to care. Agree with the behavior or not, public health goals are more achievable when harm reduction approaches complement prevention and treatment. It doesn’t have to be one or the other.
That harm reduction policies work is clear. One only has to point to the many studies demonstrating the benefits associated with, say, safe injection sites to notice a decrease in infectious disease transmission, reductions in overdose deaths, and improvements in overall health. Between 1991 and 2001, seven government studies concluded that syringe access programs had decreased HIV transmission without increasing illicit drug use. Today, users who utilize clean syringe services are more likely to access treatment programs, pointing to another overlooked benefit of harm reduction services: providing another point of intervention for people who might not otherwise connect with health services.
Time has shown these approaches are not only wildly successful in their primary objective but also enormously cost-effective. In 2008, Washington, DC allocated $650,000 to increase harm reduction services, including syringe access. It was estimated this investment has already averted 120 cases of HIV, saving $44 million. As of 2014, there are over 200 syringe access programs (SAPs) operating in 33 states and the District of Columbia. Tellingly, in 2016, the Federal ban on providing funds for SAPs was partially lifted. Money can now be used to pay for salaries and overhead costs associated with distribution of sterile syringes, but cannot be used to directly pay for them.
Still, focusing too much on numbers can obscure important questions. For instance: Under a policy of harm reduction, when is coercion an appropriate tactic for moving people to safer behaviors? Who benefits from harm reduction? In what way is this policy strategy better or worse than the competing alternatives? Finally, should it matter if corporations profit off the relevant interventions?
To answer these questions, it is helpful to examine programs aimed at opioid harm reduction, first pioneered in Europe. Following an outbreak of Hepatitis B Virus in Edinburgh a pharmacist believed that providing sterile syringes could help stop the spread of infection by reducing needle sharing. Around the same time, in 1982, the first official syringe access program opened in Amsterdam.
Here in the United States, the first pioneer of needle distribution, Jon Parker, risked jail time and high fines to reduce the risk of infectious disease transmission among injection drug users in New Haven and Boston. Making such programs accessible was not an easy thing to do, but was considered well-worth the effort among public health activists who witnessed the positive effects. Soon, underground SAPs cropped up in Tacoma, San Francisco, Seattle, and Portland, all with some degree of public acceptance. Three years after Jon Parker went rogue, the country’s first legal SAP opened with endorsement from the New Haven Department of Health in 1989. Soon, syringe exchange access would expand across America and Europe.
Of course, none of this was easy, and there were many legitimate reasons to be wary of harm reduction as applied to drug use. Would this be viewed by segments of the public as a tacit approval of drug use? Would it encourage experimentation among those who had never tried drugs? Most importantly, would it discourage people from seeking treatment for addiction?
Fortunately, there is little evidence to support the fears that stalled the initial programs. Indeed, decades of evidence now allow us to conclude that the scary outcomes of harm reduction approaches to illicit drug use were unfounded. Today, harm reduction services intended to reduce transmission of HIV among injection drug users and reduce overdose deaths among opioid users are often executed at the blessing of public health officials and agencies.
Cigarettes: Old Battles, Same Results
First introduced in 2006 by a pharmacist in China, e-cigarettes evolved over the last decade or so to give smokers an alternative to the deadly cigarettes to which we have all grown so accustomed. The first-generation e-cigarettes, however, weren’t so effective, delivering too little nicotine to prove satisfying to the average smoker. But today, just as the quality and utility of cell phones have finally allowed us to ditch their inconvenient predecessors, e-cigarettes are finally good enough to relegate combustibles to landline status. Sure, some people will continue to ride with the Marlboro Man. But at last count, 68 percent of people who smoke expressed a desire or intention to quit within one year. Unfortunately, this desire is a difficult one to achieve, with one-year success rates consistently below 10 percent. Couple that with the boredom, loss of work breaks, and even the loss of identity that accompanies quitting (let’s please acknowledge there are some things about smoking that people like), and it seems obvious that harm reduction policies should be allowed to succeed where alternatives like patches and outright bans have failed.
E-cigarettes are undeniably safer than combustible cigarettes and there is robust evidence of improved health outcomes for those who switch. In its comprehensive report, Public Health England stated that e-cigarettes are unlikely to exceed 5 percent of the risk associated with combustible cigarettes; the American Cancer Society has conceded that vaping is better than smoking cigarettes; and the Office of the Surgeon General has recognized nicotine products exist on a continuum of risk, with e-cigarettes, Snus and heat-not-burn technologies at the lower end of the spectrum. The reason these products present a reduced risk is because they don’t employ the traditional cigarette combustion process that release 7,000 chemicals—some of which are highly carcinogenic—into the lungs of the smoker.
Moreover, it has been demonstrated that chronic obstructive pulmonary disease (COPD) patients who switch to e-cigarettes have improved COPD symptoms demonstrated by decreased exacerbations and improved exercise capacity. In addition, e-cigarettes have positive effects on hypertension. Switching from combustible cigarettes to e-cigarettes is associated with a significant reduction in blood pressure. It is therefore no surprise that e-cigarettes are estimated to have the potential to save up to 6 million lives by 2100 if only 10 percent of current smokers switch to e-cigarettes over the next 10 years.
The Food and Drug Administration (FDA) has taken notice of their potential and once upon a time there was promise that e-cigarettes and other “reduced-risk” products such as heat-not-burn technology and certain oral smokeless products would be able to displace our beloved smokes. In 2017, then-FDA Commissioner Scott Gottlieb made reduced-risk products like e-cigarettes central to the FDA’s roadmap, shifting the focus from cigarettes to what can be done with nicotine. Here is Gottlieb explaining the agency’s thinking last year:
While it’s the addiction to nicotine that keeps people smoking, it’s primarily the combustion, which releases thousands of harmful constituents into the body at dangerous levels that kills people. This fact represents both the biggest challenge to curtailing cigarette addiction—and also holds the seeds of an opportunity that’s a central construct for our actions. E-cigarettes may present an important opportunity for adult smokers to transition off combustible tobacco products.
This promise of a new future of tobacco encouraged those who believed in it to consider a flurry of nudges to encourage people to switch. But now, in response to a youth epidemic of nicotine use, the FDA has proposed a series of restrictions that will almost certainly lead to the demise of the e-cigarette industry. Gottlieb’s surprise resignation as FDA Commissioner in March may change that trajectory; his proposed regulations have attracted their share of blowback from industry lobbying groups and Republicans in Congress. But for now, the proposed rules are still on a glide path to policy.
Under the new regulations, any store accessible to all ages, like your local 7-11, must have a sectioned-off, age-restricted area for flavors if they intend to sell e-cigarettes (or just age-restrict the entire store). Moreover, the FDA has slowed down the approval process for flavored products, such that it will be much harder to find fruit and dessert flavors in stores. This might sound like great news to a parent who worries about their child experimenting with tutti frutti or mango tango, but adult vapers overwhelming prefer those flavors to tobacco as well. That will reduce the appeal of e-cigarettes relative to tobacco, which means more people—adults and children—will end up smoking the latter.
We should be very clear on this last point. If the FDA, state legislators, or any other governing body with power to excessively tax or ameliorate e-cigarettes has their way, and e-cigarettes go the way of the dodo, or flavor-restrictions are popularized, we will see a corresponding rise in combustible cigarette use. With nowhere to turn, smokers who can’t quit will be forced to stick with what is accessible. And if the “nudging” turns to shoving and cigarette bans begin to crop up, get ready for a corresponding rise in black markets.
However, if legislators and the public are seriously interested in affecting positive, lasting health outcomes, methodical, empirically measured harm reduction strategies should at least be given a chance to work. We hope, like clean syringe use initiatives in their infancy, the scare-mongering about e-cigarettes and the willful ignorance about tobacco harm reduction will eventually abate. Until that time—until leaders embrace rational, fair policies grounded in a realistic understanding of human nature rather than utopian schemes—people will stay hooked and continue to die.