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Public Health Promotion is OK

The Erowids thought I was unclear about my position “with regard to the government actively promoting misunderstandings and inaccuracies about disapproved drugs and their use,” so I will be explicit. I think it OK (meaning not unconstitutional and not outrageous if the majority want it) for the government to promote health and well being through public health campaigns that seek to change behavior, particularly when the campaigns are directed toward youth. I generally prefer for such campaigns to achieve their ends simply by providing accurate information, but acknowledge that sometimes appealing to emotions or providing only selective information is more effective at changing behavior. So those who design and implement public health campaigns end up trying to strike a balance between two sets of values: promoting health and respecting individual autonomy by merely informing, rather than trying to sway decisionmaking.

None of that is specific to illegal drugs. The government and various nonprofits try to persuade youth to eschew not only illegal drugs, but also tobacco and alcohol, dropping out of school, becoming obese, and not exercising enough. All of those efforts include more than just providing complete, balanced information. For example, the income gap between high school graduates and dropouts is often reported without adjusting for omitted variables such as differences in intelligence; youth are left to infer, incorrectly, that the observed gap is all caused by dropping out of school. Likewise, my elementary school kids were taught that cigarettes contain rat poison. I suspect that is true in some sense. Among the very many chemicals in tobacco and its combustion byproducts, there is probably one that is an active ingredient in rat poison. But I doubt it is one of the top ten by weight, so omitting mention of the others is selective reporting, and describing the chemical as “rat poison” rather than using a more technically precise term is clearly appealing to emotions.

I understand that many Cato readers who are committed to libertarian principles could dislike any taxpayer-funded, government-managed campaign designed to promote healthy behavior. I personally do not mind being nudged to eat better and exercise more because my willpower is imperfect, but I can see why other adults might view that as meddlesome. It is important to remember, though, that most drug prevention programming is directed at youth, for the simple reason that few people initiate drug use as adults. Activities that bring immediate pleasure but carry a roughly one-in-six risk of substantial adverse outcomes a few years down the road are less likely to appeal to adults than to adolescents.

To avoid any misunderstanding, when I used the word “drug” in the previous paragraph I meant the big four illegal drugs (marijuana, cocaine/crack, heroin, and meth). The statement also happens to be true of tobacco. I have no idea whether it applies to caffeine, and I do not much care. That is not, as the Erowids imply, because I do not think caffeine can reasonably be considered to be a psychoactive drug. It is simply because I do not think caffeine poses problems that merit public policy discussion or intervention. There are many serious problems associated with drug use and/or attempts to control use, including overdose, family dysfunction, crime, violence, corruption, etc. Caffeine barely registers on any of those metrics.

If outcomes associated with a psychoactive substance were determined entirely by policy, and had nothing to do with the substance’s characteristics, then the absence of problems with caffeine would be tremendously important. We could, for example, regulate tobacco and alcohol the same way we do caffeine and save ~500,000 premature deaths per year.

The reason that idea is absurd is that alcohol and tobacco are very different from caffeine, even though all three are psychoactive drugs. Ditto for the big four illegal drugs. There is no reason all psychoactive substances need be treated the same with respect to public policy, and no reason that statements that apply to one substance need apply to another.

The Erowids had many nits to pick about my saying that only 8% of people report past-month use of an illegal drug in the household survey. First of all, I stand by the number. Anyone can check it by accessing the data set from the SAMHDA website. Second, anyone can nitpick. The Erowids’ original essay cited “nearly 90%” lifetime prevalence of illegal drug use among 45-year-olds based on the Monitoring the Future study (Johnston et al., 2007). They didn’t mention that the study authors reported it as 80-87% (pp.75-76), that it comes from a birth cohort with unusually high rates of use, and that it overstates because high school dropouts have lower rates of lifetime prevalence than do high school completers. (The opposite may be true for problematic use, but with respect to ever trying a drug even once, prevalence generally increases with education up through college completion.) They noted many weaknesses of the household survey but weren’t similarly critical of Monitoring the Future, even though, for example, sample selection biases can affect attempts to follow up subjects more than 25 years later.

I had let this selective reporting pass because the Erowids’ general point that most people will try an illegal drug at some point in their life is true, even if lifetime prevalence for typical cohorts is closer to 67% than to 90%. I think current use is more relevant for assessing what is normative because lifetime prevalence of many bad or dumb actions (theft, assault, sexual infidelity, etc.) is rather high. If anyone really doubts that current use of illegal drugs is not normative within the general population of the United States, we can dive into details, but I hope that isn’t necessary.

Finally, as for the Erowids’ last point: I agree that all people, not just users need to be informed about drugs. I’m not sure how I created the impression I thought otherwise and apologize for any confusion I created on that point.

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Johnston LD, O’Malley PM, Bachman JG, et al. “Monitoring the Future National Survey Results on Drug Use, 1975-2006. Vol II.” NIDA. 2007. 98.

Also from This Issue

Lead Essay

  • Towards a Culture of Responsible Psychoactive Drug Use by Earth and Fire Erowid

    In their lead essay, Earth and Fire Erowid stress the importance of developing responsible, fully informed relationships toward psychoactive drugs. Although drug prohibition has persisted for decades, the overwhelming majority of adults have tried at least one illegal drug, and these substances aren’t going away any time soon. Sadly, prohibition itself has stunted our knowledge of these substances, and, as in so many things, ignorance is both dangerous and irresponsible. Provocatively, they criticize even the word “drugs” as a tag for illegal psychoactives: Lumping them all together, they write, betrays a lack of understanding of their vastly different effects, risk profiles and – yes – benefits.

Response Essays

  • Is Responsible Drug Use Possible? by Jonathan Caulkins

    Jonathan Caulkins argues that the responsible use of psychoactive drugs is an overstretched concept, if by “psychoactive drugs” we mean everything from caffeine to heroin. In many cases, he argues, temperance may be the only responsible “use” of a given substance.

    Further, state prohibitions on pleasurable but risky acts are hardly confined to this area of law; their violation is not a genuine form of civil disobedience as long as pleasure itself is the real goal of the act. And the risks remain regardless. Duly enacted laws in a democracy deserve far more respect than this, and following the law is a part of the responsibility of all citizens.

  • True Temperance by Jacob Sullum

    Jacob Sullum notes that temperance and abstinence have been wrongly conflated, and that the Aristotelian view of temperance encompassed all of the moderate, reasoned, and honorable pleasures of life. He reiterates that virtually everyone uses psychoactive drugs of one kind or another, and that the overwhelming majority of use is responsible. He challenges the notion that the state has any interest in the private actions of individuals that do not harm anyone else, and he terms the impulse to protect people from themselves “unethical” and “an open-ended rationale for government intervention that logically leads to totalitarianism.”

  • Drug Policy in Principle, and in Practice by Mark Kleiman

    Mark Kleiman takes up a theme already addressed by the other participants, namely the distinctions to be found within the catchall category “illegal drugs.” He notes that the risk profiles, motivations for use, and public health considerations of these substances are so far removed from one another that it may make no sense to continue to treat them as similar in public policy. Given the choice between full legalization and the status quo, he would choose the status quo, but, he argues, these alternatives should not be the only ones we consider.

The Conversation