TCS Daily


First, Do No Harm Reduction?

By Robert B. Ekelund - May 27, 2004 12:00 AM

Half a century of tobacco regulation has had dramatic effects on smoking behavior in the United States. But at the beginning of the twenty-first century, according to the Center for Disease Control, a definable "hard core" of cigarette smokers persists in the addiction. Approximately twenty-five percent of Americans, about 47 million people, remain smokers and that percentage changed little over the past thirteen years. Despite massive and expensive admonitions on the part of public and private agencies, so-called "quit rates" remain all but impervious (at only a three percent success rate in most studies) to "cold turkey" solutions and recalcitrant to many of the standard aids to cessation.

Is there hope for these people, many of them poor and bearing the highest burden from smoking and cigarette taxes? A relatively new and important response to the problem is a "harm reduction approach," one which, according to the National Academy of Science, lowers total tobacco-related mortality and morbidity despite the fact that the product may expose individuals to tobacco-related toxins. A nicotine substitute called smokeless tobacco or, snus as the Swedes dub it, offers some of the highest probabilities of smoking quits at low cost while creating minimal potential for harm. (It is the cigarette constituents and products other than nicotine that are primarily responsible for morbidity and mortality association with smoking).

Just what would be the harm reduction associated with the use of these products in the United States? A statistical study conducted by researchers at Auburn University, using the National Health and Nutrition Examination Survey (NHANES III) and published this year in the British journal Applied Economics, finds that the use of smokeless tobacco by an average U. S. male smoker would increase the average probability of smoke cessation by over 10 percent. Under reasonable assumptions this means an additional two to three million quits from those who try smokeless tobacco products. The estimation of the probability of smoke cessation permits calculations of cessation within certain age groups. In general males between 16 and 35 and between 46 and 55 have a 13 to 14 percent probability of quitting but that probability falls beyond age 66.

Clearly the harm from smoking would be reduced in terms of both life extension (a benefit from quitting) and health care costs. The Auburn study concluded that life-years would be enhanced significantly for male smokers (about 25 million), with total life-years extended by 18 million years if all adult male smokers try smokeless tobacco. This is clearly unrealistic. If adult U. S. males behaved as their Swedish counterparts in terms of smokeless tobacco use rates, there would be about 1.1 million additional quits with a saving in "life years" of about 2.16 million. When the increased risk from smokeless products is included in the calculation, life expectancy is reduced by only 15 days for the average individual. This means that the harm in harm reduction is likely to be quite small and the benefits in life extension quite large.

In addition to improved health and extended life expectancy, the promotion of smokeless tobacco among current smokers also has the potential to substantially reduce health care expenditures. Using the National Medical Expenditure Survey and health insurance statistics, Auburn researchers calculated the health care cost savings due to likely smoking cessation from the use of smokeless tobacco. Depending on which smoking cost estimate one accepts, savings on total smoking-related health care costs would be on the order of $3 billion per year. Naturally life extension and health care cost savings would be significantly larger if women smokers are included.

It appears that an indiscriminant zero tolerance towards all tobacco products in the U.S. is costing lives if, as research suggests, quits would increase for those who try smokeless tobacco. For example, a lowering of the excise taxes on smokeless tobacco products might encourage smokers, particularly low-income smokers, to try the product and to hopefully quit smoking. "Nirvana thinking," when it comes to cancer prevention and the total elimination of addictions, must be replaced by "possibility thinking" if the goal of public policy is to save life years and improve health.

Robert B. Ekelund, Jr. is Eminent Scholar in Economics (Emeritus), Auburn University.


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