This is a guest post from Transform board member Clive Bates.
After caffeine and alcohol, nicotine is the third most popular drug globally. Smoking does a great deal of harm to health - six million and rising premature deaths annually and a huge burden of morbidity. However, the drug nicotine itself is not the source of the great harms that arise from smoking. The damage is done by the products of tobacco combustion, the smoke particles and toxic gases that deliver the nicotine deep into the lungs.
It’s often-stated folk wisdom that if cigarettes had been invented today, they’d be banned. Many in the tobacco control field quietly believe that the right response to tobacco would be prohibition, but wistfully concede that it just isn’t practical given the size of the legal market ($800 billion/year, 1.3 billion users, 6 trillion sticks/year). So they make do with taxes, regulation, usage bans, shock campaigns etc.
But the prohibitionist instinct is never far from the surface, and we see it burst through when there is an opportunity to ban a product that doesn’t have millions of law-abiding users. So when new nicotine products emerge, that’s when this faction takes their chance. And there’s a particularly ugly dimension to this, because the new products are likely to provide nicotine in forms much less hazardous than smoking - the ‘harm reduction’ options in this field. In a choice between prohibition and harm reduction, prohibition often wins.
Let me give three examples of prohibition in the nicotine market: past, present and future…
Past: oral tobacco or “snus”
In the late ‘80s a moral panic developed through fears that oral tobacco (a porous sachet of tobacco that is placed between the lip and gum) would be used to ‘hook kids’ and get them into smoking. The result was a ban on this product was imposed at European Union level in 1991 and has remained in place ever since, to be reconfirmed as recently as in 2014. Never mind that snus itself has somewhere between 98% and 100% lower health risk than smoking. Never mind that its widespread use in Sweden, which has an exception to the EU ban, means Sweden has an adult smoking prevalence of 11% compared to the EU average of 26%, and much lower ill-health as a result. Rather than embrace snus for tobacco harm reduction, the negligent public health establishment preferred to sate its lust for prohibition. For a full account, see Death by regulation: the EU ban on snus.
All but one of these countries has a prohibition on oral tobacco
Present: e-cigarettes and vaping
In the last five years we have the emergence of a truly disruptive technology in which the nicotine is delivered by electrically heating a flavoured liquid to create a an aerosol drawn into the lungs. Harmful smoke is no longer required, smoking becomes vaping. According to the Royal College of Physicians (Nicotine without smoke, 2016):
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”.
The promise of nicotine without smoke (and the cancer, heart diseases and emphysema) has not deterred the prohibitionists. Canada has imposed a ban (the requirement for a medicines license which no products have). Australia has classed nicotine other than in tobacco or prescribed medically as a poison and as a medicine and imposed a ban on nicotine liquids. In an even more deranged act, Western Australia prosecuted a vendor for selling e-cigarettes because they looked like cigarettes. Outright e-cigarette bans are being imposed in Singapore, Hong Kong, Malaysia, much of the Gulf and several Latin American states - all have cigarettes freely available. The WHO has even encouraged prohibitions. In a completely irresponsible statement made in China, home to one third of the world’s smokers, Director General Margaret Chan said:
“E-cigarettes will prompt young people to take up smoking. I recommend that national governments ban, or at least regulate, them."
As with snus, there is not a shred of evidence that e-cigarettes prompt young people to smoke. The data is far more consistent with the opposite effect. Perhaps egged-on by WHO, the worst manifestation of nicotine prohibition so far is the 3-year prison sentence handed down to a 25-year-old e-cigarette vendor, Parvesh Kumar, in Mohali in the State of Punjab, India. See: Indian Merchant Gets Three Years of 'Rigorous Imprisonment' for Selling E-Cigarettes.
Future: low nicotine cigarettes
The US National Institutes of Health and Food and Drug Administration have a multi-million dollar programme to research low-nicotine cigarettes. These would have nicotine reduced in the tobacco to a level below the threshold for making a viable ‘addictive’ cigarette - the idea being to prevent youth ever getting ‘hooked’. The intent is to require this to be compulsory and done by regulation. They don’t call it prohibition of course, but it would be - in the same way that regulating the maximum alcohol content of whiskey to 1% would be prohibition. Leaving aside all the overwhelming problems of prohibition or coerced smoking cessation, this proposal would actually make cigarettes more dangerous, by adversely increasing the ratio of smoke toxins to nicotine in the smoke - the exact opposite of a harm reduction strategy.
A unified regulatory philosophy
Just as the utter failure of the war of drugs is finally grabbing the attention of world leaders and legally regulated drug markets are finally emerging, we seem to be moving in the opposite direction in nicotine policy. We need a unified regulatory philosophy for all drugs. Whether currently legal or illicit makes little difference.
Policy: focus on harm and harm reduction - not on drug use per se.
Policymakers: first do no harm and pay far more attention to harms that are caused by policy interventions
Discussed in more detail in: Harms or Highs: Regulating narcotics, alcohol and nicotine, my recent paper in the journal, Politique Internationale.
Clive Bates is former Director or Action on Smoking and Health and former civil servant and now runs Counterfactual, a sustainability consultancy and advocacy practice. He is a board member of Transform.