Core claims of tobacco harm reduction advocates

What makes THR THR?

[Epistemic status: I’ve been involved in the tobacco harm reduction (‘THR’) community for several years and have run this post by a number of people with longer experience. While THR is a diverse group whose members, just like effective altruists, often and vocally debate the nuances of its goals and assumptions, I feel confident this represents a fair expression of their core claims. This is distinct from my confidence in the truth of the specifics of each claims themselves, which will be explored in future posts.]

In “Learning from non-EAs who seek to do good,” Siobhan argues that it’s healthy for lower-case effective altruism (“EA as a question”) to engage with other communities that share some of our goals but differ from us in significant ways — including empirical beliefs, explicit and implied ethical commitments, and epistemic standards — in order to learn from them. One of the main goals of this blog is to apply this proposal to the tobacco harm reduction community, a diverse group of advocates working to improve knowledge of and access to noncombustible tobacco products that are less risky than combustible ones. This post starts off that process by enumerating a few of the community’s core beliefs. The first three of these are primarily empirical, the next three normative.

While I believe all of these claims have at least a grain of truth to them, this post doesn’t endorse or attack any of them nor attempt to provide substantial evidence for or against them. The goal here is to show what, by and large, THR advocates agree on, and that the beliefs are distinctive in the sense that they often aren’t shared by the broader tobacco control world or the general public. In subsequent posts, I plan to critically examine each of them through an EA lens to help discover whether and how they could inform cause prioritization, generate new ideas for promising projects, or diversify our thinking in other areas.

Nicotine isn’t particularly dangerous

“People smoke for nicotine but they die from the tar.” - Michael Russell

Many discussions of the deadly effects of smoking begin with the role of nicotine, and THR advocates emphasize the substantial evidence that the substance, when consumed on its own, does not cause cancer, COPD, or heart disease, the main risk factors for smokers. One of the strongest points of evidence — emphasized because it’s generally uncontested even by opponents of THR — is that nicotine replacement therapy in the form of gums and lozenges has been used for decades by people attempting to quit smoking, to no detectable ill effect. One comparison often, and almost exclusively, made by THR advocates is to caffeine, arguing that the risk level of the two stimulants is similar.

This claim is core to the THR argument since the vast majority of products and approaches they recommend contain nicotine. That said, there is nuance regarding opinions on what specific groups may be exposed to additional risk, like people who have heart disease or are pregnant. There is also lively debate about whether the substance is not just low-risk but improves quality and length of life for some. Advocates present evidence of benefit from nicotine use for those suffering from a number of different conditions regardless of whether or not they are a current or past smoker, with investigation into its role in ameliorating the likes of schizophrenia, ADHD, and mild cognitive impairment.

Tobacco control organizations more skeptical of harm reduction maintain that nicotine bears unique risks. They claim that the framing of nicotine as similar to caffeine can “undermine public health” as, for example, the former is associated with mental health concerns among young people, and that studies with animals have shown nicotine to be more similar to opioids and cocaine than to caffeine in their propensity for self-administration.

Reduced-risk products provide the most effective known method to stop smoking

“FDA is forcing Juul to pull the most successful anti-smoking device ever made.” — Clive Bates

Citing both the studies on e-cigarette effectiveness in smoking cessation and testimonials from former smokers, government recommendations, as well as the population-level data from countries like Japan and Sweden, THR advocates argue that reduced-risk products not only work in helping smokers achieve better health outcomes, but that they are in fact the tool most likely to lead to success for the average smoker trying to quit. Therefore they are seen as the most promising path to achieving lower mortality at a population level.

In addition to highlighting the need to make products more accessible and smokers more informed about them, this belief implies that suggesting cold turkey or some combination of pharmaceutical nicotine replacement therapy and counseling to smokers before switching to a reduced risk product may be misguided. If use of less harmful products is more likely to help someone stop smoking sooner, then any potential harms from them need to be weighed against the additional risk from having smoked longer.

A number of tobacco control practitioners and medical professionals don’t accept this framing and argue that the research supporting cessation through noncombustible products is insufficient to serve as a reason to change recommendations to smokers. They suggest that the best message is “quit, don’t switch” because the studies indicating their effectiveness are flawed due to participation bias and other factors, and that other work has produced evidence of absence of a cessation benefit.

Experts and the general population are misinformed about basic facts regarding nicotine, tobacco, and smoking

“No education curriculum or public health campaign has bothered to de-construct the simplistic “smoking=tobacco=nicotine=harm” narrative.” — Sudhanshu Patwardhan

One of the few things both skeptics and enthusiasts about THR agree on is that some nicotine and tobacco products present a greater chance of health harm than others. This fact is often referred to as the “continuum of risk” by both groups, with cigarettes at the most harmful end of the spectrum.

The THR community observes a distressingly poor awareness of the specifics of this continuum among the general public, smokers, and even professional medical practitioners. Pointing to data like surveys showing basic misunderstandings about the health impacts of nicotine among doctors in related specializations, incorrect risk perceptions — in some countries, increasingly so — among smokers, and the “misinformation shock” caused by the “E-Cigarette and Vaping-Related Lung Illness” (EVALI) outbreak brought on by black market THC cartridges in 2019, they argue that providing each of these groups with more correct information is a missed opportunity for improving health outcomes, and that the numbers shows that efforts up until now have been not only inadequate but often counterproductive.

The broader tobacco control movement generally doesn’t overtly contest the idea of a continuum of risk; the term was coined in a mainstream journal article and the director of the US FDA’s tobacco division has referred to it explicitly. Nor does it deny the validity of the data indicating that majorities of important stakeholders hold false beliefs about it. However, some stauncher THR opponents have referred to the idea as a “hypothesis lacking sufficient empirical evidence” due to its not taking into account supposed population-level effects on smoking initiation, and most acknowledgments of the misinformation problem tend to be followed by heavy caveats around ensuring prevention of youth use.

Offering choice is morally preferable to coercive strategies

“The right to health underpins the right to tobacco harm reduction.” — Global State of Tobacco Harm Reduction

Effective altruists, while a diverse group in terms of specific moral philosophical commitments, tend to endorse some flavor of utilitarianism as most conducive to guiding correct action. The THR community comprises a range of groups with a more varied set of moral intuitions and commitments. One very commonly held idea is that of the moral importance of allowing people to choose the risks they take rather than attempting to limit their options through regulations.

The idea that choice is a moral end in and of itself, irrespective of how or whether it affects measured health outcomes, is shared by (or, one might say, inherited from) the broader harm reduction community, who have appealed to it in debates around the use of other psychoactive substances. One of the leaders of that movement defines harm reduction as helping people “achieve their drug use aims (including abstinence) in the way that causes the least harm to them” and argues this is “a basic human right that should be available to everyone.”

Notably, the argument does not rely on or cite any cost-benefit analysis of looser or tighter regulatory approaches, but is a rights-based moral claim that allowing choice is inherently better than attempting to restrict it. The practical implications of accepting some version of this argument can run the gamut from pushing for the legalization of all psychoactive substances to more incrementalist arguments that bans on less harmful products be replaced by taxes commensurate with the level of risk.

Skeptics of this line of thinking note that the use of psychoactive substances including nicotine and tobacco products can impose negative externalities both on a societal and personal level (citing second hand smoking as an obvious example).

Consumers should participate more in policy decisions and research

“[T]he legitimate concerns of public health advocates about the tobacco industry and its products had the unintended consequence of also marginalising and stigmatising smokers.” — Gerry Stimson

A normative belief related to but distinct from that of the importance of the right to choose one’s own risks is the view that nicotine and tobacco product consumers form one of the core stakeholder groups that should be consulted as part of policy debates (“nothing about us without us”) and as helpful partners in research. THR advocates argue that as a result of the hostility produced by the fake science peddled by the tobacco industry for decades in order to protect its profits, a broad range of groups, many of which attempt to give a voice to people who use nicotine, continues to be excluded from discussions that inform policy decisions and research priorities.

One oft-cited example is the closed nature of the Conference of the Parties (COP) on the WHO Framework Convention on Tobacco Control (FCTC), which has stringent requirements even on observer status ostensibly to prevent industry interference. These requirements result in a lack of representation from both organizations representing current smokers and those that have benefited from noncombustible alternatives as no grass roots organizations of any kind participate in the conference. This, advocates claim, means an essential perspective remains unheard, and the decisions made are more likely to be biased in a way that makes them less effective.

THR supporters also argue that greater consumer involvement in research on smoking cessation improves its quality. Switching to noncombustible products is quite different, they argue, from stopping smoking in other ways, in that a distinct culture and identity has developed around each of them. Therefore their users can provide knowledge of the practical realities of how that culture operates that would be difficult to obtain in any other way, and that is essential to designing research that meaningfully answers questions about whether and how they can benefit others.

THR skeptics argue that, given the history of the tobacco industry’s interference in policy and its attempts to deceive the public, extreme caution is warranted when dealing with anyone that could be suspected of deliberately or unwittingly advancing its interests. They point out that a number of consumer organizations have received industry funding or describe them as outright front groups.

Supporters of harm reduction in other contexts should apply the same logic to smoking

“The politicians who were my key allies, on […] on harm reduction more broadly […] [t]hose are often the same people who have been at the forefront in opposing tobacco harm reduction.” - Ethan Nadelmann

While philosophically aligned with the broader harm reduction world, THR is often felt by its advocates to be a neglected and underappreciated niche within it. They point out that both governmental and non-governmental organizations and individuals supportive of things like needle exchanges, safe injection sites, and birth control are sometimes simultaneously dismissive of, or outright hostile to, what THR supporters see as a substantially similar approach to tobacco use.

Explanations for this disconnect vary. Harm reductionists in other areas may not be familiar with the evidence regarding noncombustible options. The injustices motivating their engagement in issues around other substances or behaviors (e.g. racial justice, mass incarceration, or reproductive freedom) may not apply to smoking. They may simply not be aware of the scale of the problem because smoking has drastically reduced to the point of near-disappearance in their immediate social environment.

THR skeptics argue that the case of smoking is, in fact, materially different. They see the adoption of harm reduction language as an attempt by the industry to co-opt a sympathetic brand and hoodwink people into helping them maximize their sales by branching out into new product lines.