ONLINE ONLY: What’s the Difference Between Heroin and Cigarettes?

With heroin addicts, doctors focus on harm reduction—why don't they do the same with smokers?

Theodore Dalrymple

Harm reduction has long been the mantra of the British approach to the problem of drug addiction, particularly to heroin. The argument in favour of this approach is as follows:

Certain people will continue to take drugs whatever prohibitive or restrictive measures are taken to interdict supply, and whatever   therapeutic means are employed to encourage them to stop.

These people are a hazard to themselves and to others, for example by taking variable quantities of the drug, thus risking dangerous overdose, and by sharing needles so that they spread blood-borne viruses which, by means of sexual contact, can enter the general population.

Moreover, these people who will take drugs irrespective of anything else generally find it difficult or impossible to meet the economic costs of continuing by legal means, and therefore resort to crime to ‘feed their habit,’ thus causing much misery to the rest of the population. 

In view of the intractability of their addiction, then, it is best to supply them with drugs and injecting equipment that will reduce, though not entirely eliminate, the harm they do to themselves and others. 

It is not my purpose here to argue whether harm reduction works or not, a question of formidable complexity and indeed moral import. I wish merely to point out an interesting contradiction, of some cultural significance, in the British Medical Journal, which has in the past published a large number of articles in favour of harm reduction. 

The edition for 5 January, 2013, included a three-page article about the concept of harm reduction in addiction to tobacco. If the argument is sound for heroin, why should it not be sound for tobacco? There are, after all, certain people who, come what may, will not give up their habit. It is true that, for the moment, smokers do not commit many crimes in pursuit of their poison but, if the argument about the connection between addiction to heroin and crime were correct (which, actually, I believe that it is not) – if, I say, it were true, then the time could come, if the price of cigarettes were increased much further in an attempt to reduce consumption, when smokers, who generally come, as do heroin addicts, from the lower economic reaches of society, would feel obliged to commit crimes in order to ‘feed their habit.’ No doubt criminal gangs would move into the trade in contraband tobacco. And, of course, second-hand smoke is the tobacco equivalent of the blood-borne viruses of heroin addiction.  

Now it so happens that substitute devices for delivering nicotine – the drug to which smokers are addicted – have been developed both by tobacco and pharmaceutical companies. They assist inveterate smokers to avoid the more harmful contents of tobacco smoke. Whatever the hazards of nicotine might be, they are much less when separated from the other contents of tobacco smoke. Hence the arguments for harm reduction for tobacco are very similar to those for harm reduction for heroin addiction.  

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers? 

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive. 

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem. 

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it. But inconsistency is rarely greater than in the spying-out of other people’s economic interests. Motes and beams come to mind.

Let me illustrate this point by a letter from a consultant paediatrician in the same edition of the BMJ. The letter is entitled ‘What hope is there for ethical investment?,’ and draws the attention of readers to the investments of the Wesleyan Life insurance company, which specialises (inter alia) in pension funds of doctors, and claims also to be an ethical investor. But the Wesleyan holds large quantities of shares in tobacco companies. The author of the letter pointed out that tobacco companies were among the top 10 holdings of the Wesleyan’s fund and finished by asking “If investing in tobacco counts as responsible policy in a company specifically catering for doctors, what hope is there for any ethical investment?” 

The unfortunate paediatrician does not realise just how hypocritical his letter is. His salary is paid entirely by the British government; if a packet of cigarettes costs £7.00, at least £5.47 of it goes to the British government, which is by far the biggest financial beneficiary of smoking, far bigger than the tobacco companies in absolute terms (it has, after all, only to collect the excise, while the tobacco companies actually have to make the product). Moreover, tobacco excise is one of the top ten sources of income of the British government. Thus, by working for the British government, the paediatrician is working for a tobacco trafficker. He should resign at once, and work only in the private sphere. 

The economic interests involved in harm reduction for heroin addicts are no doubt relatively small by contrast, but that it not to say they are unimportant for those who have them, or that they will not fight to retain them. The manufacturers who make substitute drugs and the governmental therapo-bureaucrats who distribute them will defend their interests just as the rest of us do. 

Consistency, no doubt, is the hobgoblin of little minds, but we must make some effort, at least, in its direction, or else deliver ourselves up to our own prejudices.          

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