Harm Reduction as Public Health Strategy

Published April 7, 2005

Prepared remarks delivered on April 7, 2005, at the Heartland Capital Forum in Springfield, Illinois

I would like to talk to you briefly today about an important concept in public policy and regulation, the idea of “harm reduction.”

The idea of harm reduction sounds noncontroversial, or at least it did to me the first time I heard of it. After all, who here is against reducing harm?

The problem arises, however, when harm reduction is pitted against harm elimination. At one level, it only makes sense to prefer harm elimination over harm reduction – why stop at reducing harm if you can eliminate it instead?

I hope to answer that question today, showing you how harm reduction may in fact be preferable to harm elimination in some cases.

The basis of harm reduction is simple: people occasionally, sometimes frequently, engage in risky, unhealthy behavior. We can’t help it – so many things that are “bad” for us, or at least pose some hazard or risk, are also fun, tasty, comforting, or even thrilling.

Examples that come immediately to mind are ice cream, riding motorcycles, smoking cigars, skiing, whiskey, and attending loud rock concerts.

Harm reduction acknowledges that people are going to do these things, and others of equal or greater risk, and rather than seeking to eliminate the risk by trying to eliminate the potentially risky behavior, harm reduction seeks to modify or adjust the behavior in some way to achieve a better outcome.

I’d like now to briefly discuss a few examples of harm reduction, some of which may be controversial, some not. I hope these examples will allow you to see, as elected officials and those that advise them, how the idea of harm reduction can be incorporated into public policy.

The first examples are the Designated Driver and the “Contract for Life” programs.

Designated Driver programs are an excellent example of harm reduction in action. It is also a combination of both the law and voluntary actions by individuals to reduce an obvious risk.

Tens of millions of Americans drink alcoholic beverage every year. Most drink responsibly and in moderation. A few, however, do not.

The main danger is an intoxicated person behind the wheel. Here, both the government and the private sector jump in to reduce, but not eliminate, the risk associated with drunk driving.

On the government’s part, laws against drunk driving, police on the streets, and in some cases incarceration all serve to substantially reduce the risks connected with drunk driving.

Similarly, public service announcements alerting the public to the dangers, legal and otherwise, of drunk driving are an important part of the government’s efforts at harm reduction.

Dram shop laws, which impose liability on those who serve alcohol, provide a significant incentive for bar owners and hosts to ensure that their patrons and guests have safe travel arrangements in the event they become intoxicated.

Private action is also a key component of the Designated Driver idea of harm reduction. It is, after all, private citizens who volunteer to be the Designated Driver for their friends, family, co-workers, and even occasionally strangers.

Without this private, voluntary action, there would be no Designated Driver program worth discussing.

Have Designated Driver programs been successful? Most would say yes. Since 1982 drunk driving fatalities are down 41% according to the U.S. Department of Transportation.

Much, although not all, of this decline can be attributed to Designated Driver programs. More than 112 million Americans have either been a Designated Driver, or been driven by one. Roughly speaking, that’s about one out of every 2 adults.

Needless to say, there is little controversy about Designated Driver programs as a way of reducing harm, as opposed to trying to eliminate harm. The same cannot be said about the next program, which has a similar aim.

“Contract for Life” is an agreement promoted by Students Against Destructive Decisions, also known as SADD, which was originally founded as Students Against Drunk Driving.

The Contract for Life is signed by both student and parents. The student signs a pledge that reads in part:

I pledge my best effort to remain free from alcohol and drugs; I agree that I will never drive under the influence; I agree that I will never ride with an impaired driver… Finally, I agree to call you if I am ever in a situation that threatens my safety

The parent signs a pledge that reads in part:

I agree to provide for you safe, sober transportation home if you are ever in a situation that threatens your safety and to defer discussions about that situation until a time when we can both have a discussion in a calm and caring manner

These contracts, which have been around for about 20 years, embody the idea of harm reduction very well. It recognizes the ideal (the student won’t drink at all), but also provides for the possibility that the ideal may not be adhered to and prepares for that possibility with a plan that reduces the likelihood that a student will get in a car with a drunk driver, either themselves or another person.

What seems like common sense to some is taken by others to be a solution worse than the problem. Many parents express concern and even alarm about these contracts, believing that it sends a message to their children that underage drinking is acceptable, or at least not as unacceptable as it might seem without such a contract.

Similar controversies surround other activities focused on teens and efforts at harm reduction. Sex education is probably the most contentious of these issues, with some arguing that a strategy of harm reduction through comprehensive sex education is appropriate, with others taking the perspective that such programs increase the likelihood of risky behavior, and that “abstinence only” education is a more effective approach.

It is in its own way an argument between harm reduction and harm elimination.

I can offer little to suggest who is right concerning the last two examples. There is little research on the effectiveness of the Contract for Life program, and there is an enormous amount of research that is almost all contradictory on the issues related to sex education.

Another subject where harm reduction frequently comes up is tobacco use. The discussion largely centers on comparisons between smoking and the use of smokeless tobacco, although issues related to filtered vs. unfiltered cigarettes and low-tar cigarettes are also relevant to the idea of harm reduction.

This is a case where the risks are fairly well known and understood. According to the American Cancer Society, approximately half of all smokers will die prematurely, and smokers die on average approximately 6 to 7 years before non-smokers.

Men who smoke increase their risk of death from lung cancer by more than 22 times and from bronchitis and emphysema by nearly 10 times.

Women who smoke increase their risk of dying from lung cancer by nearly 12 times and the risk of dying from bronchitis and emphysema by more than 10 times. Smoking triples the risk of dying from heart disease among middle-aged men and women.

The health effects of smokeless tobacco are also well known and understood among researchers, but not generally among the public. Research consistently shows that smokeless tobacco is not “risk free,” but it also shows that it poses substantially less risk to users than smoking does.

One number stands out: while smokers lose on average 6 – 7 years off their lives, smokeless tobacco users lose approximately .04 years, or about 15 days compared to nonsmokers.

The most widely cited risk of smokeless tobacco is oral cancer, although epidemiological studies have shown that cigarettes actually pose a higher risk for oral cancer. There is no lung cancer risk associated with smokeless tobacco, nor is there a risk for heart disease.

According to Dr. Brad Rodu, Professor and past Chairman of Oral Pathology at the University of Alabama – Birmingham, and currently Senior Scientist at the their Comprehensive Cancer Center, smokeless tobacco is 98% safer than smoking.

Given these facts, the question then becomes: Would encouraging, or at least not discouraging, large numbers of smokers to switch to smokeless tobacco be good public policy?

Although for many years the prevailing sentiment among public health officials was an emphatic “NO”, that is beginning to change.

Dr. Neal Benowitz, a professor of medicine at the University of California at San Francisco and director of its cancer center’s Tobacco Control Program, had this to say recently:

“If someone can’t quit smoking, there is no question that smokeless is much safer. It doesn’t cause heart or lung disease, and if it does cause cancer, it does so at a much lower rate.”

Sweden’s experience with smokeless tobacco is a case study in the potential benefits incorporating harm reduction strategy regarding tobacco. During the past 40 years, a large percentage of Swedish smokers – primarily men – have switched from smoking cigarettes to using a moist snuff product called “snus.”

As a result, Sweden’s cancer rates for men, including oral cancer, have declined and are the lowest in Europe.

Cancer rates for Swedish women, on the other hand, who did not make the switch from cigarettes to smokeless tobacco in nearly the numbers men did, remain as high as rates for most other European women.

Not all of the public health community are sold on the appropriateness of harm reduction in this area. Some, such as the U.S. Surgeon General’s office, argue that allowing people to know that smokeless tobacco is significantly safer than smoking will prevent people from doing what is ultimately the safest thing, quitting tobacco use altogether.

Needless to say, these two opposing viewpoints have radically different recommendations for policymakers. Advocates of harm elimination generally support high taxes on all tobacco products and adamantly oppose any advertising that would publicize the significantly reduced risks of smokeless tobacco compared to cigarettes.

From their perspective, all tobacco use is bad, and recognizing that some forms of tobacco use are significantly less harmful than others is unacceptable.

Harm reduction advocates, however, support allowing the public to better understand the comparative risks between smoking, smokeless tobacco, and quitting. This would include allowing, for example, smokeless tobacco producers and sellers to advertise that their product is 98% safer than smoking.

Another harm reduction strategy often recommended is that in recognition of smokeless tobacco’s lesser risks, taxes to discourage tobacco use should focus on cigarettes, not smokeless tobacco.

This last approach, levying a lower relative tax burden on smokeless tobacco than cigarettes, is gaining some acceptance. Governor Ernie Fletcher of Kentucky, in his “Jobs for Kentucky” plan, states that:

“The relative taxes on tobacco products… reflect the growing data from scientific studies that although smokeless tobacco poses some risks, those… risks are significantly less than other forms of tobacco products.

It… acknowledges that some in the public health community recognize that tobacco harm reduction should be a complimentary strategy to… public health policy…

Taxing tobacco products according to relative risks is a rational tax policy and may well serve the public health goal of reducing smoking-related mortality and morbidity and lowering health care costs associated with tobacco-related disease.”

There are numerous other ways in which harm reduction is a part of many people’s everyday lives and in public policy which we don’t have nearly enough time to go into. To mention briefly a few, helmets for bicyclists, filtered cigarettes, catalytic converters on cars, and gambling treatment programs are all examples of harm reduction being used.

I’d like to wrap up now with a few concluding thoughts.

First, harm reduction, in its many different forms, should be considered a valuable compliment to public health strategies. That is not to say, however, that it is always appropriate.

A harm-reduction strategy for Russian Roulette, for example, might indeed find a way to statistically reduce the likelihood of someone shooting themselves playing this game.

However, I suspect nobody here would support this as a public health strategy, instead opting for what I think we all would agree is the only sensible goal: harm elimination, a total prohibition on playing Russian Roulette.

Second, harm reduction is obviously not without controversy. In only 12 minutes, I’ve touched on drinking, sex, and tobacco – all issues that are hotly debated by advocates of all stripes.

As policy makers, I would encourage you to listen to the comparative risks posed by different harm reduction strategies, without pre-judging them. After you have been able to assess the relative risks of harm elimination and harm reduction, then you should feel free to make your judgement as to whether harm reduction is an appropriate strategy in that instance.

Pay particularly close attention to claims that one thing is “just as bad” or “just as dangerous” as another thing, and then ask for evidence showing that to be true.

Third and finally, good harm reduction strategies seem to rely on government having at most a supporting role while individuals ultimately take responsibility. Designated Driver programs are an example of allowing private individuals to be responsible for their own actions, while the government steps in regarding those who aren’t with incarceration and legal liability.

Similarly, harm reduction for tobacco consists largely of allowing the information to become widely known about the relative health risks of smoking vs. smokeless tobacco vs. not using tobacco at all, and allowing individuals to make their own choices.

With that, I’d like to conclude my presentation, and I’d be happy to take any questions.

Sean Parnell, Vice President – External Affairs, the Heartland Institute