Alternative nicotine products—including e-cigarettes, lower-risk tobacco alternatives like snus, and heat-not-burn devices—have fallen under disproportionate levels of scrutiny all over the world. In the United States alone, now-former Food and Drug Administration (FDA) commissioner Scott Gottlieb—without intention, I’m sure—engineered a nationwide panic that suggests that nicotine consumption among youth through electronic delivery systems (vapes, e-cigarettes, etc.) is at endemic levels.
By consequence, policymakers and legislators at all levels of American governance find justifications to heavily regulate or promote outright bans of safer nicotine products—Public Health England estimates e-cigarettes to be 95 percent less harmful than regular cigarettes—even as combustible tobacco products remain fully available.
Due to the widely believed insinuation that vaping products are equally harmful to population-level human health as cigarettes, nicotine policiesrarely follow harm reduction approaches. This situation begs the question: What should policymakers and legislators do to respect the tenets of harm reduction when it comes to nicotine consumption?
HIV/AIDS Responses Point the Way
A key part of the answer involves learning from earlier, initially controversial but hugely successful harm reduction approaches. In particular, government officials should heed the success of harm reduction strategies in curtailing the spread of HIV/AIDS.
Abstinence-only messages were not up to the job.
For years, jurisdictions all over the US and the world have utilized risk minimization methods that limit the spread of HIV through injected drug use. According to the Centers for Disease Control and Prevention (CDC), one in 10 new cases of HIV in the United States is attributable to “injection drug use or male-to-male sexual contact and injection drug use.” But a diverse set of community health initiatives, social support programs and public policies—ranging from syringe service and condom distribution programs to educational campaigns—were developed to greatly reduce rates of new infections since the height of the US HIV/AIDS crisis. Abstinence-only messages were not up to the job.
Developed in the Netherlands in the 1970s, syringe exchange programs were conceptualized to counter a hepatitis B outbreak at the time. Other countries saw the success of this model, and many governments have since adopted syringe exchange to combat HIV/AIDS and other blood-borne diseases—despite initial and sometimes ongoing controversy. State and local jurisdictions in the US have been adopting syringe exchange programs since 1988. Today, 39 states, the District of Columbia, and Puerto Rico have them—and the federal government began funding them after a multi-decade ban was lifted in 2009.
According to a recent policy brief from the Cato Institute, among much other evidence, syringe exchange has been successful in reducing the spread of infection. A CDC analysis of 15 important studies found decreases in the prevalence and incidence of HIV and other blood-borne pathogens. A socially conservative, moralist opposition still exists, but the numbers don’t lie.
Many harm reduction policies, in theory, include drastic overhauls to criminal justice and existing health systems. Based on their 2008 study into the role of harm reduction in combating HIV infection among injection drug users, Alex Wodak and Leah McLeod argue that harm reduction strategies should lead policymakers and law enforcement authorities to adopt a “humanized” approach.
Drawing the Parallels for Our Crisis of Smoking Deaths
While tobacco harm reduction does not directly deal with intravenous drug use or HIV, the “humanization” approach from that defining period in harm reduction history is directly applicable to smoking—a public health crisis that results in over 7 million annual deaths worldwide, almost half a million of them in the US. We need to apply the principles of programs like syringe exchange to this problem.
The New England Journal of Medicine published a seminal study earlier this year which found that e-cigarettes were more successful in helping users of combustible cigarettes quit than traditional nicotine replacement therapies. But even with this evidence, and the ever-growing field tobacco harm reduction research suggesting improved health outcomes with alternative nicotine products, the stigma still exists.
As with any drug, the first step requires acceptance that nicotine use is happening, and that it’s not going to stop just because we want it to.
Standard drug policies focus heavily on law and order and the limitation of access to specific substances. Nicotine is not illicit in most jurisdictions. However, fear-based feedback loops between policymakers and the public, commonly derived from controversies associated with Big Tobacco and cigarettes being so deadly, surround non-medical reduced-risk nicotine products.
These concerns are in most cases very understandable. Yet, the concept of denying nicotine-addicted adults and youth (in some cases) access to safer products poses far more urgent concerns. As with any drug, the first step for effective tobacco harm reduction policymaking requires widespread acceptance that nicotine use is happening, and that it’s not going to stop just because we want it to.
Another step involves efforts to destigmatize nicotine use and addiction and the people directly impacted, in the knowledge that shaming people for drug use is as ineffective as it is unethical. Harm reduction happens when we engage impacted people and support their agency in making healthier choices.
In the US, in contrast, vaping is stigmatized, particularly among youth, as a deviant and deadly act—just as the behaviors associated with HIV infections once were, and continue to be. While tobacco control advocates and harm reduction proponents share a common goal—that underage nicotine use should be curtailed as much as possible—such an achievement should not come at the expense of adult smokers. They are the ones who are dying, right now, in large numbers.
“Quit or Die” Won’t Cut It
One of the most effective ways to work towards destigmatization would be to promote policies and regulations that help explain the bigger picture around nicotine products. Such a platform would include the FDA reforming marketing regulations to allow companies to communicate the reduced-harm characteristics of vaping products, for example. The implementation of policies that limit the sharing of facts is indicative of a prohibitionist mindset. People in America and around the world deserve access to accurate information that could impact their health.
Prohibitionist approaches to cessation will contribute to millions more unnecessary deaths.
Australia, to take another example, is notoriously one of the few high-income countries that criminalizes the possession, sale and use of liquid nicotine. State and local governments in Australia treat possession of nicotine-containing vape and e-juice products as a crime comparable to possession of drugs that are more typically illicit. This criminal model, by design, promotes a “quit or die” position among regulators at all levels of governance in Australia.
Many national governments in all parts of the world have similar “quit or die” positions when it comes to many other forms of drug use. Policymakers, regardless of jurisdiction, in turn further narratives that counteract the concept of harm reduction entirely. We know that public health and human rights suffer as a result—and exactly the same applies when such narratives are applied to nicotine.
Peter Anderson et al. found that policies that promote the prohibition of nicotine, alcohol and certain illicit substances only compound problems with treating addiction and promoting cessation. With nicotine as with all drugs, legalization, decriminalization and smart regulations will promote an environment of acceptance and transparency, in which people are empowered to make informed choices. This approach will support human rights.
Harm reduction values demand that policies be crafted to promote access to the products that smokers need to quit combustibles. Individuals having the freedom to choose to quit or switch is a requirement. Prohibitionist approaches to cessation—mandating medical-only NRT therapies, banning flavored vapes, deploying discriminatory sales or taxation policies—will contribute to millions more unnecessary deaths.