by Carl V Phillips
In response to a couple of recent requests and my schooling of FDA in a recent Twitter thread, it seems time for me to again write a primer on the meaning of tobacco harm reduction (THR). Rather than return to a previous version I have written, I am doing this from scratch. This seems best given the evolution of my thinking and changing circumstances.
The key phrase, of course, is “harm reduction”, with “tobacco” denoting the particular area it is applied to. This is important: THR is not a concept that stands apart from HR. It means “the principles of harm reduction, applied to the use of tobacco and nicotine products, and other products that tend to get lumped in with them” (see my previous post for an explanation of that last bit and some other useful background about the current politics). Indeed, when my university research and education group was trying to decide on a name and URL in 2005, it was far from obvious that this was the right term, and we considered others (e.g., “nicotine harm reduction”). While the first prominent use of “THR” appeared in 2001, it was far from established as a common term. (There is probably some endogeneity here, of course — if we had chosen a different term, that might have ascended instead.) In any case, the key to answering “what is THR” is asking “what is HR” rather than thinking it is something different.
Harm reduction refers to trying to help people who choose to engage in a potentially harmful behavior improve their welfare. As with most terms that are constructed from multiple words, those words point you in the direction of the meaning but are not sufficient (a hammer is not a screwdriver, even though you can drive a screw in with it). This has created some confusion, though most often the “confusion” is not honest mistakes, but intentionally engineered (only an intentionally obnoxious child responds to a request for a screwdriver with a hammer and the above observation). Most important, anyone who reads the word “harm” like a “public health” person, to mean only disease risk, rather than seeing its broader meaning like an economist or, frankly, any normal person, is not understanding the concept (so please read on).
Harm reduction does not refer to just any policy or practice that reduces harm like, say, pollution standards or consumer protection laws. It is specific to behaviors that people choose to engage in. (I trust you know that I understand there are factors largely beyond people’s control can cause them to engage in risky behaviors. The point is that — unlike with an actual disease or environmental threat — people could, at least theoretically, choose to stop engaging in the behavior as an act of volition.) Moreover, the term tends to be reserved for risky behaviors where there is strong advocacy for abstinence as the “proper” “solution”. There is no bright line there, but we tend to speak of drug use harm reduction or sexual behavior harm reduction, but not transport or sport harm reduction. Indeed it should be clear from what follows that what we practice in transport (e.g., auto safety) is exactly what harm reduction principles call for. Indeed, the phrase “harm reduction” is basically reserved for behaviors where there is not already general agreement that harm reduction is the right approach.
In the 2000s, a cabal that was apparently led by Mitch Zeller tried to hijack the term “tobacco harm reduction” to basically refer to abstinence and prohibition (“hey, what reduces harm better than abstinence!”). That proved to be a nonstarter. Now Zeller’s FDA division is again trying to hijack the term: They are attempting to claim that they support harm reduction merely because their rhetoric does not exhibit the most extreme possible hostility toward the use of low-risk tobacco products as an alternative to smoking, even as they pursue backdoor prohibition. Despite being as much of a perversion of the ethic of harm reduction as the first attempt, this has gained more traction because THR has become widely misused to merely refer to anything having to do with low-risk products. But as Clive Bates put it when amplifying my Twitter thread, “harm reduction is not a product set”. It is an ethic of humanitarianism and human rights. Indeed, it is just a special case of the most widely-accepted health ethics.
The three key elements of a harm reduction approach, in order of litmus test status, are:
- Reduction (ideally elimination) of caused-harms. These are generally harms caused by government directly (e.g. imprisonment, punitive taxes) or indirectly (e.g., criminalization preventing sex workers from seeking police protection when they are abused). However, sometimes they are caused by other social forces or institutions (e.g., gay men who engage in risky sex not seeking medical care because of stigma).
- Empowerment of the individuals who choose to engage in, or want to stop engaging in, the behavior.
- Offering (developing, providing, encouraging, decriminalizing, destigmatizing) technical tools for reducing the harm from the behavior, or lower-risk versions of the behavior that are sufficiently attractive to the consumers.
The order is important. Most of what gets talked about under the rubric “tobacco harm reduction” falls under point 3. But when it is done without embracing point 2, this does not represent support for harm reduction. It is merely medicalized social engineering, trying to impose a “fix” on people as if they were malfunctioning equipment.
But it is important to step further back and start with point 1. Anyone who supports inflicting harm upon tobacco (etc.) users, including specifically upon smokers, does not support harm reduction. In most wealthy jurisdictions (i.e., where approximately all of my readers live and deal with public policy) the caused-harms inflicted on smokers are greater than the harms from smoking itself (and more so for low-risk products). Converting among different types of harms is necessarily a little fuzzy, of course, but there is a good case to be made that decades of paying high punitive taxes inflicts more harm on the average smoker’s lifecycle well-being than dying a few years early. Then there is the loss of social options and the stigmatization, both of which are engineered.
Naturally, it is possible to make a case that certain limitations on behavior are justified to reduce externalities, such as by forbidding smoking and even vaping in particular places. This includes some ostensibly private places that function as public places (it should really be common knowledge, since the time of Coase, that free markets are often terrible at dealing with externalities like this). But intentionally preventing people from setting aside any social “safe space” where they can gather and smoke (or whatever) is clearly intended to cause harm to smokers. Tobacco controllers admit as much.
Similarly, it is possible to make an argument that high taxes serve the arguably legitimate purpose of discouraging use by hapless children, even though the harm inflicted on the inframarginal user (i.e., those who choose to use the product in spite of the elevated cost) is unfortunate. (Please spare me the claim that the health impacts of smoking impose net costs on the rest of society and smokers need to pay for that; the opposite is true, overwhelmingly.) But the argument that “the costs are unfortunate, but the benefits are positive on net” is, of course, is never made. The supposed benefits on one side are not quantified and balanced against the obvious harm on the other. Rather, the harm inflicted on the inframarginal users is intentional and celebrated. Indeed, it seems to be the primary goal; it is supposed to “help” them to quit. Inflicting harm on people “for their own good” is antithetical to harm reduction, as well as most enlightened codes of ethics more generally.
And then there are even more radical ideas for causing harm, like the FDA’s proposal to reduce the quality of cigarettes by reducing the nicotine content. There are, of course, many ways to intentionally reduce the quality of a product, ranging from making it uglier (e.g., disease porn on the packaging) to making it toxic (e.g., poisoning alcohol during Prohibition; doing nothing to stop deadly adulteration of street drugs and preventing pill testing services). Like any of these, FDA’s effort, which motivated me to rant at them about their bullshit claims of supporting harm reduction, is antithetical to harm reduction. Their current signature policy consists of intentionally harming product users.
This really is a litmus test. The “moderate” tobacco controllers who are positive about point 3 and low-risk alternatives to smoking (or, more often, their one pet low-risk alternative to smoking), but who think this pairs nicely with continuing to punish smokers, are not supporters of harm reduction. They still advocate causing harm. At best they can be credited with wanting to empower tobacco product users to have low-risk alternatives, though even this is not true for many of them. A few even support freedom to choose to use those products, though most favor restricting use of the low-risk products to “curing” smoking to the extent possible.
Perhaps that most important thing to realize is that point 2 is basically an application of the primary rule of health ethics: Individuals have a right to informed autonomy over their own bodies. Like all overarching principles, this is not perfectly precise. In particular, there is the question of how much and what type of communication is sufficient to inform people. But obviously disinforming them (e.g., the common practice of exaggerating the harms from all the products in question) violates the fundamental ethical rules and disempowers people.
(Some might also be inclined to argue that point 1 is just a special case of what is often mistakenly believed to be a primary rule of health ethics, “do no harm.” But since simple economics tells us this is not really a meaningful rule — and really was coined as a nice way of saying “stop doing random things to people when you have no clue about whether it hurts them or helps them” — I would not choose to do so. Rather, I would go with the more general point that intentionally inflicting harm is a decent definition of evil. A better encompassing “special case” observation is that this is all just a just a special case of the benefits of idealized free markets (not to be confused with the political rhetoric about “free markets”); I basically approached it from that angle in this paper.)
For some areas of harm reduction, empowerment is an operational and ethical challenge. How, for example, do you empower a person who uses drugs and has become dysfunctional or has given up on herself? At some point, even the strongest harm reduction supporter will see paternalism as the only answer. Real empowerment and freedom often requires affirmative provision of resources (e.g., syringe exchange facilities), especially when caused-harms remain great (e.g., buying a clean syringe is criminalized).
But this is moot in the case of tobacco because tobacco use does not make people dysfunctional nor — despite the best efforts of tobacco control — does it remove people from mainstream society or force them into the criminal economy. So it really is quite simple. For tobacco harm reduction, point 2 is exactly the same as that preeminent health ethics rule. People need only be given informed autonomy. Tobacco harm reduction means helping smokers understand about low-risk alternatives and making sure they have the opportunity to switch to them if they want. But it also means letting them choose to keep doing what they are doing if that is what they want. Ideally the latter would also include reducing the harm from the behavior (e.g., technical tweaks that make cigarettes produce less carbon monoxide; improving early diagnosis of lung cancer). Needless to say, no matter how much it is dressed up in Orwellian rhetoric about making the product less risky, taking the nicotine out of cigarettes is antithetical to this.
It is worth noticing that the quintessential example of harm reduction, syringe exchanges, is an example of letting people continue the same behavior, using their drug of choice in a particular way, while making it less risky. Low-risk tobacco products are more analogous to offering methadone, an alternative consumption choice that some consumers will find to be a better alternative, all things considered. Moreover, switching to methadone is often inflicted upon people involuntarily, an example of using a reduced-harm alternative in a manner incompatible with the harm reduction ethic.
As for point 3, there is really not much to say. Even though it all that some people mean when they refer to tobacco harm reduction, it is the most trivial aspect of it. A low-risk alternative to cigarettes existed for centuries before cigarettes became popular. Extracted nicotine products — whether oral or inhaled — are a trivial technology. Dozens, if not hundreds, of potential entrepreneurs independently redeveloped or rediscovered the technology for e-cigarettes over the course of many decades. The story of them finally becoming established is a fascinating story of sociology and commerce, to be sure (it turns out the trick was setting up shop in a regulation-free jurisdiction and simply ignoring legalities). But that is ultimately a story of how THR had failed, or more precisely that active opposition to it had succeeded.
If inhaling smoke had stopped being the only “normal way” to consume tobacco in the 1970s (as happened in Sweden), when the harms from smoking had become generally understood, there might be little demand for an alternative inhalation system. This observation applies even more so to the new heat-not-burn products that are poised to overtake e-cigarettes in popularity. Sort-of-smoking is the most promising alternative because smoking never stopped being the “normal way”. Or, going down a different thread of alternative history, e-cigarettes could have been produced, and allowed and encouraged, three and perhaps even four decades ago.
But those who worked on anti-smoking efforts ignored these options at first, letting their vision of the perfect (“everyone is going to realize they should just quit any day now”) become the enemy of the good. But that “perfect … enemy … good” story ceased to describe what was happening three decades ago, and was grossly inaccurate by two decades ago. Even as it became obvious that “everyone will quit any day now” was fantasy, the response to THR ceased to be “nah, we don’t need that” and became brutal suppression of the idea and those who supported it. Those who still suggest that tobacco controllers’ anti-THR efforts are motivated by a childlike quest for the perfect are the ones who are naive.
What actually happened is that anti-smoking advocacy morphed into a typical drug war. Harm reduction is anathema to drug warriors, who are all about creating more caused-harm and disempowering people. They are tribalist hawks who see sworn enemies who must be beaten. To tribalist hawks, beneficial compromise, showing respect for the differences among people, and granting others self-determination makes you a cuck. It is worse than losing the war.
One of the great ironies of the war on tobacco harm reduction is that the people fighting it tend to come from political factions and social strata that despise other (largely identical) wars on drugs. They despise hawkish tribalist foreign policy. They despise the sort of people who would use the word “cuck” non-ironically. And yet they are everything they despise. I suppose it is an example of atavistic tribalism being all too common a human trait; those inclined toward it will find a way to act on it, even if they are acculturated to despise its more traditional manifestations.
There was a point to this digression: A lot of the confusion that makes it easy to dismiss or hijack the real meaning of harm reduction — the misuse of “tobacco harm reduction” to merely refer to low-risk alternatives — has been caused by the tactics of those of us who fought for THR. It is the common dilemma of making bad arguments to try to convince bad people to do good things.
When fighting for, say, free school breakfasts and lunches, the good argument is that it is evil that a rich society would let little kids go through the day hungry rather than spend the trivial sum it takes to stop that. But everyone who is persuaded by that obvious point is already on the same side. So instead the political rhetoric focuses on how feeding kids improves test scores and lets people grow up to produce more. Or when fighting against deporting DACA kids, the good argument is that ripping law-abiding people, guilty of nothing, from the only home they have ever known, to send them to a country they do not even remember, is a cruel violation of human rights. But to try to convince people who inexplicably do not get that, we say “they pay lots of taxes, are more productive than natives on average, and cannot even collect most government entitlements if they want to.”
Similarly, we could focus on the self-evident truth that people should be able to put whatever they want into their own bodies — the harmful stuff, the not so harmful stuff, or nothing. They have a right to do that, they should not be punished for it, and we should make sure they know which stuff is which. As an added bonus, we can work on making the all the stuff safer, though this remains tertiary. But instead we craft arguments intended to persuade the ethically and morally challenged people who deny that:
We don’t want injection drug users spreading HIV and hepatitis in the community, so we should encourage syringe exchanges. (subtext: I know you really don’t care if people who inject drugs get sick and die, but maybe you will act to protect “decent” people.)
If people think that low-risk tobacco products actually pose high risk, consumers will switch from them to smoking and dramatically increase their risk. (subtext: I know you do not hesitate to blatantly lie to people to manipulate their behavior and further your social engineering agenda, but perhaps you really do care enough about health outcomes to see this as an unfortunate effect of particular lies.)
We can’t stop people from being non-monogamous, so we should push them to at least use condoms. (subtext: I realize you want to impose 17th century puritanical rules on everyone because you can’t stand the thought that your daughter has sex, but maybe your thoughts will drift somewhere near reality if I point out the disease risk.)
Since we are not achieving the goal tobacco abstinence, isn’t it better if people are encouraged to switch to something less harmful? (subtext: Even though I know you probably do not really care about people’s health, I am going to pretend that your goals are what you say they are and try to persuade you to adhere to them.)
Every time we indulge these facile and deprecating arguments — “yeah, gee, it sure would be great if everybody just did the right thing, but for some reason they don’t, so maybe was should at least….” — we concede there is some ethical validity to the prohibitionists’ vision of what everyone should be doing. Moreover, every time we refer to one of these arguments as “the harm reduction approach”, it implies that harm reduction is merely an unfortunate choice, a necessary evil that must be pursued only because prohibition is not working.
This has sometimes been an effective, albeit distasteful, tactic in some areas. However, it turns out that tobacco is not one of them. Other drug wars involve not just extremists and those they hate — the consumers and anyone who stands up for them — but pragmatic and persuadable “moderate” politicians and opinion leaders who are seriously interested. The tobacco wars do not. There are only the extremists, the consumers and those who stand up for them, and people who do not really care. The attempts at appeasement have had no effect on the anti-tobacco extremists, who are as anti-THR as ever. A few tobacco controllers claim to be pro-THR but (per they above) they are not, and moreover most remain authoritarian extremists, just with a slightly different set of authoritarian rules. The number of “moderate” opinion leaders who have bought into the appeasement rhetoric and who are not true believers in harm reduction (i.e., human rights) — the target audience of that rhetoric — is so small you can basically name them all.
What the attempts at appeasement have done is dilute the concept of tobacco harm reduction to the point that the phrase is probably used inaccurately more often than accurately. They have allowed it to be hijacked by anti-THR activists. They have created a divide, wherein many smokers’ rights advocates are hostile to the concept of harm reduction because they mistakenly think it is hostile to them. The more sophisticated among them understand what THR really is, of course. But probably a majority of them who have heard the term (along with most vaping advocates who have heard the term) have such a perverted notion of what it means that they consider it yet another antagonist.
A harm reduction approach embodies basic human rights, concern for people’s welfare, an enlightened view of individual freedom and dignity, and an effort to resist egocentrism and appreciate others’ perspective and preferences. Oh, and it also involves some tools and behavior changes that can lower risk. For tobacco controllers, the first of the previous two sentences might as well have been written in Sanskrit, and so they misconstrue tobacco harm reduction as being about a product set. Clearly a few of their puppet masters do this knowingly, to try to undermine advocacy for human rights and consumer welfare. But given the moral blindness that characterizes drug warriors, it is safe to say that most of tobacco controllers would genuinely not understand the first sentence of this paragraph.