Ian Irvine – Tobacco Harm Reduction (Part One) – Guiding Principles

From: Ian Irvine

To: Canadians Concerned About Vaping

Date: September 2, 2020

Re: Tobacco Harm Reduction (Part One) – Guiding Principles

The central challenge for governments in the area of e-cigarette use is to formulate policies that simultaneously encourage smokers to switch to vaping (or quit nicotine use entirely) and to discourage young people from starting. To date, the increase in youth experimentation has led government ministries, elected officials and the media to focus almost solely on policies designed to prevent youth use. But huge health gains may also materialize if habituated smokers can switch in large numbers. Several principles should guide policy to meet these twin goals.

1. E-cigarettes and traditional cigarettes differ dramatically in their toxicity. E-cigarettes are considered by multiple public health authorities to have dramatically lower risk profiles. For several years now, Public Health England has reported that e-cigarettes contain less than 5 percent of the toxins in cigarettes. Consequently, policies should recognize differences and not treat different products as if they were identical. Other reduced-harm products such as Snus (nicotine from steamed and treated tobacco that comes in a moist sachet, and placed in the mouth), and heat-not-burn products also contain a small fraction of the toxins found in cigarettes. This principle demands that we determine the degree of toxicity in the array of products on the market.
2. Restrictive policies must consider the likely incentives that accompany their implementation. In particular, we must examine the likelihood that the law will be broken if regulations or restrictions are excessive. Illegal activity erodes social capital, erodes the legal tax base and requires police resources.
3. The use of the precautionary principle when a new product arrives in the market is an almost ‘natural’ reaction on the part of policymakers. The precautionary principle is akin to a ‘let’s wait and see before we permit product X’ approach. A decision to reject a new technology that has a degree of in-built risk does not always equate with, or result in, minimum societal risk. When society is uncertain as to the ultimate cost-benefit outcome of a new product, society may err by being excessively cautious. In this instance the UK Royal College of Physicians has stated that if an overly risk-averse approach  … “makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking." 
4. New technologies are disruptive, and their arrival is accompanied (reasonably) by fear of potential long-term consequences. Best-effort scientific research on new technologies may not yield unambiguous findings or prescriptions. But where findings do appear strongly suggestive, it is important to incorporate these into policy.
5. Governments have an obligation to educate their citizens on the advantages and potential dangers of new products. It is unreasonable for governments to legislate without presenting a full picture of the subject matter of the legislation. Science is challenging for non-scientists, and the media frequently is not well placed to interpret research results. The outcome is sometimes a public clamor, which in turn pressures governments to take (perhaps) counter-productive action. Statistics Canada’s 2019 Canadian Tobacco and Nicotine Survey indicates that about six out of seven citizens are unable to correctly determine if electronic cigarettes contain substantially reduced toxins.
6. The principle of horizontal equity should be a foundation for regulations. This means that if a government declares that a specific standard is appropriate for the implementation of controls or freedoms in one choice domain, such as access to alcohol or cannabis, then a similar standard should pertain across the board.
7. Where multiple objectives are involved, it is vital that more than one policy measure be available. It is also vital that measures adopted in pursuance of one objective – minimizing youth initiation – not hinder the attainment of the other – getting hardened smokers to switch. Broadly, we can call this the ‘objectives and instruments’ principle. And beyond having a sufficient number of instruments on hand, it is also critical that we choose the sharpest instruments.
8. Governments should recognize that many people use nicotine as a non-medically prescribed antidote to loneliness and anxiety. A substantial literature details high use rates among Indigenous peoples, the LGBTQ+ community and those who suffer from depression and anxiety. Policy should recognize why individuals use nicotine and avoid treating users as if they simply lacked self-discipline. In practice, nicotine represents a comfort, while at the same time is strongly addictive. Harm reduction has a potential role here. 
9. Finally, we should learn from other societies where cigarette use has declined. More pointedly, there exist several case studies where the decline in cigarette use is accompanied by a corresponding increase in the use of nicotine in other forms – Snus or heat-not-burn products or e-cigarettes. This suggests that reducing overall nicotine use on the part of a significant minority of the population may be difficult.

Tomorrow, we examine trends in cigarette sales and other nicotine delivery systems in Canada.

Ian Irvine is a professor of economics at Concordia University, and a research fellow at the C.D. Howe Institute.

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The views expressed here are those of the author. The C.D. Howe Institute does not take corporate positions on policy matters.