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Can Risk-Reduction by Individuals Be Bad for Public Health?

The emergence of a new generation of tobacco products raises a twist on the "prevention paradox," Richard Bonnie said at the Student Scholarly Lunch on September 24, a regular lunch time discussion in which faculty members discuss their current research interest with law students.

Usually the "prevention paradox" works so that for any given individual the change in risk is trivial -- possibly so insignificant that a person need not bother to do it -- but applied over the whole population that small change would shift a disease's impact away from more people and reduce its harmful social effects. For example, what is the likely risk to one person in not wearing a seatbelt for a trip to the grocery store? Virtually none. But if no Americans wear a seat belt on their way to a grocery store, some injuries will certainly occur needlessly. Similarly, even small personal weight losses could reduce the general costs of high blood pressure's health consequences by making Americans generally less overweight.

However new tobacco products that purport to be safer than conventional ones raise the reverse possibility: that what might be good for the health of an individual can be bad for the health of the population as a whole. When 'lite' cigarettes lower in tars and nicotine were introduced smokers responded to the reduced toxicity by increasing their consumption of them. "Some say, 'at least the individual is not worse off'," Bonnie said. "But maybe some are, because some of them might have quit otherwise." The point of the new version of the product, after all, is to retain current users of the product.

Bonnie said some public health officials are concerned that the marketing of supposedly safer cigarettes will encourage more kids to start smoking and will reduce quitting by adult smokers.

Is it moral to constrain the development of these products, which Bonnie labeled "nicotine maintenance products," since they might be better for individuals who cannot quit? Does access to other risk-reducing products -- such as needle exchange programs aimed at intravenous drug users -- end up encouraging drug use by people who would have otherwise stopped? (Bonnie noted there is no evidence that needle exchange programs have raised the numbers of the drug-addicted.)

Similarly, there is some research evidence suggesting that moderate drinking of wine -- one or two glasses a day -- reduces heart attack risk. If promoted, would this lead to more drinking? Would people not now drinking wine begin drinking and would those who already drink feel encouraged to drink more? Would the number of those addicted to alcohol potentially rise? What choices are clearly risk-reducing for individuals but in the aggregate might be harmful for society? Bonnie's aim is to identify ethical principles that could inform health policymaking in this domain.

New tobacco products such as Accord and Eclipse (which looks like a cigarette) reduce exposure to toxins in tobacco smoke by reducing combustion, but they increase exposure to carbon monoxide. "We don't know if any of the changes in toxicity in the components are actually meaningful," Bonnie pointed out. "There'll be no data for a generation on the risk of use of the new products. We don't have a clue about what their effects are."

Right now these products are not being regulated and public health officials are worried, Bonnie noted, about how the manufacturers might market the new products and what claims would be made for them in advertising.

Citing First Amendment protections, Bonnie said, "It's never permissible to reduce access to information but we should be very careful about how products are characterized [in advertising]. We should be truthful but not misleading. Tobacco use has stuck at about 25 percent of Americans (the youth smoking rate is going up) and the 'quit rate' is also stuck."

The ethical tension he is trying to balance is between reducing harm and reducing initiation of the practice, he said.

Some of the students attending the workshop were interested in Bonnie's opinion about proposals to legalize marijuana and other illegal drugs. "Any institutionalization of availability, such as exists with alcohol and cigarettes, leads to more addicted users than would happen without institutionalized access," Bonnie noted. "Our current drug policy, for all the features we may not like about it, really is trying to reduce the prevalence of use. The question is how can we achieve these benefits at less cost."
• Reported by M. Marshall

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