Tobacco Harm Reduction: Polar Opposition Must be Resolved

 

To put it mildly, the tobacco harm reduction (THR) issue in the United States is polarized.  According to Professor Lynn Kozlowski, on one side are “THR supporters”, scientists and policy makers who want to inform smokers about vastly safer smoke-free substitutes for combusted cigarettes, including American moist snuff and chewing tobacco, Swedish snus, a wide array of e-cigarettes and vape products, plus new heat-not-burn tobacco products.  On the opposite side are “abstinence-only (AO) supporters” who reject any divergence from their vision of a tobacco-free society.

Is there a way to bring these opposing parties together to achieve meaningful improvement in public health?  As a THR researcher and advocate for over 27 years, I have never refused to participate in serious discussion of the way forward.  I know of only one truly independent THR debate in which AO advocates, represented by the Campaign for Tobacco Free Kids, participated: “Tobacco at the Crossroads: A Debate on the Ethics of Reduced Harm Products,” sponsored by Southern Methodist University in 2004.  I was teamed up with the late intellectual critic Christopher Hitchens, who delivered a profound and unchallenged ethical endorsement of THR (available here).  Other encounters suffered various degrees of failure:  

 

·         In 2002, Elizabeth Whelan, founder and then-president of the American Council on Science and Health, convened a meeting, chaired by former editor of the Journal of the American Medical Association Dr. George Lundberg, to discuss THR.  My colleague, epidemiologist Dr. Philip Cole, made the case for THR.  He was opposed by AO supporter Dr. Gregory Connolly, who erupted in ad hominem attacks before abruptly quitting the meeting. 

·         In 2006, I attended a THR meeting sponsored by the Open Society Institute.  Unfortunately, AO advocates refused to attend.

·         AO advocates also boycotted the University of Virginia-sponsored Morven “Dialogue on Tobacco, Nicotine and Alternative Products” in 2011, the first of several attempts by organizers to engage all sides of the THR debate. 

These personal recollections illustrate that while THR supporters are willing to engage, AO advocates are not.  It is an impasse, and there is only one way forward: a respected authority, who cannot be ignored by either faction, must convene a substantive symposium on the pros and cons of THR. 

Some might think that the federal tobacco regulator, the FDA Center for Tobacco Products, should organize such an event, but that is naïve.  The Center’s staff are fundamentally opposed to THR; the agency spends about $160 million annually, some 22 percent of its budget, on anti-tobacco, anti-vaping campaigns like “Real Cost.”  It has previously demonized e-cigarettes by showing them invading teens’ bodies as worms (the original material has been removed by the FDA, but this image is still available) and depicting a magician converting e-cigarettes into combustible cigarettes.  Now the FDA has partnered with Marvel Comics to produce a ghoulish video that casts vaping as a “mind control menace.”  While this video hasn’t a fact to stand on, it apparently comports with the FDA mission to tell “target audiences” about the “harms of tobacco product use.”

There is only one entity with the authority to command a rigorous debate: the White House, in the person of President Biden or Vice President Harris.  Either could override the THR opposition at federal agencies, and both have indicated they are open to the concept of harm reduction.  On April 20, 2021, White House Press Secretary Jen Psaki said that Biden supports states’ rights to legalize recreational marijuana, he supports legalizing medical marijuana, and he wants to look at rescheduling marijuana as a Schedule II drug to encourage scientific research.  She also said that Biden supports decriminalizing marijuana use and automatically expunging prior criminal records, which moves him incrementally closer to his campaign promise to release “everyone” jailed for pot.

Vice President Kamala Harris has been open to decriminalizing marijuana, though her history of dealing with the drug is mixed.  She supervised over 1,900 cannabis-related convictions as San Francisco’s District Attorney.  However, as a U.S. senator, Harris supported or sponsored several marijuana legalization bills. 

A Biden/Harris call for meaningful discussion and debate of THR would not interfere with FDA’s regulatory activities.  The agency’s Center for Tobacco Products already has procedures in place to approve new tobacco products for sale that are “appropriate for the protection of the public health,” and to approve modified (i.e., lower) risk tobacco products (MRTPs); some products have already received these approvals.  In the last six years, the agency has approved the sale of one snus product and one heat-not-burn product and also issued MRTP authorizations for those products.

If an FDA regulatory framework is in place, why should Biden and Harris call for THR discussion/debate?  There are 480,000 reasons – smokers who die prematurely every year.  That’s 6.4 million early smoking-related deaths since Mr. Biden was sworn in as Vice President in 2008. 

President Biden and Vice President Harris have used their clout to provide all Americans with life-saving vaccines for COVID-19, which has killed over a half-million Americans.  Now they need to initiate scientific debate on another “vaccine” – THR – that could help America’s TRTHgive 34 million smokers step away from the fire.