lectronic cigarettes aren’t good for you in the way that an apple or exercise are good for you. But compared to tobacco cigarettes, they can reduce the harm of smoking. The value of using e-cigarettes as a harm reduction strategy will be a focus of the inaugural US E-Cigarette Summit on Monday. Unfortunately, the specter of the tobacco industry hovers over any policy choices we make on e-cigarettes.
Harm reduction encompasses strategies aimed at reducing harmful physical or social consequences that stem from legal and illegal behaviors. It accepts that individuals will engage in potentially risky behaviors, and so aims to minimize their impact. Examples of harm reduction strategies include providing methadone to heroin users, endorsing the use of condoms to prevent pregnancy and the spread of sexually transmitted diseases, opening needle exchanges to prevent the spread of HIV and hepatitis among individual who inject drugs, and promoting e-cigarettes or smokeless tobacco as alternatives to smoking combustible cigarettes.
Harm reduction interventions reduce some, but not all, of the short-term and long-term risks for any given behavior. It is not necessarily inconsistent with the goal of total cessation or abstinence, but that isn’t its main priority.
The E-Cigarette Summit replicates an approach taken over the last four years in London. It will provide a neutral forum for critically debating the emerging evidence — and sometimes widely divergent perspectives — on e-cigarettes, as well their implications for public policy. Two core questions will be central to the ongoing debate: Does harm reduction represent an appropriate strategy for confronting the threat posed by tobacco? If so, what evidence would justify such an approach?
A chief challenge to harm reduction in general is that providing a safer alternative fails to address the underlying problematic behavior. With regard to smoking, it means individuals will continue to use nicotine, an addictive substance. There are also concerns that using e-cigarettes for harm reduction might nudge some individuals, especially adolescents and young adults, to take up vaping because it is “less dangerous.” Similar worries were raised when the US first considered needle exchanges.
Harm reduction also throws into question the value of cessation. Why not simply focus on getting people to stop the risky behavior — like drug use or smoking — rather than replacing it with something that poses lesser harms?
Should we settle for lesser harms? Yes. But that requires policymakers to take some risks and accept some risks.
Harm reduction options are often pursued in the face of uncertainty. We don’t know whether they will cause more harm than good until we try them, and sometimes even then can’t answer that question.
During the early years of the AIDS epidemic, American public health professionals embraced harm reduction after intense and often contentious debate. Police officials in Connecticut were some of the first to back needle exchange programs. They recognized that, given the consequences of HIV and the futility of punishing drug users, it was important to take pragmatic steps to reduce the risk of getting AIDS, even though it would not eliminate the risk. This same sensible approach, seen in the form of making overdose-reversing Narcan available without a prescription, is beginning to inform the response to the opioid epidemic.
When it comes to smoking, experts are deeply divided about harm reduction. In part that is because the tobacco industry, which was responsible for 100 million deaths worldwide during the 20th century and possibly 1 billion deaths during the 21st century, could play a central role in developing products that deliver nicotine in a less-dangerous fashion.
This raises an issue that never vexed harm reduction in other domains. Methadone manufacturers didn’t create heroin addiction. Needles weren’t responsible for HIV. Condom companies didn’t invent sex. Tobacco companies, however, created the very problem they are now trying to “help” reduce.
From the 1950s through the early 1980s, national public health institutions and voluntary organizations supported the idea of tobacco harm reduction. In a context in which smoking was the norm, efforts to develop a “safer” cigarette were politically and socially appealing. Enthusiasm for that strategy was snuffed out when it became clear that the tobacco industry had actively suppressed evidence that smoking causes cancer and heart disease while at the same time it had been manipulating nicotine levels in cigarettes to promote addiction.
Some of today’s most vocal e-cigarette opponents are less opposed to harm reduction as a principle than they are to the tobacco industry as one of its champions. We’ve been down that road with the “safer cigarette” and got burned, they say.
At best, making and marketing e-cigarettes represents a conflict of interest for Big Tobacco since it could, in theory, push its main money-making product off the shelves. At worst, e-cigarettes represent a Trojan horse, yet another way to attract smokers and get them hooked on tobacco products, potentially expanding the shelf space of combustible cigarettes after decades of hard-won victories against smoking.
E-cigarettes are not the brainchild of the tobacco industry. Yet big tobacco companies have been quick to develop their own e-cigarettes and buy out independent e-cigarette companies. In either case, e-cigarettes don’t just represent a promising means to help people stop smoking, but also a way to market the recreational use of nicotine. That means an industry in the business of addiction will profit from tobacco harm reduction.
Policymakers are faced with a hard choice. They can follow the evidence that, while not without uncertainty, increasingly suggests that e-cigarettes can reduce the use of tobacco cigarettes and then support the development of rationally regulated nicotine delivery devices like e-cigarettes. Following this path means tolerating some level of recreational nicotine use, just like clean needles required accepting that not everyone will stop injecting drugs. It also means accepting a role for the tobacco industry.
The other option is to maintain a purist stance — no smoking, no drugs, no sex, no collaboration with the enemy, and therefore no smoking — and impose limitations that will all but assure that e-cigarettes and other non-combustible alternatives to smoking are driven from the open market.
Rejecting e-cigarettes because the tobacco industry will profit from them has the virtue of being uncompromising. But it also means rejecting the evidence and accepting the predictable, deadly toll of cigarette smoking. That’s a virtue, we argue, the world can no longer afford.
Amy Fairchild, PhD, MPH, is associate dean of academic affairs at the Texas A&M School of Public Health. Ronald Bayer, PhD, is a professor of sociomedical sciences at Columbia University’s Mailman School of Public Health.