Archives For harm reduction

The Economist takes on “sin taxes” in a recent article, “‘Sin’ taxes—eg, on tobacco—are less efficient than they look.” The article has several lessons for policy makers eyeing taxes on e-cigarettes and other vapor products.

Historically, taxes had the key purpose of raising revenues. The “best” taxes would be on goods with few substitutes (i.e., inelastic demand) and on goods deemed to be luxuries. In Wealth of Nations Adam Smith notes:

Sugar, rum, and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.

The Economist notes in 1764, a fiscal crisis driven by wars in North America led Britain’s parliament began enforcing tariffs on sugar and molasses imported from outside the empire. In the U.S., from 1868 until 1913, 90 percent of all federal revenue came from taxes on liquor, beer, wine and tobacco.

Over time, the rationale for these taxes has shifted toward “sin taxes” designed to nudge consumers away from harmful or distasteful consumption. The Temperance movement in the U.S. argued for higher taxes to discourage alcohol consumption. Since the Surgeon General’s warning on the dangers of smoking, tobacco tax increases have been justified as a way to get smokers to quit. More recently, a perceived obesity epidemic has led several American cities as well as Thailand, Britain, Ireland, South Africa to impose taxes on sugar-sweetened beverages to reduce sugar consumption.

Because demand curves slope down, “sin taxes” do change behavior by reducing the quantity demanded. However, for many products subject to such taxes, demand is not especially responsive. For example, as shown in the figure below, a one percent increase in the price of tobacco is associated with a one-half of one percent decrease in sales.



Substitutability is another consideration for tax policy. An increase in the tax on spirits will result in an increase in beer and wine purchases. A high toll on a road will divert traffic to untolled streets that may not be designed for increased traffic volumes. A spike in tobacco taxes in one state will result in a spike in sales in bordering states as well as increase illegal interstate sales or smuggling. The Economist reports:

After Berkeley introduced its tax, sales of sugary drinks rose by 6.9% in neighbouring cities. Denmark, which instituted a tax on fat-laden foods in 2011, ran into similar problems. The government got rid of the tax a year later when it discovered that many shoppers were buying butter in neighbouring Germany and Sweden.

Advocates of “sin” taxes on tobacco, alcohol, and sugar argue their use impose negative externalities on the public, since governments have to spend more to take care of sick people. With approximately one-third of the U.S. population covered by some form of government funded health insurance, such as Medicare or Medicaid, what were once private costs of healthcare have been transformed into a public cost.

According to Centers for Disease Control and Prevention in U.S., smoking-related illness in the U.S. costs more than $300 billion each year, including; (1) nearly $170 billion for direct medical care for adults and (2) more than $156 billion in lost productivity, including $5.6 billion in lost productivity due to secondhand smoke exposure.

On the other hand, The Economist points out:

Smoking, in contrast, probably saves taxpayers money. Lifelong smoking will bring forward a person’s death by about ten years, which means that smokers tend to die just as they would start drawing from state pensions. In a study published in 2002 Kip Viscusi, an economist at Vanderbilt University who has served as an expert witness on behalf of tobacco companies, estimated that even if tobacco were untaxed, Americans could still expect to save the government an average of 32 cents for every pack of cigarettes they smoke.

The CDC’s cost estimates raise important questions regarding who bears the burden of smoking related illness. For example, much of the direct cost is borne by private insurance, which charge steeper premiums for customers who smoke. In addition, the CDC estimates reflect costs imposed by people who have smoked for decades—many of whom have now quit. A proper accounting of the costs vis-à-vis tax policy should evaluate the discounted costs imposed by today’s smokers.

State and local governments in the U.S. collect more than $18 billion a year in tobacco taxes. While some jurisdictions earmark a portion of tobacco taxes for prevention and cessation efforts, in practice most tobacco taxes are treated by policymakers as general revenues to be spent in whatever way the legislative body determines. Thus, in practice, there is no clear nexus between taxes levied on tobacco and government’s use of the tax revenues on smoking related costs.

Most of the harm from smoking is caused by the inhalation of toxicants released through the combustion of tobacco. Public Health England and the American Cancer Society have concluded non-combustible tobacco products, such as e-cigarettes, “heat-not-burn” products, smokeless tobacco, are considerably less harmful than combustible products.

Many experts believe that the best option for smokers who are unable or unwilling to quit smoking is to switch to a less harmful alternative activity that has similar attributes, such as using non-combustible nicotine delivery products. Policies that encourage smokers to switch from more harmful combustible tobacco products to less harmful non-combustible products would be considered a form of “harm reduction.”

Nine U.S. states now have taxes on vapor products. In addition, several local jurisdictions have enacted taxes. Their methods and levels of taxation vary widely. Policy makers considering a tax on vapor products should account for the following factors.

  • The current market for e-cigarettes as well as heat-not-burn products in the range of 0-10 percent of the cigarette market. Given the relatively small size of the e-cigarette and heated tobacco product market, it is unlikely any level of taxation of e-cigarettes and heated tobacco products would generate significant tax revenues to the taxing jurisdiction. Moreover much of the current research likely represents early adopters and higher income consumer groups. As such, the current empirical data based on total market size and price/tax levels are likely to be far from indicative of the “actual” market for these products.
  • The demand for e-cigarettes is much more responsive to a change in price than the demand for combustible cigarettes. My review of the published research to date finds the median estimated own-price elasticity is -1.096, meaning something close to a 1-to-1 relationship: a tax resulting in a one percent increase in e-cigarette prices would be associated with one percent decline in e-cigarette sales. Many of those lost sales would be shifted to purchases of combustible cigarettes.
  • Research on the price responsiveness of vapor products is relatively new and sparse. There are fewer than a dozen published articles, and the first article was published in 2014. As a result, the literature reports a wide range of estimated elasticities that calls into question the reliability of published estimates, as shown in the figure below. As a relatively unformed area of research, the policy debate would benefit from additional research that involves larger samples with better statistical power, reflects the dynamic nature of this new product category, and accounts for the wide variety of vapor products.


With respect to taxation and pricing, policymakers would benefit from reliable information regarding the size of the vapor product market and the degree to which vapor products are substitutes for combustible tobacco products. It may turn out that a tax on vapor products may be, as The Economist notes, less efficient than they look.

In January a Food and Drug Administration advisory panel, the Tobacco Products Scientific Advisory Committee (TPSAC), voted 8-1 that the weight of scientific evidence shows that switching from cigarettes to an innovative, non-combustible tobacco product such as Philip Morris International’s (PMI’s) IQOS system significantly reduces a user’s exposure to harmful or potentially harmful chemicals.

This finding should encourage the FDA to allow manufacturers to market smoke-free products as safer alternatives to cigarettes. But, perhaps predictably, the panel’s vote has incited a regulatory furor among certain politicians.

Last month, several United States senators, including Richard Blumenthal, Dick Durbin, and Elizabeth Warren, sent a letter to FDA Commissioner Scott Gottlieb urging the agency to

avoid rushing through new products, such as IQOS, … without requiring strong evidence that any such product will reduce the risk of disease, result in a large number of smokers quitting, and not increase youth tobacco use.

At the TPSAC meeting, nine members answered five multi-part questions about proposed marketing claims for the device. Taken as a whole, the panel’s votes indicate considerable agreement that non-combustible tobacco products like IQOS should, in fact, allay the senators’ concerns. And a closer look at the results reveals a much more nuanced outcome than either the letter or much of the media coverage has suggested.

“Reduce the risk of disease”: Despite the finding that IQOS reduces exposure to harmful chemicals, the panel nominally rejected a claim that it would reduce the risk of tobacco-related diseases. The panel’s objection, however, centered on the claim’s wording that IQOS “can reduce” risk, rather than “may reduce” risk. And, in the panel’s closest poll, it rejected by just a single vote the claim that “switching completely to IQOS presents less risk of harm than continuing to smoke cigarettes.”

“Result in large number of smokers quitting”: The panel unanimously concluded that PMI demonstrated a “low” likelihood that former smokers would re-initiate tobacco use with the IQOS system. The only options were “low,” “medium,” and “high.” This doesn’t mean it will necessarily help non-users quit in the first place, of course, but for smokers who do switch, it means the device helps them stay away from cigarettes.

“Not increase youth tobacco use”: A majority of the voting panel members agreed that PMI demonstrated a “low” likelihood that youth “never smokers” would become established IQOS users.

By definition, the long-term health benefits of innovative new products like IQOS are uncertain. But the cost of waiting for perfect information may be substantial.

It’s worth noting that the American Cancer Society recently shifted its position on electronic cigarettes, recommending that individuals who do not quit smoking

should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.

Dr. Nancy Rigotti agrees. A professor of medicine at Harvard and Director of the Tobacco Research and Treatment Center at Massachusetts General Hospital, Dr. Rigotti is a prominent tobacco-cessation researcher and the author of a February 2018 National Academies of Science, Engineering, and Medicine Report that examined over 800 peer-reviewed scientific studies on the health effects of e-cigarettes. As she has said:

The field of tobacco control recognizes cessation is the goal, but if the patient can’t quit then I think we should look at harm reduction.

About her recent research, Dr. Rigotti noted:

I think the major takeaway is that although there’s a lot we don’t know, and although they have some health risks, [e-cigarettes] are clearly better than cigarettes….

Unlike the senators pushing the FDA to prohibit sales of non-combustible tobacco products, experts recognize that there is enormous value in these products: the reduction of imminent harm relative to the alternative.

Such harm-reduction strategies are commonplace, even when the benefits aren’t perfectly quantifiable. Bike helmet use is encouraged (or mandated) to reduce the risk and harm associated with bicycling. Schools distribute condoms to reduce teen pregnancy and sexually transmitted diseases. Local jurisdictions offer needle exchange programs to reduce the spread of AIDS and other infectious diseases; some offer supervised injection facilities to reduce the risk of overdose. Methadone and Suboxone are less-addictive opioids used to treat opioid use disorder.

In each of these instances, it is understood that the underlying, harmful behaviors will continue. But it is also understood that the welfare benefits from reducing the harmful effects of such behavior outweigh any gain that might be had from futile prohibition efforts.

By the same token — and seemingly missed by the senators urging an FDA ban on non-combustible tobacco technologies — constraints placed on healthier alternatives induce people, on the margin, to stick with the less-healthy option. Thus, many countries that have adopted age restrictions on their needle exchange programs and supervised injection facilities have seen predictably higher rates of infection and overdose among substance-using youth.

Under the Food, Drug & Cosmetic Act, in order to market “safer” tobacco products manufacturers must demonstrate that they would (1) significantly reduce harm and the risk of tobacco-related disease to individual tobacco users, and (2) benefit the health of the population as a whole. In addition, the Act limits the labeling and advertising claims that manufacturers can make on their products’ behalf.

These may be well-intentioned restraints, but overly strict interpretation of the rules can do far more harm than good.

In 2015, for example, the TPSAC expressed concerns about consumer confusion in an application to market “snus” (a smokeless tobacco product placed between the lip and gum) as a safer alternative to cigarettes. The manufacturer sought to replace the statement on snus packaging, “WARNING: This product is not a safe alternative to cigarettes,” with one reading, “WARNING: No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes.”

The FDA denied the request, stating that the amended warning label “asserts a substantial reduction in risks, which may not accurately convey the risks of [snus] to consumers” — even though it agreed that snus “substantially reduce the risks of some, but not all, tobacco-related diseases.”

But under this line of reasoning, virtually no amount of net health benefits would merit approval of marketing language designed to encourage the use of less-harmful products as long as any risk remains. And yet consumers who refrain from using snus after reading the stronger warning might instead — and wrongly — view cigarettes as equally healthy (or healthier), precisely because of the warning. That can’t be sound policy if the aim is actually to reduce harm overall.

To be sure, there is a place for government to try to ensure accuracy in marketing based on health claims. But it is impossible for regulators to fine-tune marketing materials to convey the full range of truly relevant information for all consumers. And pressuring the FDA to limit the sale and marketing of smoke-free products as safer alternatives to cigarettes — in the face of scientific evidence that they would likely achieve significant harm-reduction goals — could do far more harm than good.