Damned Tobacco

Part of the problem is simply inconsistency. After all, if public health specialists can endorse oral methadone as a safer alternative to injected street heroin, why can’t they endorse oral tobacco on similar grounds? If they recognize that drinking coca tea is not tantamount to smoking crack, why can’t they concede that sticking a Skoal Bandit between your lip and gum is not the same as smoking cigarettes?

But there is a sense in which it may be a good thing that public health specialists are inconsistent. If, as they seem to assume, the government has the authority to minimize morbidity and mortality by discouraging risky behavior, there is no end to the interventions that could be justified in the name of "public health"–and no safe harbor for individual freedom. Although the public health approach to illegal drug use may look good compared to the status quo, public health prescriptions for legal activities tend to increase government interference with personal decisions.

I’ll return to that point later. First let’s compare the public health model with the prohibitionist approach that has long dominated U.S. drug policy.

We can start with slogans. It’s hard to beat "a drug-free America" for sheer hubris, but "a smoke-free society" comes close. And while "Just Say No" and "zero tolerance" are admirably mindless, "Health for All"–the official goal of the World Health Organization–is breathtakingly so. Both "a smoke-free society" and "Health for All," by the way, were supposed to be achieved "by the year 2000." They’ve still got time.

Slogans, of course, can be misleading as well as revealing. Let’s dig a little deeper. The stated aim of the prohibitionists is to eliminate drug use–by which they generally mean the use of certain drugs, set apart from accepted intoxicants by custom, superstition, and historical accident. The stated aim of the public health specialists is to minimize morbidity and mortality–including the harm associated with the use of all drugs, whatever their legal status.

Thus, the public health specialists are in some ways more realistic than the drug warriors: They acknowledge that any drug, licit or illicit, can be harmful in certain circumstances. And they stress harm rather than drug use per se. This implies that the consumption of psychoactive substances is not necessarily problematic. It also suggests a willingness to consider the undesirable effects of attempts to discourage drug use.

Public health specialists recognize that the costs of a given anti-drug policy may outweigh its benefits, even if it succeeds in reducing drug use. In practical terms, this willingness to consider all costs, which also implies an openness to evidence, is the most important way in which public health specialists differ from prohibitionists.

This open-mindedness leads public health specialists to oppose restrictions on access to clean injection equipment, because dirty needles spread disease. It leads them to criticize state and federal regulations that discourage the proper treatment of pain. It leads them to question the Schedule I classification of marijuana, which prevents doctors from prescribing a potentially useful medicine. It leads them to reject punishments for drug offenses that seem disproportionate to the harm caused by use of the substance. It leads some public health specialists to go further, calling for decriminalization of drug use.

Punishment or Treatment?

Even the most moderate prohibitionist is not likely to go that far. The prohibitionist orientation is basically punitive: Using certain drugs is a crime; people who do it deserve to be arrested, humiliated, imprisoned, and divested of their property. The public health orientation, by contrast, is therapeutic: Drug use is a disease; people afflicted by it need to be treated. There is a wide range of opinion about what kind of drug use constitutes a disease and whether treatment should be voluntary. But the disease model, to which I’ll return, is central to the claim that drug use is a public health issue.

In terms of policy, both prohibitionists and public health specialists talk a lot about "education." Prohibitionists seem more willing to bend the truth if they think it will help scare people away from drugs, while public health specialists are more likely to insist that drug "education" have a sound scientific basis. They note that scare tactics tend to backfire in the long run, as people recognize that they’ve been misled and learn to distrust the source. Still, public health messages about drugs, like public health messages in general, are aimed at changing behavior, not simply disseminating facts.

And public health officials are not above misleading the public if they think it will help discourage smoking. Consider the recent campaign against cigars. For decades we’ve known that cigar smoking, though risky, is not nearly as dangerous as cigarette smoking, mainly because cigar smokers typically do not inhale. That point was confirmed by a recent NCI monograph.

Overall, the NCI reported, daily cigar smokers get oral and esophageal cancers almost as often as cigarette smokers. But they face much lower risks of lung cancer, coronary heart disease, and chronic obstructive pulmonary disease–the three main smoking-related causes of death. In a 1985 American Cancer Society study cited by the NCI, men who smoked a cigar or two a day were only 2 percent more likely to die than nonsmokers, a statistically insignificant difference. By contrast, the mortality rate was 69 percent higher for men who smoked a pack of cigarettes a day and 88 percent higher for those who smoked more than that.

The NCI emphasized that the risk from cigars increases with the frequency of smoking and the degree of inhalation. Cigar smokers who inhale deeply face measurably higher risks of heart disease and emphysema (though still not as high as those faced by cigarette smokers), and the risk of lung cancer for a five-cigar-a-day smoker who inhales approaches the risk for a pack-a-day cigarette smoker.

That sort of cigar smoker is unusual, however. "As many as three-quarters of cigar smokers smoke only occasionally," the NCI noted, and "the majority of cigar smokers do not inhale." Since the available data apply only to people who smoke at least one cigar a day, it said, "the health risks of occasional cigar smokers...are not known." In other words, there is no evidence that smoking cigars in moderation–with moderation defined by the way most cigar smokers actually behave–poses a measurable health risk.