Tuesday, May 30, 2006

Nicotine harm reduction

There's a fantastic Op-Ed in today's Washington Post about the failure of the abstinence-only approach many anti-smoking advocates take. Some good parallels can be drawn to the larger anti-drug effort.
Cigarette smoke is a deadly delivery device for a benign but habit-forming product: nicotine. Nicotine isn't especially dangerous -- about like caffeine. Good policy toward tobacco use would reduce the grave harm of smoking by replacing cigarettes with non-smoked forms of nicotine for the addicts. They might use nicotine safely forever, if harmless delivery systems were widely available.Instead, nicotine abstinence is the policymakers' only approach to tobacco. Like other abstinence campaigns (alcohol prohibition, sexual abstinence before marriage, just saying "no" to drugs), this one is both moralistic and ineffective.

[snip]

Obviously, nicotine use is a popular and tenacious habit. Equally obviously, tobacco policy is a failure. Surveys show that a majority of current smokers would like good alternatives to smoking as ways of getting nicotine. But we will not tell nicotine users that there are safe ways to continue to use the legal drug they crave. Apparently, our policymakers would rather see those people get sick and die.
This approach is eerily similar to the way that the drug warriors would apparently rather see injection drug users die from AIDS than have access to clean needles. Unfortunately, drug control policy in the U.S. is dominated by ideology and moralism rather than by science and reason. The drug warriors keep sticking their heads in the sand and hoping for a drug-free America while real solvable problems go unaddressed because public resources are tied up in ineffective abstinence-only programs.

1 comment:

rachelrachel said...

This article has so many things wrong with it, I don't know where to start.

The first thing I notice is that the author of the op-ed, Philip Alcabes, seems to contradict himself. First he says, "They might use nicotine safely forever, if harmless delivery systems were widely available." A little later on he says, "Yet health officials label smokeless tobacco as 'not a safe alternative to smoking,' despite much evidence that it is quite safe."

Obviously, if he thinks smokeless is 'quite safe,' then he can't very well say that 'harmless delivery systems' aren't available, unless he's talking to those who have never stepped foot inside a convenience store.

However, the view that smokeless tobacco is harmless is, to be quite charitable, a minority view among people who study this sort of thing. Every health group that has weighed in on this has concluded that tobacco in any form poses a significant danger to health, in particular cancer of the mouth and throat.. Here's one, for example, from the National Cancer Institute. Looking at the evidence, they all think it's pretty clear that smokeless is a significant factor of mouth cancer. I know it's fun to rail against the medical establishment, but when the consensus is overwhelming, you need some pretty strong evidence to refute it, not just some lonely guy in Alberta who gets his funding from the tobacco industry. I do not believe that they are lying, only that they have found

Here's where Dr. Phillips gets his grant money:


Researcher defends grant to study smokeless tobacco
The makers of Copenhagen and Skoal chewing tobacco have provided a $1.5 million grant to one U of A researcher for his study of smokeless tobacco.
The controversial grant was approved by the University’s board of ethics, providing the funding to Dr Carl V Phillips, expert in health policy and epidemiology and assistant professor of public health in the faculty of medicine.
“The salient underlying fact is that smokeless tobacco is a very good substitute for cigarettes from a health perspective, and from a perspective of providing nicotine—it’s much, much safer than the use of cigarettes,” Phillips said.


The health community is not, by and large, a bunch of moral busybodies. As Dr. Alcabe points out:

We prefer health promotion in the form of seat belts, motorcycle helmets, condoms, syringe exchange, ingredient labels, and warning labels, rather than forcing people to quit their habits. But with tobacco we have jettisoned our tolerance and thrown all our support to nicotine abstinence.

So who's "forcing people to quit their habits"? If he's talking about illegal drugs, then sure; I think that's something that should be changed. But nobody's forcing anybody to quit using tobacco in any form. There have been recent restrictions on smoking in public places, where the smoke itself can pose an irritant or even a hazard to health. But, come on now, nobody's forcing anybody not to smoke!

But what about the harm reduction question? Is Dr. Alcabes an apostle of harm reduction?

Good policy toward tobacco use would reduce the grave harm of smoking by replacing cigarettes with non-smoked forms of nicotine for the addicts. They might use nicotine safely forever, if harmless delivery systems were widely available.

If we can replace one form of drug for a less harmful form of the drug, we've reduced the harm. But he never, never says that we can reduce the harm even more by avoiding the drug completely. He misses one of the most important concepts of harm reduction. I've never heard of any needle exchangers who haven't said, "It's good if you can swap needles, but it would be even better if you could kick the habit completely."

Obviously, nicotine use is a popular and tenacious habit. Equally obviously, tobacco policy is a failure.

Fifty years ago, most adult Americans smoked cigarettes, and most of them smoked a lot: about a pack a day or so. Today, most adult Americans do not smoke cigarettes; of those who do, most smoke a lot, about a pack a day or so. If the goal of the policy is to get fewer people to smoke, the policy has been pretty successful.

I don't know whether smokeless can be used as a way to wean smokers, or whether nicotine patches should be approved for long-term use. I don't think the science is there, yet. I don't have any problem with studying the issue, although preferably getting funding from sources other than Skoal and Copenhagen.