In defiance of history, science, and human nature, governments around the world are warming up to the idea of prohibition. While maintaining easy access to combustible cigarettes, governments are increasingly considering policies to ban, tax, or heavily restrict non-combustible forms of nicotine. Such policies, among others, will keep smokers smoking and millions around the globe dying as a result.
There is little point in trying to prove that the harms associated with nicotine, as with any substance, depend largely on how it is used. This is just a fact, as true as the adage that “the dose making the poison.” Certainly, nicotine can be poisonous if ingested in large enough quantities, but the same is true of water. Prescription pain killers can be dangerous if abused, but millions of people around the world use them all the time without becoming addicted or overdosing.
Nicotine is no different. Used in moderate quantities, nicotine is not particularly harmful and has actually been shown to be beneficial for a number of conditions. It is also not as addictive as some continue to insist (hence, why we don’t see nicotine gum or patch “addicts”). But, like prescription opioids, caffeine, alcohol, Adderall, and less socially acceptable substances, there are ways to consume nicotine that are relatively safe and ways that are significantly harmful.
Unfortunately, the most popular means of nicotine consumption continues to be in its deadliest form: combustible tobacco cigarettes, which some researchers believe kill approximately half of those who maintain the habit over a lifetime. Even with myriad forms of nicotine replacement therapies available without a prescription and often at no cost, most of the nicotine users in the world continue to get that nicotine by smoking. But not everywhere. In a few nations, smoking is being displaced by safer forms of nicotine use. And where that is happening, we are already seeing the benefits in terms of population health.
Snus, if you’re not familiar, is a moist tobacco chew. While available in a number of countries, it has gained widespread popularity in Sweden, where it has been used since the 17th century. Beginning in the 1980s, as the dangers of smoking became more widely known, Swedes began switching en masse from smoking to snus use with approximately 21 percent of Swedish men classified as “current users” by 2016. On the other hand, just about 7 percent of the adult population in Sweden continues to smoke (with just 5 percent smoking daily). That means that Sweden has not only the lowest prevalence of smoking in Europe, but also the lowest rates of smoking-related diseases like lung cancer and mouth cancer. In contrast, the average smoking rate in the rest of the European Union which bans snus, remains at 26 percent.
Sweden is not alone in achieving real public health success by offering consumers a safer nicotine alternative. In Japan, declines in cigarette sales have quintupled since the introduction of Philip Morris International’s IQOS around 2014. That is, while cigarette sales were declining an average of 2 percent per year between 2011 and 2015, they declined by a whopping 10 percent per year between 2015 and 2018.
Because IQOS heats tobacco without burning it, the vapor produced by the device contains far fewer harmful and carcinogenic compounds. Thus, while the exact risk is unknown, heated tobacco products are expected to carry significantly less risk than traditional smoking, a belief the U.S. Food and Drug Administration recently affirmed. Thus, as more Japanese adults switch from smoking to heated tobacco products, officials expect smoking-related illness to decline as well.
Similar effects have been observed in Great Britain and the United States, where the governments embrace or, at least, tolerate “e-cigarettes” as a safer alternative to smoking. Both countries have experienced accelerated declines in smoking that are greater than declines observed in nations, like Australia, that have banned or practically banned these products. In fact, in the United Kingdom, which actually promotes nicotine vapor products for smokers, smoking rates have declined an impressive 16 percent since 2006. In the European Union, where e-cigarettes are not as welcomed, smoking rates have only declined 6 percent over the same time period.
What Sweden, Great Britain, Japan, and the U.S., to a lesser extent, are doing is called harm reduction. This approach, while recognizing that safer alternatives to smoking may not be completely free of risk (nothing is), also acknowledges that attempting to force every adult to abstain entirely from nicotine use is both impossible and unethical. But, while we can’t prevent nicotine use, we can encourage people to use it in ways that are less harmful.
This recognition of human nature and the limits of public health underlies the idea of harm reduction and has been widely embraced in almost every other realm of health policy. We offer clean needles to intravenous drug users in an effort to reduce the spread of disease, provide methadone to opioid addicts to prevent overdose and relapse, and educate youth about safe sex and the use of prophylactics to prevent unwanted pregnancy and sexually transmitted infections. Even requiring the use of helmets and seat belts to minimize injuries from auto accidents is a form of harm minimization. Public health professionals agree that harm reduction is more effective for public health than say, throwing drug addicts in jail, banning motorcycles and cars, or forbidding adolescents from having sex (good luck, with that). But not when it comes to nicotine.
Harm Reduction Denied
The success these nations have had in reducing smoking and smoking-related illness by allowing smokers access to less harmful alternatives is undeniable. Yet, denial is the path chosen by a growing number of powerful people around the world. Even while the evidence continues to show that nicotine without combustion eliminates most of the risk associated with smoking, the number of countries banning these alternative products continues to grow.
As discussed in Part 1 of this series, these bans are usually couched in the language of “reasonable restrictions” rather than outright prohibition. Australia disallows the sale of nicotine vapor products and may soon prevent their importation from abroad, but as Health Minister Greg Hunt is quick to point out, they aren’t “banned.” Consumers can still get nicotine by prescription. Of course, that requires them to find a doctor willing to write such a prescription, of which there are only eight on the entire content. Even if you manage to get that prescription, you then need to find a pharmacist authorized to import and sell that nicotine to you, which reportedly involves a significant amount of paperwork and hurdle jumping. It isn’t clear how many have or would go through this licensing process.
In the United States and to a lesser degree the United Kingdom, not-quite prohibition measures have centered on restricting where nicotine vapor can be purchased, banning non-tobacco flavors, increasing prices through taxation, and setting a maximum on the amount of nicotine they can contain. While less restrictive than criminalizing the products, these policies produce many of the same unintended consequences as outright prohibitions.
In the U.K., for example, which banned menthol cigarettes as of last May, smokers looking for that minty sensation have turned to all manner of potentially dangerous DIY strategies. Even lighter restrictions, like San Francisco’s ban on flavored e-cigarettes or Minnesota’s high e-cigarette tax backfired, causing more people to smoke traditional cigarettes. And, of course, Australia’s ban/not-ban on nicotine vapor has led to many Australians buying nicotine concentrate from overseas, a practice not likely to be stopped if the government closes the existing “loophole.”
The Church of Tobacco Control
Those unfamiliar with the issue may wonder why more and more countries pursue restrictions on nicotine vapor products if the evidence for their benefits, and against prohibition, is so clear. The answer, regrettably, is that laws governing recreational substances are rarely based on evidence. More often than not, they are based on public opinion, which has even less to do with evidence.
Few of us have the academic background to comprehend scientific research and even those of us who have this background don’t often have the time to read it if it isn’t directly related to our work. Most simply absorb the prevailing narrative on scientific issues under debate. We believe what is repeated by the media, what our friends and family are saying, or trust the perspective of respected authority figures.
The individuals and groups comprising the tobacco control movement know this. They know that with enough time, money, and influence, they can craft whatever narrative they want even if it directly conflicts with the existing science. And, for decades, that is what they have set out to do.
People are, in general, resistant to public health initiatives aimed at controlling people’s personal choices for their own good. But, as advocates learned from their fight against smoking, if the public can be persuaded that a choice poses risks, not just to the individual making it, but to those around him as well, they can bypass the tricky issue of civil liberties and enlist non-users to their cause.
That is what activists did on the issue of child welfare and secondhand smoke. As anti-tobacco lobbyist Anne Marie O’Keefe said in 1992, “attacks on individual smokers were doomed to fail,” because, as she said, it kept the issue in the “civil rights, individual personal liberties arena, where we were going to lose the fight.” But there were two issues that those supporting individual rights could not overcome, as long-time anti-smoking activist Stanton Glantz recognized: passive smoking (secondhand smoke) and kids. But it was always about stopping adults from smoking. As Glantz noted in a 1983 speech at the Second World Conference on Tobacco and Health, “the effects of involuntary smoking on the non-smokers, probably holds the key to controlling and reducing primary smoking.” He was not wrong.
Government reports, biased studies, and public health advertisements, paid for by taxes collected on smokers, effectively convinced many in the public that smokers were not just hurting themselves, but an “act of aggression” against those around them.
Years of frightening headlines about secondhand smoke being dangerous, even more dangerous than smoking (though with no explanation as to how that could be possible) successfully scared non-smokers into legislating smokers to the margins of society. “Today, smokers huddle in doorways and excuse themselves from meetings,” prominent anti-tobacco activist Simon Chapman gloated in 2002. But, despite the rhetoric, this effort had little to do with protecting nonsmokers from the potential risks of secondhand smoke.
By stigmatizing smokers themselves, portraying them as dirty, uneducated, and downright dangerous, anti-smokers hoped they could force smokers to “do the right thing for themselves.” As Glantz wrote in 2000, “indoor air legislation reduces smoking because it undercuts the social support network for smoking by implicitly defining smoking as an antisocial act.” Thus, when anti-tobacco advocates decided that e-cigarettes were just as bad as smoking, they simply copied and pasted their anti-smoking strategies onto this new product category to convince the public they were no different.
As with smoking before, anti-vaping activists have framed their opposition to e-cigarettes, not as an issue of personal choice, but as an effort to protect young people from the predatory tobacco industry. For most people, particularly those in government, the fear of being accused of putting big business over child welfare was enough to enlist them in the cause or, at least, silence skeptics.
But the debate over low-risk forms of nicotine was never really about children, bystanders, or even the risk the products might pose to users. Opposition to e-cigarettes stems from dogma, the ethos of tobacco control that holds that enjoyment of nicotine—regardless of harm—is an unacceptable sin. Sinners can be redeemed, but only through punishment, either by suffering the misery of trying to quit smoking cold turkey, enduring the drudgery and side effects of cessation medication, or should those methods fail, by getting sick and dying. This suffering is not just punishment, but also deterrent. The advent of nicotine products that are enjoyable and don’t cause illness or death is an existential threat to the tobacco control doctrine.
So, those opposed to e-cigarettes on moral grounds have waged a messaging campaign—similar to Big Tobacco’s efforts to downplay the risks of smoking—to ignore or silence any evidence or person that might challenge their narrative that e-cigarettes are a threat to public health. For many, the ends justify the means.
Not So Noble Lies
But not everyone bearing the Tobacco Control banner is a true believer. Some are motivated by the earthlier concerns like power, money, and prestige. Careers and entire organizations have been built off the billions that were dedicated to stopping the scourge of smoking—money threatened by products that might actually achieve this goal. Governments, too, have a lot to lose, including the significant revenue derived from the sale of traditional cigarettes, through taxes, sales-based payments made by tobacco companies, or outright ownership stakes in tobacco companies. Politicians enjoy an ongoing stream of donations from both tobacco and pharmaceutical companies, industries threatened by competition from products like e-cigarettes. And many others are simply too afraid or powerless to oppose the tobacco control orthodoxy, with its history of attacking, defunding, de-platforming, and excommunicating apostates.
That, in a long-winded nutshell, is why the anti-vaping panic that started in the U.S. has spread, like a virus, around the world. It is simply easier and more profitable for most people and groups involved to continue believing that nicotine, in any form, is bad and should be banned, no matter what the science says about how safe it might be or how many lives it could save. And these perverse incentives have allowed a small group of people and interests benefit at the expense of individual autonomy, public health, and science.