Harms or highs? Regulating narcotics, alcohol and nicotine


This is a guest post from Transform board member Clive Bates.
 

This was originally published in the French political journal Politique Internationale, in a special issue on public health and tax policy. It is now available on my web site (PDF). 

It makes the possibly over-optimistic case that policy focus in drug, alcohol and nicotine policy is shifting (or should shift) in two directions:

  1. Away from judgemental efforts to eliminate drug use per se towards a focus on reducing harms, these being very often unrelated to the drug itself. This is the harm reduction case. 
  2. Towards a rising awareness that the actual policy interventions designed to address recreational drug use are themselves the cause of significant harms.  This is the unintended consequences case - especially relevant to prohibitions, but pretty pervasive in all drug policy. 

I thought I'd share the final section on principles for managing and regulating psychoactive drugs and a word on protecting children. 

  • Avoid unrealistic goals. We should accept that a risk-free or drug-free society is impossible and undesirable, and the efforts to achieve it will be immensely harmful, as they always have been in the past.
  • Focus objectives on harm and welfare. The policy objective should be to manage the use of recreational drugs in way that maximises welfare and reduces harm, while respecting individual liberties and personal choices. Policy measures should differentiate to the extent possible between problem users and users who do not suffer or cause particularly serious harms, with intervention targeted to address harms not all use.
  • Develop a clear rationale for intervention. The policy choices should be grounded in a clear rationale for government intervention, based largely on: preventing harm to third parties; reducing harm to users without preventing use; and limiting uptake by new users, but mediated by respect for individual liberty and the right to engage in risky behaviour if it does not harm others.
  • Assess all relevant costs, risks and benefits. The policy framework must be based on nuanced consideration of the broad risks and benefits of the use psychoactive substances and the risks and benefits of policy interventions, accounting carefully for the impact of unintended, though foreseeable, consequences of poorly designed policy. 
  • Design regulation to be sensitive to risk. Where users have a range of options to achieve similar functional effects, particular care should be taken to ensure that regulation does not distort choice or favour the more risky options.  More restrictive regulation should be reserved for those drugs with the highest abuse potential. For example, heroin could be available on medical prescription, while cannabis and alcohol could be sold in licensed premises. Cigarettes could be heavily taxed, but smokeless tobacco and e-cigarettes lightly taxed.
  • Apply principles of good regulation. Regulatory measures should be evidence-based, proportionate to risk, and non-discriminatory while subject to justification and challenge and to change in response to new information. These are tests that should apply to regulation in any consumer market, and there is no reason not to apply them to recreational drugs.
  • Consider the situation not just the product. Policy-makers should consider the situation in which recreational drugs are used, which can vary from sipping fine wine in high-end Parisian restaurant to the squalor of a Mexican crack house. The harms are often defined by context, and can be mitigated by improvements to the situation in which drugs used.
  • Help consumers make choices through good communication. In communication of risk, it is necessary but not sufficient to be merely truthful. Risk communicators must be truthful but also take care to ensure communications are correctly understood and well aligned with a realistic scientific understanding of risks.
  • Engage consumers as stakeholders. Many consumers have valuable knowledge and insights not captured in established literature, and there are many value judgements in policy-making that need to be informed by those directly affected. The mantra “nothing about us without us”, which originated in the policy discourse over the response to HIV/AIDS should ring in the ears of those making policy on recreational drugs.
     

Think of the children: the danger of infantilising adult society

Given the emotion, fear and anger that surrounds this issue, the ideas discussed above represent an immensely challenging agenda for anyone holding office, even though a vast prize is there to be won for the leaders who will eventually make it work. The arguments against prohibitions and for enlightened risk-based regulation are extremely strong. However, opponents of this direction in policy thinking have what they consider a potent force majeure argument that overrides all else: “think of the children”.

Of course we should think of the children.  But we should not let adult society be bent out of shape by excessive attempts to control the behaviour of young people or to isolate them from adult life.  When it comes to recreational drugs, we should recognise that many young people grow up with a risk appetite, are hostile to authority, seek adult experiences to bond with each other and so on. Just as the availability of contraception for teenagers may appear to condone teenage sex, it offers a better strategy than abstinence only “true love waits” lectures followed by inevitable teenage pregnancies.

Much can be done to discourage adolescent drug use, but too much discouragement or blockage will stimulate an in-principle opposition to the imposition of adult authority. For the best welfare outcomes, we should treat young people with respect and try to reduce the risks they are exposed to, an approach no different to an enlightened approach to adult recreational drug use.  

The reaction to the rise in e-cigarette use among adolescents in the United States has provided a fascinating insight into divisions in public health.  For some it is a tragedy and emergency, demanding a forceful regulatory intervention.  For others, including me, it is a triumph because it is accompanied by record declines in teenage smoking – it appears the far less harmful nicotine delivery technology, e-cigarettes, is displacing the most dangerous way to take nicotine: smoking.

 

This article was written in May. No funding received and no competing interests.