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Between Politics and Reason

  Chapter 10.   Alcohol and Tobacco: The Real Dangerous Drugs?

    Erich Goode — State University of New York, Stony Brook

James Q. Wilson (199Oa) asks us to perform a mental experiment. Imagine, he says, that in the 1920s, alcohol had been criminalized, and cocaine and heroin remained legal. Would the criminalization of alcohol have produced a criminal underworld of users and addicts? In contrast, would the two currently illegal drugs have become socially acceptable and widely used? If so, would the legalizers now be claiming that it is cocaine and heroin that are the more dangerous drugs, and that alcohol, being safer, should be legalized? In short, are the legalizers being duped into thinking that legal drugs are the more dangerous, not because of their intrinsic qualities, but simply because they are more widely used? Shouldn't we be worried about what will happen when cocaine and heroin are legalized and, hence, much more widely used? There's a lesson to be learned from this mental experiment, Wilson warns.
    Legalizers claim that the legal drugs, alcohol and tobacco, are more dangerous than has been acknowledged and, in fact, more dangerous than the illegal drugs—heroin, cocaine, marijuana, LSD, methedrine ("ice"), PCP (Sernyl, or "angel dust"), and the prescription drugs (when used for the purpose of intoxication rather than medication). Consequently, they say, the law and its enforcement are targeting the wrong drugs. As a result, prohibition is both discriminatory and ineffective. Why waste tens of billions of dollars, ruining hundreds of thousands of lives in the process, by criminalizing the users of comparatively safe drugs while the use and sale of more dangerous drugs are tolerated, even encouraged?
    Let's go back to a point I made early in the book and separate two entirely different issues here: the moral/ideological and the empirical issues. The moral or ideological issue says, arresting illegal drug users but permitting consumers of alcohol and tobacco to go their merry way is unfair and discriminatory. The empirical issue says, alcohol and tobacco are medically more harmful than cocaine, heroin, and the other illegal drugs. The first issue, that of fairness, is essentially unresolvable; it has its roots in philosophy and even theology. Once again, it is a non sequitur, a "So what?" argument. To say that it is unfair to arrest drug users and sellers but tolerate drinkers and smokers and that, therefore, the former substances should be legalized, does not logically follow. There may be a variety of reasons why a given activity or substance is banned while another is permitted; their relative dangerousness is only one of them. For instance, penalizing one activity may result in far more negative consequences than the other; the total damage may tip the balance in favor of cracking down on one and tolerating the other. Consequently, let's concentrate on the second issue, the consequentialist or empirical question, and ignore the first, the moral issue. More specifically, let's examine the evidence on the relative harm of the substances in question.
    What is the scorecard on harm? There is no doubt whatsoever that the legal drugs are a great deal more dangerous than most of us believe, while it's possible that the illegal drugs are less so. It's hard to imagine any public health expert questioning this point. But what about the harm of the illegal relative to the legal drugs? The legalizers argue: Let's compare the number of deaths from legal drugs with the number of deaths from illegal drugs. Pile up the bodies, and which source wins? It's legal drugs, hands down. But they also make a second empirical point as well; they argue that if the currently illegal drugs were to be legalized, their medical harm would decline, just as with crime and violence. Legalized, heroin and cocaine would cause less disease and fewer deaths than they do now.
    As to the first point, let's look at the medical record, they say. We've already seen that the two legal drugs cause or significantly contribute to the loss of well over half a million American lives per year—430,000 for tobacco and between 100,000 and 150,000 for alcohol. The methods by which these estimates were reached are complex and technical, and widely accepted; they need not detain us here. The important point is that our legal drugs kill hundreds of thousands of users—and nonusers as well, counting victims of homicide, accidents, and passive smoke. In contrast, the legalizers say, the total number of deaths from illegal drugs adds up to a mere 3,500 in a recent year, according to one advocate (Nadelmann, 1989, p.943). Are legal drugs almost 150 times more dangerous than illegal drugs? Are alcohol and tobacco far more dangerous than heroin and cocaine? Is this possible? Are the legal drugs more dangerous than the illegal drugs?
    The legalizers make a second and even stronger point: It is criminalization that makes the currently illegal drugs as harmful as they are. Legalize them, and they would be even less harmful. Here's what legalization would do, they say: regulate the production and sale of the now-illegal drugs, standardize the dose, make certain that they contain no impurities, distribute clean needles and condoms, make sure that treatment and maintenance programs are available to addicts and abusers on a walk-in basis. All these changes would result in a dramatic reduction in drug-related deaths (Nadelmann, 1989, p.942).
    Legal or illegal drugs: Which category is more dangerous? While legal drugs do cause more deaths, there are at least four problems with the legalizers' comparison between legal and illegal drugs as sources of death. First, the comparisons that are most often made are between apples and oranges. For the legal drugs, deaths from all sources, as well as for the entire country, are tallied; for the illegal drugs, deaths from only certain sources and only in certain areas of the country are tabulated. Second, the figures on drug-related deaths are meaningless until they are connected to the extent and frequency of use. Third, as I've emphasized, we don't know whether or how these figures will change under legalization. The legalizers are placing their money on no increases in the use of heroin and cocaine under legalization; the rest of us aren't so sure about this. What if use skyrockets? And fourth, the legalization tally makes no mention of an absolutely crucial measure in the field of public health: number of years of life lost. But the legalizers do insist on a crucial point, one that is in their favor: A distinction must be made between primary (or direct) and secondary (or indirect) drug harms.



Let's start with the "apples and oranges" issue; for the illegal drugs, we need to estimate roughly the overall total deaths they cause. We've already seen that DAWN estimates that 430,000 drug-related emergency room episodes took place in the coterminous United States. During the same period, 8,500 drug abuse-related deaths were tallied by DAWN, but only 43 metropolitan areas were included in the program (HHS, 1994b, 1994d, 1995b). If we use the same formula DAWN used to extrapolate from the emergency rooms they studied to the country as a whole, we come up with a total of 16,500 acute drug-related deaths. Some of these deaths entailed the use of alcohol in combination with illegal drugs, and some entailed the recreational use of, or suicides by taking, prescription drugs, that is, the illegal use of legal prescription drugs. A few are the result of taking overdoses of over-the-counter drugs like aspirin and Tylenol. Even so, 16,500 deaths is a very long way from the tally racked up by the legal drugs—430,000 for cigarettes and roughly 100,000 to 150,000 for alcohol.
    Of course, these medical examiners' reports on drug-related and drug-caused deaths only entail acute reactions, as well as deaths from fairly direct medical causes. We know nothing from the DAWN data about deaths from chronic illegal drug-related causes. We know that most of the deaths that legal drugs cause are from chronic, not acute, causes—for instance, lung cancer as a result of cigarette smoking and cirrhosis of the liver from excessive drinking. Yes, the major slice of the deaths that the illegal drugs cause is acute in origin. This is partly because most drug addicts, unlike drinkers and smokers, do not live long enough to become victims of many chronic drug-related illnesses. But at least two additional sources of death are worth mentioning; one is nonacute in nature and the other is not, strictly speaking, medical in origin: the first, contracting the AIDS/HIV virus, and the second, drugrelated violence.
    Half the roughly half a million to a million needle-using heroin addicts in the country are infected with the HIV virus. It is not unlikely that almost all of them (that is, a quarter to half a million) will die within a decade or two. And a very high proportion, perhaps as many as 10 percent, of the heaviest chronic cocaine and crack-dependent abusers are similarly infected, some through the use of needles and some as a result of engaging in unprotected sex (McCoy and Inciardi, 1995); hence, they share the same medical fate as the infected heroin addicts. Clearly, then, drug abuse is a prodigious—and growing—source of AIDS-related death. It is possible that, as a result of their use of heroin and cocaine, 25,000 to as many as 50,000 Americans a year will die of AIDS in the early years of the twenty-first century. The legalizers argue that these deaths are largely or entirely due to the current ban on needle exchange programs; their numbers would drastically decline under the plan legalizers propose. And AIDS is a secondary consequence of drug use, but that's a separate issue. And violence? Here, we're relying on a bit more speculation than for AIDS-related deaths. Roughly 25,000 Americans are murdered each year. How many are drug-related? A common estimate is that half of all large-city criminal homicides, or perhaps a quarter of the total, some 6,000 to 8,000, are causally related to the use of illegal drugs. This is a lot of people, but the total is unlikely to exceed the deaths racked up for alcohol. We discussed the issue of whether this total would rise fall, or remain the same under legalization in the last chapter.
    Suffice it to say that, if the total sources of yearly death from illegal drugs are tallied for the country as a whole, we'd come up with a total many times higher than Nadelmann's 3,500 figure. Illegal drug use is a great deal more dangerous than the legalizers claim.



Second point. To me, the key question here relates to the extent and frequency of use: Under legalization, would the use of heroin and cocaine rise and, with it, the damage their use causes? Many observers say yes. I agree. As John Kaplan says, denying that it would simply ignores one of the most basic generalizations in the field of pharmacology (1988, p.33). Statistics on harm must be considered with reference to total use, or prevalence. I've already summarized the statistics on prevalence rates for the legal and illegal drugs. Not only are there more users of legal than illegal drugs, but their continuance rates, likewise, are considerably higher. Suffice it to say that legal drugs are used vastly more often than the illegal drugs are, on an episode-for-episode basis. Roughly 60 to 70 billion "doses" of alcohol (that is, drinks containing one ounce) and something like 500 billion "doses" of nicotine (that is, individual cigarettes) are consumed in the United States each year. The point is, when discussing the dangers of these two legal drugs, we must keep in mind their total number of users and the total number of episodes of their use. In contrast, there are between half a million and a million heroin addicts or more-or-less daily abusers, and between two and three million Americans taking cocaine weekly or more (Goldstein, 1994, p.241; Kleiman, 1992b, p.288), which add up to vastly smaller use figures for the illegal drugs than for alcohol and cigarettes. Estimating the total number of times addicts as well as the more casual users of these two drugs take heroin and cocaine is likely to be tricky; still, it is unlikely to be more than a tenth the number of doses of alcohol and one one-hundredth that of cigarettes.
    On an episode-for-episode basis, which is more dangerous: using legal or illegal drugs? We may not come up with a clearly more dangerous category. Different drugs kill in different ways, and our evidence is quite messy and inexact. In the absence of more precise measures, it should be sufficient to say that, while, descriptively, the legal drugs kill many more Americans than the illegal drugs do, relative to the extent of their use, we may have something of a tie. To answer the question definitively, we'd need more data. Both categories certainly kill a lot of people; both categories include very dangerous drugs. Consider the fact that heroin appears almost as often in DAWN's lethal "overdose" statistics as cocaine—and the fact that, in the United States, cocaine is used something like 10 times as often as heroin. It seems almost certain that there is something intrinsic about heroin itself, not the mere fact that it is illegal, that is related to its capacity to kill.



Another point concerning the legalizers' flawed argument: ignoring years of life lost. Legal and illegal drugs do not kill their victims at the same age in the life span. The legal drugs kill older victims, and, hence, there are fewer years of life lost per victim; the average victim of the illegal drugs tends to be younger, and, hence, for each death, far more years of life are lost. Tobacco and alcohol are most likely to kill persons in their fifties, sixties, and seventies—tobacco kills those a bit older, alcohol those a bit younger; but taken as a whole and on average, they kill the middle-aged to the elderly. In contrast, heroin and cocaine are most likely to kill victims in their twenties and thirties. The fact that AIDS, almost entirely contracted from drug-addicted mothers, is the number-one killer of children age one to four in New York City is dramatic evidence that age cannot be ignored in any evaluation of harm. Thus, on a death-by-death basis, far more years of life are lost as a consequence of the use of the illegal drugs than of the legal drugs. This point cannot be ignored in any public health tabulation of the relative harm of these two categories of drugs. Even factoring this into the equation, we're still a long way from parity for the two drug categories as a source of death, but it does tip the scales a bit.



One problem with any exercise which equates sources of death as a result of the use of different drugs is that it is difficult to separate the contribution that drug use per se makes to drug-related medical problems, death, accidents, violence, and other measures of harm and dangerousness from the legal status of these drugs. That is, are the correlations between drug use and harm a primary effect of the drug itself or a secondary product of the circumstances of use, including the drug's legal status? Says Mark Kleiman: "The failure to distinguish between the bad effects of drug abuse and the bad effects of drug abuse control sometimes reduces public discourse about drugs to gibberish" (1992b, p.17). At the same time, in some cases, this distinction is not always easy to make. "Some aspects of the drug problem defy division into results of pharmacology and results of legislation" (p. 17). We know that, by itself, heroin does not make the user sick, and that moderate and controlled doses do not cause the user to die. On the other hand, heroin addicts are taking a drug that can kill them; it is heroin that causes addicts to overdose if they take too much. It is not legal policy by itself that causes the medical problem addicts experience, nor is it the pharmacology of narcotics alone. We must free ourselves from the clutches of either-or thinking; we must stop imagining that drugs, by themselves, are magical substances that have harmful effects—and that law enforcement alone is responsible for the medical harm we see in addicts and abusers. It is a combination of the two.
    Nonetheless, if the currently illegal drugs were legalized, would they inflict less—or more—harm on the American public? Would as many users die of drug overdoses? Of drug-related disease? The legalizers claim that, in comparison with the legal drugs, not only are the currently illegal drugs relatively safe but they also would be a great deal safer if they were to be legalized (Nadelmann, 1989, pp.941-942). In opposition, the prohibitionists argue that the statistics measuring the relative harm of legal versus illegal drugs is an artifact of their legal status. Legalize the currently illegal drugs, and they will become a great deal more dangerous, not less. It is only because of their illegality that heroin and cocaine are expensive, difficult to obtain, and therefore relatively infrequently used; legalize them, and more people will use them—and more will become sick and die as a result (Wilson, 1990a).
    As I've already argued, here I agree with the criminalizers far more than with the legalizers. The evidence is extremely strong that more people would use the currently illegal drugs if the drugs were legalized and made more readily accessible. More important, the current addicts and abusers of heroin and cocaine would use a great deal more frequently—and more abusively—if they found that they could obtain these drugs with less cost and less hassle than is true now. It is difficult to imagine that anyone would discount the role of opportunity in use; regardless of the restrictions that legalization might place in the path of cocaine and heroin users, the restrictions would inevitably be less binding than is true under criminalization. To the extent that restrictions would apply, addicts and abusers would simply seek out the illicit market for their needs. No amount of good intentions will alter that fact.
    Still, the legalizers do make several good points. First, state-distributed drugs will be purer and more dosage-controlled than are the illicit drugs currently sold on the street. Contamination is not the, or even a, major problem for drugs sold on the street; a certain proportion of the batches of illicit drugs are contaminated, of course, but dealers who sell such goods are not likely to stay in business very long. (Marijuana sprayed with Paraquat, once a serious problem, hardly ever shows up any more.) Potency and purity vary greatly from one batch to another and can pose a serious problem for any user, but users tend to be foolhardy about the number of doses they take at one time as well as taking several different drugs at the same time. Variations in potency and purity simply adds another problem on top of several others that will still prevail, whether legalization is instituted or not. Keep in mind the fact that the rate of death among heroin addicts in the United Kingdom and the United States (mostly drug overdoses in both places) is the same, about 2 percent a year (Goldstein, 1994, p.241). Although Great Britain is a long way from legalization—some of its jurisdictions, such as Liverpool, are a great deal closer to it than others—it is also a system that is far more liberal and flexible, and less punitive, than is true of the United States. The fact that Great Britain has a somewhat different system but practically identical rates of drug-related death among addicts does not speak strongly for the legalizers' argument on harm.
    Their point on expanding drug treatment programs (along with a reduction in law enforcement directed at drug violators) is well taken. The problem is, hardly any drug expert questions it. It has become almost a truism that our priorities are misplaced; instead of a budget that allocates 25 percent to treatment (and education) and 75 percent to law enforcement, including interdiction and incarceration, we should have one where this ratio is reversed. Methadone maintenance programs should be expanded; so should therapeutic communities. Needle exchange and condom distribution programs promise to keep the rate of HIV and AIDS among addicts and drug abusers from rising (Lee, 1994). Clinics in mobile vans can search out addicts who are unwilling to come into an established program and can distribute methadone, needles, condoms, medical care, and information. There are many ways that the harmful consequences of drug abuse can be kept in check short of outright legalization, and many experts support a number of them. If nothing aside from the factors that legalizers discuss were to change, of course, legalization would produce less disease and fewer deaths among addicts and abusers. The problem is, drug use is a dynamic and volatile proposition; many observers believe that many of the changes that legalization would bring about would result in more medical harm, not less.



After all the possible sources of death are considered—and we have considered only a few—what does our scorecard look like? Which is the more dangerous category of drugs: legal or illegal? Are alcohol and tobacco more capable of causing harm—or heroin and cocaine? Focusing narrowly on acute medical effects, there is absolutely no doubt that heroin and cocaine—especially heroin—are far more likely to cause a medical emergency and lead to death by overdose on an episode-by-episode basis. Their contribution to DAWN's lethal medical examiners' reports is truly prodigious. (Alcohol causes many overdoses, most not counted by DAWN, but it is a far, far more widely used drug.) In contrast, focusing narrowly on direct, chronic medical effects, heroin and the narcotics do not cause the medical pathologies that alcohol and tobacco cigarettes do. (Incredibly, overdosing aside, narcotics cause no life-threatening medical pathologies of any kind.) It would be difficult for any drug to match alcohol's ravaging impact on the liver or tobacco's carcinogenic impact on the lungs. (The exact nature of the long-term impact of cocaine—and amphetamine—on the brain remains to be seen; we already know that in large doses over a long period of time, alcohol does damage the brain.) In addition, the illegal drugs are indirectly implicated in death in at least two major ways: the transmission of the HIV virus, through contaminated needles and unprotected sex, and murder resulting from dealing-related conflicts.
    All in all, the sources of drug-related death from both legal and illegal substances are considerable. It is difficult to select one category over the other as incontestably safer or more dangerous. Certainly criminalization contributes to some sources of illegal drug-related death (violence and AIDS), but it may inhibit others (acute and chronic medical pathologies). In the process of weighing the relative dangers of these two drug categories, it is difficult to come away with anything other than a mixed scorecard. Legalization is extremely unlikely to result in all the medical benefits legalizers argue for it. Addicts and drug abusers lead extremely unsafe lives; a surprisingly high proportion of them drink heavily—a substantial minority of methadone maintenance patients drink at alcoholic levels—take a variety of drugs simultaneously, use wildly different quantities and potencies of heroin and cocaine from one day to the next, use unsterile needles, are oblivious to nutrition, engage in dangerous illegal activities (such as robbery), are often arrested, and so on. While some of these factors will probably change under legalization, the total picture is not likely to change very much, for the one burning factor the legalizers are unable to dismiss is a rise in drug use following legalization. This renders their argument shaky if not specious.



As I said at the beginning of this chapter, the question of whether it is fair or just to criminalize the possession and sale of heroin and cocaine while keeping alcohol and tobacco legal is essentially unanswerable; it is a moral and ideological, not a sociological, issue. However, there is no contradiction between advocating legal reform for the currently illegal drugs—even legalization—and tighter restrictions on the legal drugs. In fact, following the "harm reduction" line of reasoning, it is likely that more lives will be saved by making tobacco and alcohol less accessible than by instituting any conceivable drug legalization or decriminalization program. In fact, Ethan Nadelmann, a major legalization spokesperson, has argued for control strategies aimed at tobacco and cigarettes (1989, p.945), and Mark Kleiman, a drug reformer who advocates limited legalization of marijuana, supports a variety of controls on the legal drugs (1992b, 203ff., 317ff.). The logic? Again, consider the numbers: Alcohol and tobacco kill many more people than the illegal drugs do because they are much more widely used; in the case of tobacco, roughly 50 million addicts use it dozens of times each day. The legal drugs are harmful because too many people use them far too frequently. Said another way, the legal drugs are far too readily available; too many people are finding it far too easy to get their hands on them. There is practically no "hassle factor" involved in obtaining and using them. (It is only after many episodes of use—in the case of tobacco, after literally decades of use—that the debt for use must be paid.) Hence, the question becomes, how do we lower the use of alcohol and tobacco? If we are serious about rewriting legal policy to reduce harm, this is an extremely important question.
    Please note that the following discussion of harm reduction strategies aimed at the legal drugs is not a display of my ideological or moral biases. I am not endorsing them as strategies so much as proposing that it they are adopted, fewer people will get sick and die as a result of use-related ailments. This is an empirically defensible exercise. Also note that, for tobacco at least, almost all smokers began the habit by age 19. Hence, any strategy that delays the onset of smoking will prolong life. This means that the most meaningful and most viable harm reduction strategies should be aimed at teenagers. The earlier in their lives that potential smokers are targeted, the greater the possible impact such a strategy is likely to have.
    Can we control tobacco and alcohol abuse through the vehicle of taxation? In fact, why not kill two birds with one stone? We could increase taxes to reduce use and, at the same time, offset the costs that smokers and drinkers impose on the rest of us by charging them more for using those substances. We already know that the cost of a psychoactive substance is correlated with its use—the higher the cost, the lower the use. What increases the cost of legal drugs? Why, an increase in taxation, of course; increase the taxes on tobacco and alcohol products, and use will decline (Goldstein, 1994, p.278; Goldstein and Kalant, 1990). The data supporting our ability to kill (or at least wound) the bird of high-volume use is fairly clear-cut and unambiguous. Of course, with higher taxation comes its inevitable by-product: a certain volume of clandestine, illegal, or underground sales of the product that is taxed. But once again, choosing a total package—lower use and a larger black market versus higher use and a smaller black market—is a political and ideological not an empirical question.
    The other bird isn't so easy to kill or wound, in part because the figures are more difficult to come by. Weighing the economic cost that smoking and drinking impose on the society versus the tax revenue that these products generate is an exceedingly complicated exercise. Tracing out all the economic costs, direct and indirect, of indulgence in these two legal drugs is not an easy matter; as soon as we alter one factor, the entire picture changes. Moreover, what do we include in the picture? In the case of alcohol, do we include the increased cost of an already-substantial criminal justice system? How do we measure the decline in productivity that takes place when the drinker can't show up for work? Or a decline in efficiency on the job the morning after an alcoholic binge? Another consideration: Often, observers fail to distinguish between costs that public facilities or nonsmokers incur ("external" costs) and those costs that are paid for directly by the smoker ("internal" costs). And do we calculate the costs incurred by a smoker's or a drinker's family as "external" or "internal" costs? Likewise, consider the following: Smokers get sick more often than nonsmokers and, hence, cost the rest of us far higher medical bills. However, they also tend to die at a significantly younger age; thus, they are less likely to need medical care and collect Social Security and retirement benefits when they become aged—because they more rarely live to be aged. Hence, ironically (at least in this one respect), the smoking habit actually saves the society a great deal of money! And, while heavy drinking is also related to an earlier demise, this is offset by the fact that alcoholics are more likely to retire significantly earlier than nondrinkers and moderate drinkers and, hence, are likely to draw public benefits for a longer period of time. Again, it should be clear that calculating the strictly economic costs of the use of the legal drugs is an exceedingly tricky proposition.
    Alcoholic beverages are taxed about 25 cents per ounce of absolute alcohol; this has actually declined, relative to inflation, over the past half century. For cigarettes, the current total for local, state, and federal taxes—averaged out nationwide—is about 53 cents per pack. To put a very long and complex equation into extremely simple terms, economic experts who have studied the question say that alcohol taxes do not pay for the costs they impose, while taxes on cigarettes do pay their own way. Taxes on alcohol would have to be approximately doubled to reach a break-even point (let's say to 50 cents per ounce of absolute alcohol); in contrast, all things considered, each pack of cigarettes sold only costs the society 33 cents in economic cost, for a net saving of 20 cents (Gravelle and Zimmerman,1994; Kotata, 1989; Manning et al., 1989; Viscusi, 1995; Warner et al., 1995). One major difference between smokers and heavy drinkers is the fact that drinkers are more likely to harm other parties in addition to themselves (accident and crime victims, for instance), while smokers are more likely to harm only themselves.
    Whether we are killing one bird or two, taxation can be used as a policy both to discourage use and to pay for the costs legal drug users impose on the rest of us. To reduce the harm inflicted on society and reduce use, one expert has tentatively proposed a tax of $ 1 per alcoholic drink and $5 per pack of cigarettes (Kleiman, 1992b, pp.248, 352). Of course, the tax rate would have to be standardized—or at least the differences minimized—for all states to keep the level of smuggling to a minimum. For tobacco at least, increasing taxation "offers the single greatest opportunity for reducing the toll drug taking takes on American life. There is no comparable opportunity for improving health through policy regarding any of the currently illicit drugs" (1992b, p.354). Another consideration: The likelihood that a proposal entailing hugely increased taxes on cigarettes and alcohol will be enacted within the next two decades is very nearly zero, however much sense it makes from a public health standpoint; too many powerful vested interests would oppose the measure and, chances are, would also convince the public that it is in their interest to oppose it as well. Still, restrictions on both alcohol and cigarette consumption are taking hold nationwide on a piecemeal basis; perhaps, eventually, the wisdom of control through taxation, likewise, will begin to occur to harm reduction reformers. Keep in mind that younger users and potential users, who have the least amount of money, will be most likely to be affected by tax increases. And keep in mind, too, that the further down the income ladder we look, taxes on alcohol and cigarettes will take up a greater proportion of the user's total income.
    Harm reduction control strategies need not remain the exclusive domain of federal, state, and local government; private citizens, too, could explore ways to reduce the harm that the legal drugs cause. Aside from increasing taxes, some possible strategies might include:
Ban all cigarette vending machines. This not only would reduce availability and possibly use overall but also would almost certainly reduce use among underage smokers. Although only one pack of cigarettes in 20 purchased by a teenager is obtained from a vending machine, roughly 10 times as many 14-year-olds as 18-year-olds obtain cigarettes from a vending machine. Harm reduction strategy dictates that vending machines dispensing cigarettes be banned altogether—or, at the very least, that they be banned in areas that are accessible to minors.
Enforce the law against cigarette sales to minors. Some 90 percent of teenagers say they purchase their own cigarettes (Kleiman, 1992b, p.343). Unlike establishments that sell liquor, vendors selling cigarettes do not have a license to lose; hence, violations are common. Knowing that selling to minors is illegal, nearly three-quarters of vendors questioned said that they would be willing to sell cigarettes to an l l-year-old girl (DiFranza et al., 1987). A 1993 study commissioned by the New York City Department of Consumer Affairs found that 48 of 60 stores sold loose cigarettes (for 15 to 20 cents apiece) to 12-to-14-year-old undercover agents; all the rest sold packs of cigarettes to these same teenagers (Messenger, 1995). Perhaps licensing for the sale of cigarettes could be explored: If vendors violate the law by selling to a minor, they lose the right to sell cigarettes. One study of 6,000 teenagers found that nearly half (45 percent) were never asked for proof of age (Feder, 1996).
Increase negative advertising. The alcohol and tobacco industry could be taxed to support a vigorous and effective campaign designed to reduce heavy drinking and smoking. In addition, cigarette ads blatantly aimed at children (such as the current "Joe Camel" campaign) could be banned altogether. The misleading and false disinformation distributed by the tobacco industry—the alcoholic beverage industry has not launched comparable campaigns—could be offset by counteradvertising and valid information that have a concrete impact on use. The distribution of free samples of cigarettes could be outlawed. The effectiveness of banning all cigarette and alcohol advertising could be explored. Would a ban it be effective? If evidence says yes, outlaw it.
Ban the export of American cigarette products abroad. As the number of cigarettes sold domestically declines, tobacco companies are targeting sales to other countries. All too often this means sales to developing Third World countries, which can least bear the burden of crushing medical expenses and the premature death of substantial segments of their populations. Should the American tobacco industry have the legal right to export death abroad? Jesse Helms, a senator from the tobacco-growing state of North Carolina, has put strong pressure on some countries that import U.S. tobacco to lift any and all tobacco restrictions. (Recall that Helms urged that federal support for AIDS be reduced because its victims brought the disease on themselves.) Such complicity with death might be exposed, publicized, and counteracted (Goldstein, 1994, p.279; Kleiman, 1992b, p.348).
Enact legislation outlawing the use of tobacco by minors. The fact is, purchasing a pack of cigarettes takes a few seconds, while smoking a cigarette takes a number of minutes—and, hence, the latter is much more vulnerable to detection. Such laws should not fall in the realm of the criminal law—entailing, as they could, arrest, jail, prison, and an arrest record—but should be regarded as minor offenses, somewhere in between a speeding ticket and a citation for driving while intoxicated. Fines, community service, or meaningful reeducation programs would be appropriate penalties (Kleiman, 1992b, pp.344-345).
Enact legislation further restricting public smoking. This has begun to take place in some locales—for instance, in restaurants in San Francisco, in restaurants above a certain size in New York City, on most airline flights, and in many work sites nationwide. Citizens could urge legislation further restricting where smokers are allowed to blow smoke in the faces of nonsmokers. The nonsmoking majority should make it clear to legislators that they endorse their right to breathe uncontaminated air.
Enforce the drunk driving laws. At present, penalties for drunk driving are ludicrously light and only fitfully applied. In Scandinavia, a loss of one's license is the penalty for first offenses, and jail sentences are imposed for second offenses; the impact of such penalties is not clear, with some observers arguing that the policy is effective and others claiming that it has no effect. An experiment in Oklahoma (Grasmick, Bursik, and Arneklev, 1993) showed that, when legal sanctions and the threat of public embarrassment and shame for drunk driving are combined, drunk driving declines. A variety of possible sanctions should be explored; what counts is what works. For the most part, however, alcohol-related auto fatalities have declined in the United States over the past two decades, from half to a third. Even among teenagers, the decline has been significant and striking. We must be doing something right.
Restrict the sale of alcoholic beverages. Should beer and wine be sold in supermarkets? In fact, perhaps the sale of all alcoholic beverages could restricted to a small number of state-run Alcoholic Beverage Control or "package" stores. Abolish all "happy hours" and all other special occasions in bars during which large discounts are offered to customers. Abolish all sale and use of alcoholic beverages at sporting events, on college and university campuses, on public transportation, and at all government functions (Goldstein, 1994, p.280). While none of these, by themselves, is likely to have a measurable impact on drinking, they send a message and set a climate that may signal a move to greater moderation in drinking.

    Four additional points. First, the goal of such proposals is not to catch offenders but to reduce drinking and smoking and therefore harm; enforcement should be flexible and pragmatic, not vindictive. Second, policy should always maximize citizen-based initiative and minimize government intervention; the latter becomes necessary only when it becomes clear either that private citizens do not have certain powers or that they are unwilling to exercise them. Third, to repeat a point worth repeating, my speculation that these proposals will reduce harm to the society are empirical in nature, not moral or ideological. They may sound Puritanical and anti-hedonistic. Personally, I am very much in favor of pleasure; I indulge in it myself. But pleasure should not be purchased at the cost of far greater pain. Worldwide, in the twentieth century, tens of millions of human beings have died as a result of indulgence in the legal drugs. Does not such a tragic loss of life deserve—demand—effective intervention? How many will die in the twenty-first century? If we do nothing, the figure could be far greater than the number of bodies that have piled up already. And fourth, again, to repeat an important point, very few of these proposals have any hope of implementation in the near future, at least in the form in which I've stated them. Right now, they are in the realm of utopianism. But consider, as Trebach does (1993, pp.81-82), the fact that before 1990, hardly anyone would have given the peaceful collapse of the Soviet Union much of a chance. He feels that this indicates that the very long shot of some form of legalization might be possible in the United States by the year 2000. I disagree, but my guess is, some of the preceding controls over alcohol and tobacco are a great deal more likely. In 1995, the American Medical Association recommended some of these reforms (Maier and Yu, 1995). And beginning in 1996, several former employees of the tobacco industry, a scientist and an executive, presented documentation that high-level managers were aware of tobacco's addicting properties and lied about this fact under oath. Perhaps these revelations will yield valuable resources for future lawsuits against the industry and will cripple its capacity to sell a dangerous drug to the public. Some of the proposals outlined above may be adopted here and there in the near future, and perhaps many of them will be implemented during the twenty-first century. If not, it is our loss.

Chapter 11.   Summary and Conclusions

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