Thursday, January 1, 2015

Doubting a Big Doubt

In Larry Gonick’s Cartoon History of the Universe, Gonick puts words in Socrates' mouth: “I doubt the really big doubts,” he has the sage saying. Let’s begin the New Year by doubting a really big public health doubt about e-cigarettes. Public health is sounding an alarm over e-cigarettes, but I doubt that is the correct response. What I am going to argue is that we are in the midst of a significant, permanent transition in our national nicotine regime from one based on tobacco to one based on pharmaceutical nicotine. When this transition is completed in a generation, mortality rates from lung cancer and heart disease will be much lower. Public health needs to understand this transition and proactively help the public manage it, so we get the greatest benefit possible.

First, a quick primer on how people in public health view the world. We use a common lens: the leading causes of morbidity and mortality. That is, things that kill people are bad (even if you like them) and things that kill more people are worse. The same goes for things that make lots of people sick. Things that don’t kill people or don't make them sick are not the business of public health (even if you don’t like them for some other reason). So if mortality due to nicotine consumption is about to start to fall, public health must take notice.

There is strong evidence this “nicotine transition” is occurring. A survey by the National Institute on Drug Abuse has found that e-cigarette use has surpassed tobacco smoking among teenagers in the US. NIDA reports that 17 percent of 12th graders reported smoking an e-cigarette in the last month, compared with 13.6 percent who reported having a traditional cigarette. The difference is bigger among younger teens. Among eighth graders, reported e-cigarette use was 8.7 percent, compared with just 4 percent who said they had smoked tobacco in the last month.  What is going on? Maybe teenagers believe tobacco is harmful, so why would they smoke it when there is an alternative? I am not saying they are being consistent (Hookahs, for example). And there are plenty of good reasons to want to keep e-cigarette use low. The nicotine capsules are toxic. As the CDC warns, nicotine by itself can affect brain development and raise blood pressure. And since e-cigarettes are not regulated, the contents can be contaminated with harmful substances or other drugs. What I am saying is that the transition is occurring.

Let’s start by assuming that current smoking rates (both e and tobacco) level off at 25 percent and stay there for the next generation. However, let’s also assume e-cigarettes as a percentage of all nicotine products continues to rise until it is near 100%. That is, very few people are being exposed to the carcinogens and other harmful substances in tobacco smoke that are what kill you. The relationship between e-cigarette use and nicotine-related mortality would look like this:


If the relationship between e-cigarette use and nicotine-related mortality is as it is depicted in the graphic above, then we can evaluate possible future states of the world of nicotine using the leading causes of death as our lens. If tobacco use increases in the future the results are bad, no matter what e-cigarettes do, because mortality would increase due to the toxicity of the ingredients in tobacco smoke. However, tobacco use is at historic lows and people understand how harmful it is, so this is not likely to happen. If both tobacco and e-cigarettes decrease that would be really good since both are harmful. But if tobacco use decreases while e-cigarettes increase it would still be good, in the sense of “better than the current state,” because while e-cigarettes are harmful, the mortality associated with their use will be much lower than the mortality associated with the tobacco they would replace. Between these two scenarios, I think the latter is more likely than the former. E-cigarette use is just beginning to grow and is likely to increase before it levels off.

Possible Nicotine Futures
e-Cigarettes Decrease
e-Cigarettes Increase
Tobacco Increases
Bad
Unlikely
Really Bad
Unlikely
Tobacco Decreases
Really Good
Unlikely
Good
Likely

Public health doesn’t like to think about this because it means accepting a less harmful—but not harmless—alternative to tobacco. But we must think about it. In order to get this good or at least “better” state of the world to happen we will need to accomplish two things: 1) We will need to nearly eliminate tobacco smoking, and 2) We will have to tightly regulate e-cigarettes to ensure they are as safe and as rarely used as they can be.

We call this kind of strategy harm reduction. In other areas public health has been a champion of harm reduction. Methadone, needle exchanges, nicotine patches, condoms, safety belts and air bags all make something that is potentially very harmful less so. Not harmless, just less harmful. And they save lives. In fact, harm reduction is the approach taken with tobacco, too. It is not illegal to smoke, but it is expensive, there are lots of restrictions on where you can smoke, and advertising is restricted. Because of this strategy we have gotten tobacco use to historic lows.

Sometimes being a purist leads to a future state of the world that is worse than what you started out with. Alcohol prohibition, which was achieved because it promised lower alcohol-related mortality, actually led to soaring alcohol mortality rates, because of the black markets it created and because people turned to toxic methyl alcohol.  Alcohol mortality fell again when prohibition was repealed, however, we missed an opportunity to reduce the harm from alcohol even further.

States adopted varying policies toward alcohol. Some restricted access to alcohol through blue laws, state sales, etc. But as time passed, alcohol became an ubiquitous, mass-marketed commodity almost everywhere, with the main social message being that alcohol consumption is acceptable, even desirable. Now we are dealing with binge drinking and the fiction that red wine is "good for you" (Medical marijuana anyone?). Social acceptability is what marijuana sellers are trying to achieve in Colorado and Washington now. I am all for decriminalizing marijuana because of the horrible, violent black market its ban created. But the alternative should not be the mass-marketing of marijuana. It should be a harm reduction approach.

Being purists about e-cigarettes could result in people continuing to smoke tobacco which will kill them. I believe we should consider trying to shift people from tobacco to other forms of nicotine by reducing access to tobacco even more, without banning e-cigarettes. But we also need to intensively regulate e-cigarettes and curtail their mass-marketing so the contents are safer and so the smallest number of people possible wants to use them.