Public Health As an Alternative to the War on Drugs

Delivered at the Drug Policy Foundation's 11th International Conference on Drug Policy Reform, October 17, 1997.

Since the theme of this panel is "Public Health As an Alternative to the War on Drugs," I thought I'd start things off by comparing the public health model to the prohibitionist approach that has long dominated U.S. drug policy. In doing so, I'll use illustrations drawn from the anti-smoking movement, for several reasons.

First, tobacco is a drug in transition: Today it is primarily the concern of public health specialists; tomorrow it could be another target in the war on drugs.

Second, there are often tensions within the anti-smoking movement between public-health and prohibitionist impulses.

Finally, talking about the anti-smoking movement is a way of reminding you that my book is coming out in the spring, and you really ought to buy it.

Let's begin 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 current legal status.

Already we can see that 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.

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.

Aside from education, the policy prescriptions offered by public health specialists sound quite different from those offered by drug warriors. Prohibitionists emphasize interdiction, crop eradication, and other attempts to reduce the supply of drugs, along with arrests, fines, property forfeiture, and imprisonment for producers, sellers, and buyers. Public health specialists emphasize treatment, taxes, and regulations.

Both sets of policies are aimed, in part, at deterring certain kinds of drug use by making them more expensive and less convenient. While the public health prescriptions certainly seem milder, their effects can be similar. Voluntary treatment, for example, is clearly preferable to incarceration, but many advocates of drug treatment would send uncooperative "patients" to jail. In her recent history of drug use in America, the journalist Jill Jonnes explains the rationale for coercive drug treatment: "It is well known in the drug world that most addicts will not seek treatment except under some sort of duress," she writes. "Nor, for the most part, will they stick with it unless forced."

This attitude is encouraged by the disease metaphor that is central to the public health model. A disease is something inherently undesirable that happens to people against their will. No one in his right mind wants to be sick. Furthermore, this is a disease that is said to impair the patient's judgment; one of its symptoms is "denial." Where's the harm, then, in forcing an addict to be well? Under the circumstances, this would seem the compassionate thing to do.

Just as treatment can resemble prison, taxation can resemble prohibition. Prohibition itself can be viewed as a tax, raising the prices of certain goods by making them riskier to produce and sell. Conversely, a high enough tax produces some of the dramatic side effects associated with prohibition.

When the Canadian government sharply increased cigarette taxes in 1989 and 1991, the consequences precipitated a crisis and a dramatic policy reversal. In response to smuggling, violence, and widespread disobedience, the Canadian government announced big tax cuts in February 1994. The solicitor general cited "a frightening growth in criminal activity" and "a breakdown in respect for Canadian law." The prime minister said "smuggling is threatening the safety of our communities and the livelihood of law-abiding merchants. It is a threat to the very fabric of Canadian society."

Regulations, too, can simulate the effects of prohibition by restricting information, discouraging innovation, and banning the sale of products that people want to buy. In the case of cigarettes, manufacturers have dramatically reduced tar yields during the last four decades or so. Although there is considerable dispute about the extent of the benefit--since the official yields are not a very good indicator of what smokers actually absorb--the evidence indicates that cigarettes today are measurably less hazardous than they were in 1950. If the government had stopped the tobacco companies from introducing low-yield brands, or if it had forbidden them to advertise tar yields, we would not have seen this trend.

The next wave of safer cigarettes, represented by the R.J. Reynolds brand Eclipse, promises more-substantial improvements. But an advertising ban or FDA regulation--both of which would make it much more difficult, if not impossible, to introduce new brands--would discourage the development of such products.

The reaction of tobacco's opponents to Eclipse and an earlier RJR attempt at a safer cigarette, Premier, illustrated the tension within the anti-smoking movement between public health and prohibitionism. Representative Henry Waxman, a California Democrat who is one of the tobacco industry's most vociferous critics in Congress, said Eclipse was a positive development. John Pauly, a smoking expert at Roswell Park Cancer Center, said: "We have come to realize that despite numerous warnings since 1964, there exists a very large segment of the smoking population who are either unwilling or unable to give up smoking. It's worthwhile to come in with a safer cigarette."

Other opponents of smoking viewed the new brands with alarm. "We think it's just a desperate attempt on their part to reverse the growing social taboo against smoking," an American Lung Association spokeswoman said of Premier. "It would be too bad to see the current momentum--which has encouraged a lot of people to quit smoking--defused or confused," said Jan Hitchcock, associate director of Harvard's Institute for the Study of Smoking Behavior and Policy. As Matthew Meyers, then staff director of the Coalition on Smoking or Health, explained, "The fact that a product is safer doesn't mean that there is a net health gain if it ends up leading more people to smoke."

Similarly, the physician and addiction specialist John Slade has argued that innovation in cigarette design threatens public health because it encourages people to keep smoking. "If the new products were not available," he wrote in 1990, "more people would be able to respond directly to concerns about illness and death from smoking and become completely abstinent from nicotine." Slade argued that the government should "prohibit any new products unless they first had demonstrated their safety. Had such a policy been in effect in 1950, the only cigarettes on the market today would be unfiltered 70 mm smokes, and far fewer people would be smoking."

Now, it's possible to make a public health case for keeping cigarettes as dangerous as possible. It hinges on the notion, suggested by Myers and Slade, that the health benefits enjoyed by smokers who switch to safer cigarettes are swamped by the health costs associated with people who start or continue smoking because safer cigarettes are available. I'm not sure how you would test this hypothesis, but I find it rather implausible.

In any case, something other than public health seems to be at work here. The opposition to safer cigarettes is reminiscent of the opposition to methadone maintenance and needle exchange programs. In both cases, critics argue that making drug use safer "sends the wrong message." Prohibitionists want drug use to be dangerous, the better to deter the uninitiated and encourage users to quit. Public health specialists, on the other hand, should welcome the opportunity to reduce the harm associated with drug use.

The same sort of conflict can be seen in the reaction to smokeless tobacco. Brad Rodu, an oral pathologist at the University of Alabama at Birmingham, thinks smokers ought to give up tobacco completely. But if they choose not to, he says, they are much better off with smokeless tobacco than with cigarettes.

In his 1995 book For Smokers Only: How Smokeless Tobacco Can Save Your Life, Rodu notes that oral cancer is the only well-established, life-threatening risk associated with the use of smokeless tobacco, and even that disease is twice as common among smokers. He estimates that "if all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from oral cancer [a year], versus the current 419,000 deaths from smoking-related cancers, heart problems, and lung disease."

By this measure, Rodu argues, smokeless tobacco is 98 percent safer than smoking. He and his colleagues estimate that the life expectancy of a smokeless tobacco user is virtually the same as the life expectancy of a nonsmoker. Still, Rodu emphasizes that "smokeless tobacco should only provide a viable and comparatively safe damage control measure for the current and last generation of nicotine addicts."

Rodu, who compares smokeless tobacco to methadone, has been condemned by other opponents of smoking because they consider his message detrimental to the cause. "To say that one form of tobacco is safer than the other at this point in the debate is just irresponsible," said Gregory Connolly, director of the Massachusetts Tobacco Control Program. "Tobacco is tobacco. -- It's like telling someone to jump from the fifth floor instead of the 10th floor."

After Rodu and University of Alabama epidemiologist Philip Cole published a letter in Nature suggesting the benefits of switching from cigarettes to smokeless tobacco, the National Cancer Institute prepared a statement rejecting "the substitution of one known carcinogen for another," which it called "medically and ethically unwarranted." The NCI said recommending a switch to smokeless tobacco "sends the wrong message."

Public health and prohibitionism also clash in the debate over proposals to force the gradual removal of nicotine from cigarettes. As tobacco's opponents themselves have been pointing out for years, people tend to adjust their behavior when they switch to cigarettes with a lower nicotine yield. They consume more cigarettes, take more puffs, inhale more deeply, hold the smoke longer, and so on. This means they absorb more toxins than the official tar yield suggests.

From a public health perspective, then, the last thing you want to do is reduce the nicotine-to-tar ratio. Indeed, what you really want is a low-tar, high-nicotine product. Yet anti-smokers are horrified when a tobacco company tries to maintain nicotine levels while reducing tar, which they see as an insidious plot to keep smokers hooked. In the name of weaning smokers from this habit, they advocate a policy that would make cigarettes more dangerous by forcing people to smoke more for the same effect. This suggests that they are worried about chemical dependence per se rather than the harm associated with it.

I've noted some ways in which the public health model is better--more rational, realistic, and compassionate--than prohibitionism. Now I'd like to suggest some ways in which it is as bad and possibly worse. Both prohibitionism and public health tend to gloss over individual differences in tastes, preferences, and behavior. They seek to achieve a collective goal using the coercive power of the state. Neither approach sets a clear limit to the use of such power.

But at least prohibitionists implicitly recognize that drug use is a matter of choice; they say it is a crime for which people may rightly be punished. Public health specialists call it a disease. At one time, the phrase "epidemic of drug use" was controversial; now it is used routinely, and people often seem to mean it literally. The consensus statement of Physician Leadership on National Drug Policy declares, "Addiction to illegal drugs is a chronic illness."

While compassion may be the motive, the main function of the disease metaphor is to banish the notion that a drug user's choices and desires should matter. A happy, productive, well-adjusted drug user is still sick, still part of an epidemic, even though he doesn't realize it. Alternatively, he is an asymptomatic carrier, spreading misery to others by setting a bad example. Either way, he has to be isolated and cured, whether he likes it or not. I'm not saying that everyone who calls addiction a disease must support coercive treatment, but we have to be aware of how such terminology affects public perceptions.

Consider how tobacco's opponents use the disease metaphor to manipulate the debate about smoking. According to the 1988 surgeon general's report on nicotine addiction, "Smoking is a disorder that can be remedied through medical attention." Former FDA Commissioner David Kessler calls it "a pediatric disease." Others have called smoking "Public Health Enemy Number One," "the greatest community health hazard," "the single most important preventable cause of death," "the manmade plague," "the global tobacco epidemic."

Thus smoking is something to be stamped out, like smallpox or yellow fever. This view of smoking is part of a public health vision that encompasses all sorts of risky behavior, including not just smoking, drinking, and other kinds of drug use but overeating, failure to exercise, owning a gun, speeding, riding a motorcycle without a helmet--in short, anything that can be said to increase the incidence of disease or injury.

Public health used to mean keeping statistics, imposing quarantines, requiring vaccination of children, providing purified water, building sewer systems, inspecting restaurants, regulating emissions from factories, and reviewing drugs for safety. Nowadays it means, among other things, banning cigarette ads, raising alcohol taxes, restricting gun ownership, forcing people to buckle their seat belts, and making illegal drug users choose between prison and "treatment." In the past, public health officials could argue that they were protecting people from external threats: carriers of contagious diseases, fumes from the local glue factory, contaminated water, food poisoning, dangerous quack remedies. By contrast, the new enemies of public health come from within; the aim is to protect people from themselves rather than each other.

Because the public health field developed in response to deadly threats that spread from person to person and place to place, its practitioners are used to enlisting the state's assistance. Treating risky behavior like a contagious disease therefore invites endless government meddling.

According to John J. Hanlon's widely cited textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place." If this is the vision of people who call for government action in the name of "public health," I'd rather take my chances with the drug warriors. Their ambitions are modest by comparison.