The war against nicotine


By David T. Sweanor J.D.

It has become a common coffee shop experience to get engaged in discussions concerning opioid and nicotine addictions, given all the frightening stories on overdoses and vaping. We wonder what can possibly be done to reduce the reported harms. After all, as we sip our lattes and cappuccinos; maybe a double espresso if we feel the need, we all have attitudes about addictions. Often, while possibly getting our cup refilled, we acknowledge that we cannot understand what could cause someone to use drugs.  Maybe if we just did more to punish, ostracize or otherwise coerce those opioid or nicotine users we’d solve the problem.

Well, coercion has certainly long been practiced in battling drug use. In fact, no less an authority than Murad IV had users of a particular drug flogged, with repeat offenders being sewn up in bags and thrown into the Bosphorus River. Sweden’s King Gustav III sentenced a condemned man to use this drug every single day until it killed him*. Frederick the Great condemned the drug as a threat to national security.  Don’t even get me started on the English reaction to it . . .

The drug in question? Coffee.

Wars on drugs have been waged on and off for a very long time. Never won, just waged, and at an enormous social and health cost. But just as the war on alcohol, known as Prohibition, abated we got a war on narcotics that became a general War on Drugs. Prohibition was a public policy disaster; the War on Drugs is a social and public health catastrophe. So why stop now?  As policy finally moves toward far more humane approaches to the users of drugs from opioids to cannabinoids, we have a whole new drug war emerging. One that is, like the past ones, based on manufacturing a moral panic, playing fast and lose with the truth, and inflicting huge harm on public health, consumer rights and the rule of law.

Welcome to the War on Nicotine.

This is, to put it mildly, an odd war. We have known at least since the ground-breaking work of Professor Michael Russell in the 1970s that people smoke for the nicotine but die from the smoke. As seen with nicotine pharmaceutical products and through very long-term use of an oral tobacco product called ‘snus’ in Sweden, nicotine can be delivered with minimal risks once the smoke and ancillary toxins are removed. What we have is akin to trying to deal with cholera not by removing the fecal contamination but by attacking the drinking of water. Essentially, we just need to focus on getting the crap out of the delivery system.

Such prestigious bodies as the UK’s Royal College of Physicians, which also led the world in detailing the ravages of cigarette smoking in 1962, states that vaping is ‘likely to be at least 95 per cent less hazardous than smoking’. That is not perfect, but it beats even what has been accomplished in auto safety since the Swedes led the way on three-point seatbelts. In fact, the Swedish efforts on automobile and tobacco risk reduction go back to the same time and the companies in question were owned by the same government entity. A good measure of how nicotine came to be seen more as the sort of moral issue that gets us the social panics that lead to drug wars, is that we praise vehicles like Volvos for the transition they led to far fewer road fatalities. But the snus they try to sell to Canadian smokers has higher taxes than lethal cigarettes, get covered in frightening but inaccurate health warnings, and if they opted to tell Canadian smokers about the difference in risks our federal tobacco legislation stipulates they’d face jail time.

Vaping products are subject to seemingly unending scare stories that stray a very long way from facts and avoid references to relative risks of cigarette smoking. For anyone familiar with Reefer Madness, this looks like a remake. While the approach we have taken to date on nicotine might make for a good Kafkaesque theatre production, it is tragic public health policy. Sensible regulation could rapidly replace cigarettes with ever less toxic and addictive alternatives. We have, after all, used such risk reduction approaches to massively reduce the harms of foodstuffs, pharmaceuticals, medical procedures, building standards, industrial accidents, auto injuries, air pollution and a very long list of other products, services and behaviours.

Public health need not be complicated. Where we find risks, we seek to reduce them. We do so by empowering people to make better health decisions. We ‘nudge’ healthier behaviours. Well, we also make use of my profession to sue-into-oblivion the corporate laggards.

Health professionals can look for guidance in dealing with patients from bodies such as the UK’s National Health Service, Royal College of Physicians or Public Health England (US entities have a poor track record on issues with moral overtones). Most importantly, focus on getting people off, and keeping them off, cigarettes. Let them know it is the smoke, not the nicotine, that will kill them; just as we would say if they were smoking rather than brewing tea leaves to get caffeine. In dealing with our leading cause of preventable death perhaps we each need a simple four word sign: ‘It’s the Smoke, Stupid’.

Effective action means acting pragmatically; discarding some often deeply entrenched ideological or moral views about what other people do. That might not for some of us be as satisfying as behaving like modern day Murads, but it would be a huge breakthrough for public health.

*The king and the jailers died first.

David T. Sweanor J.D. is Chair of the Advisory Board, Centre for Health Law, Policy & Ethics, University of Ottawa; Adjunct Professor, Faculty of Law, University of Ottawa; Legal Counsel, Non-Smokers’ Rights Association, 1983-2005 and Recipient, Outstanding Individual Philanthropist Award, Ottawa, 2016.