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Appendix I, Volume 4

POLICY ALTERNATIVES This section includes two articles that introduce the reader to some of the issues surrounding public debate on the decriminalization of, or the legalization of, drugs. Prohibition of Drugs: Pro and Con is a short summary of the diverse opinions, expressed continually over the last 80 years, about the optimal way to deal with the reality that psychoactive drugs exist; that many people like the effects of those drugs; that some who use them do so to excess; that some are necessary for medical purposes; and that the substances themselves can be toxic not just for the user but for others who are affected by the user's behavior. The second article, Safer Use of Drugs, takes the view that society can reduce the toxic personal and social effects of drugs by informing potential users about how the risks of drug use can be minimized.

The argument that harm from drug use can be reduced by teaching people how to use drugs safely is viewed by many experts as counterproductive and likely to foster drug use. The Partnership for a Drug-Free America has developed its media campaign on the premise that the decision to try a drug is powerfully driven by two specific attitudes: perception of risk and social disapproval. This premise is supported by data emerging from the national High School Senior Survey (Monitoring the Future study) that the likelihood of drug use, especially initial experimentation, goes down as appreciation of the risks associated with drug use goes up. The more a young person feels that drugs are socially acceptable and/or not dangerous, the more she or he is likely to try them. It is difficult to imagine an educational process that can teach ''ways of using drugs safely'' without simultaneously communicating a message of tolerable risk and a degree of social acceptability.

Analysis of Drug Legalization Whether or not a drug should be prohibited or legalized is perhaps the most fundamental question in drug policy. It is a moderately complex question and most who write about the issue do so from an advocacy perspective, so the debate is even more confusing than it needs to be.

It is important to start with a clear definition of what is meant by legalization vs. prohibition. There is a spectrum of policy positions. Some drugs can be used for medical but not recreational purposes (e.g., cocaine), whereas others cannot even be used for medical purposes (e.g., heroin). Some drugs cannot be used recreationally but are legal with a prescription (Valium) or when taken under medical supervision (methadone). Some drugs are legal only for adults (alcohol); others are legal for all ages (e.g., the caffeine in soda).

When a sharp line needs to be drawn between legalization and prohibition, it is useful to say that a drug is legal if it is legal for that substance to be produced and distributed for unsupervised consumption by a significant portion of the population (e.g., all adults). By this definition making marijuana available for medical use is not legalization if prescriptions are restricted to those experiencing specific, medically-diagnosed conditions (glaucoma), but it would be if any adult could write his or her own prescription. Likewise by this definition the Netherlands has legalized retail production, distribution, and use of marijuana, although wholesale (large-volume) marijuana production and distribution is still prohibited. Most other drugs in most countries are either clearly legal or clearly prohibited by this definition.

Having defined prohibition vs. legalization, the next important observation is that different people use different criteria for deciding what policy should be. Some people are implicitly if not explicitly consequentialists. They think the right policy is the policy that leads to the fewest problems. Others believe that there is a moral imperative to make substances legal (e.g. libertarians who believe people should be free to consume anything, even if it hurts them) or prohibited (e.g., people who believe the substance is evil for religious reasons) regardless of the consequences.

The challenge for the moral prohibitionists is defending to others why they favor prohibiting some drugs but not others. There are defensible positions predicated on consistent principles (''all intoxication is immoral'' or ''being physically dependent on a drug is idolatry''), but it is hard to articulate such a defense for US policy. Cigarettes are highly addictive, and alcohol is clearly an intoxicant, but they are both legal. In 1930 alcohol was prohibited, but marijuana was not. Ten years later, marijuana was prohibited but alcohol was not. One does not have to be very cynical to believe that the moral distinctions enshrined in public policy are just the legal formalization of arbitrary popular prejudices.

The challenge for the libertarian view is less simplistic but no less compelling (at least for those who recognize homo economicus as an ideal type, not a descriptively accurate model of human behavior). The basic idea is that at least some addictive, mind-altering substances may merit an exception to the general rule that a liberal society should not interfere in the private consumption decisions of its citizens. Mark Kleiman, a drug policy scholar and professor at UCLA, eloquently makes the case in his 1992 book Against Excess. The distinguishing characteristics are a combination of factors such as: drugs are intoxicating so consumption decisions are often made ''under the influence,'' for some drugs cessation is physically painful, drugs offer immediate pleasures and the possibility but not guarantee of delayed pain, drug initiation occurs primarily among minors, social influences play a prominent role in initiation decisions, etc. That skepticism of government regulations is healthy for a liberal democracy does not imply that prohibiting a drug is necessarily a bad idea. Liberal democracies tolerate other paternalistic infringements on freedom of behavior (such as a minimum wage, motorcycle helmet laws, and prohibitions against swimming where there are dangerous rip tides).

Furthermore, few want minors to have ready access to drugs, but legalizing use by adults inevitably makes a drug readily available to minors because every adult is a potential supplier, whether consciously (adults buying alcohol for minors) or unconsciously (minors stealing cigarettes from adults). Legalizers sometimes deny this, asserting that cocaine is more readily available to minors than alcohol is, but those assertions are contradicted by minors' self-reports (e.g., in the Monitoring the Future surveys).

The moral arguments for or against prohibition are in one sense unassailable. Every person is entitled to his or her values. But at the same time they are not very persuasive to people who do not hold those values.

For consequentialists, opinions about legalization tend to depend on how people trade off or value the problems associated with drug use and those associated with prohibition and black markets and on predictions about how legalization would affect those outcomes. Prohibiting a drug will generally reduce but not eliminate its use. The use that persists despite prohibition supports a black market, which generates problems of its own. Indeed, the social cost per gram or per ounce consumed will typically be greater than would be the case if the drug were legally available. So prohibition typically reduces use but increases harm per unit of use.

Those who favor legalization tend to believe that a drug's legal status has little impact on its use. They also tend to be very mindful of the problems associated with black markets (stereotyped as drug dealers shooting people in battles over ''turf''), drug enforcement (e.g., racially biased enforcement tactics), and prohibition's increasing the damage per episode of use (e.g., restricting needle availability increasing spread of HIV by needle sharing). Those who favor prohibition tend to believe that prohibition substantially suppresses use (tobacco and alcohol are used far more than cocaine or heroin) and that many problems stem directly from drug use (e.g., the damage addiction can do to familial relations) not primarily from the drug's illegal status. To them, legalization is jumping out of the frying pan and into the fire. It might eliminate the black market and associated crime, but if legalization led to a ten-fold increase in the number of addicts the country could still be worse off.

Unfortunately, the public debate about the consequences of legalization is clouded with specious arguments. For example, prohibitionists argue that drugs should be illegal because they are associated with so much crime (something on the order of one-fourth of crime in the US). Legalizers counter that most of the drug-related crime is attributable to the prohibition. Only about one-sixth of drug related crime is "psychopharmacological" in nature (i.e., driven directly by intoxication or withdrawal). Conflicts between market participants turn violent in part because they cannot resort to the court system to resolve disputes, and one reason addicts commit robberies is to get money to buy drugs that would cost far less if they were legal. Ironically, alcohol is one of the most violence-promoting substances per se, and it is legal.

To give an example from the other side, legal-izers cite statistics showing that illegal drugs such as cocaine and heroin kill only thousands of people per year, whereas alcohol and cigarettes kill hundreds of thousands. What they neglect to point out is that far more people use cigarettes and alcohol, so the death statistics per user are not so different. Furthermore, the death statistics for illicit drugs are restricted to acute effects (e.g., overdose deaths), whereas the cigarette and alcohol figures include indirect effects (e.g., deaths caused by intoxicated drivers) and delayed or chronic effects (e.g., from lung cancer). Focusing on overdose deaths would make cigarettes seem safe, whereas the expansive definition suggests that they kill more people than all other drugs combined, including alcohol.

Both sides lend a patina of scientific rigor to their arguments by citing trends in data, but the divergent trends of different indicators makes it easy to tell statistical lies. An advocate of prohibition might point out that the number of drug users fell dramatically during the 1980s when enforcement expanded rapidly. A legalizer could counter that emergency room mentions of drug use rose as fast as prevalence fell. What is lost in such bickering is the observation that the legal status of the major drugs has been stable in the US for many decades. Looking at contemporary trends might tell us about the wisdom of a more or less stringent prohibition, but we have no direct experience with legal cocaine, heroin, marijuana, or methamphetamines in recent US history. Many seek to draw lessons drawn from other times (e.g., when cocaine was legal in the US in the late 19th century) or places (e.g., Europe), but casual comparisons can be misleading and careful study of those analogies does not give definitive guidance (MacCoun and Reuter, forthcoming).

Even anecdotal evidence can be spun in different ways. Consider the periodic accounts of a mother selling her baby for crack. Some argue this proves drugs should be legalized. If they were cheap enough, addicts would not have to resort to such draconian measures. Others counter that the fundamental problem is that the drug is so powerful that it becomes more important to a mother than her own child, and we should do everything we can to protect people from the temptation to use things that so distort such societal pillars as the value of family.

The next important observation is that different drugs are different, and it may well make sense to prohibit some but not others because they have different properties (e.g., some drugs can trigger violent outbursts [PCP]; others tend to sedate [heroin]). It is by no means the case, however, that one can unambiguously rank order substances from the most to the least dangerous because a substance can be very threatening in one respect but not in others. Cigarettes are highly addictive, but they are not intoxicating. Heroin can be deadly (overdose deaths are not uncommon) but in and of itself creates almost no chronic health damage. Heroin addicts are usually in poor health because they are poor, spend money on heroin not food or shelter, and inject with dirty needles, but the heroin per does not degrade organs the way alcohol destroys the liver or smoking causes emphysema. The following table illustrates the concept.

The table divides the substances by legal status. The legalization question asks whether any substances on one side of the line should be moved to the other. It does not address changes in laws, programs, or policies that do not move a substance across the line. It might or might not be a good idea to repeal mandatory minimum sentences, cut the number of drug arrests in half, expand treatment and prevention programs, approve marijuana for medical use, eliminate profiling as an enforcement tactic, reduce the military's role in drug control, and repeal drug-related civil forfeiture statues. Doing so would blunt many of the criticisms of ''prohi bition,'' but it would not constitute legalization. Conversely, one could raise the ''smoking age,'' require people to pass a ''drinker's test'' to get an alcohol consumption license, or ban smoking from all public spaces, but none of those would extend prohibition to a new substance.

There is no constituency for prohibiting caffeine, and prohibition of alcohol is perceived to have failed so badly in the last century that there is little stomach for trying it again. There is some discussion of banning tobacco use, but such proposals are probably political non-starters.

The more seriously debated proposals would legalize one or more of the currently prohibited substances. For discussion purposes, it is convenient to differentiate three groups of substances:

(1) cocaine, heroin, and methamphetamines,

(2) marijuana, and (3) all other illicit substances.

Cocaine, heroin, and methamphetamine are not all similar pharmacologically, but they have key commonalities. They (particularly cocaine and heroin) are expensive, are subject to stringent enforcement, can dominate the lives of an abuser, and have large, established black markets. These are the substances whose use can most confidently be predicted to rise substantially and to be problematic if they were legalized. These substances are very simple to produce, but sell for many times their weight in gold because they are prohibited and subject to severe sanctions. They are also the source of most of the corruption, violence, and disorder associated with drug markets, so legalization would bring

Caffeine

Tobacco

Alcohol

Marijuana

Heroin

Cocaine

Acute health risk

None

None

High

Minimal

High

High

Chronic health risk

None

Huge

High

Some

Minimal

Some

Use affects health

No

Yes

Fetuses

Possibly

No

Fetuses

of others

Problems caused

Minimal

Unpleasant

Physical risk

Minimal

Physical risk

Extremely

by withdrawal

unpleasant

Intoxication leads

No

No

Yes

Some

Moderate

Unclear

to accidents

Intoxication leads

No

No

Yes

No

No

Some

to violence

Likelihood of addiction

Minimal

High

Moderate

Moderate

High

High

given use

[as observed in the

US in last 30 years]

Addiction disruptive to

No

No

Yes

Somewhat

Yes

Yes

daily functioning

many benefits. Most observers, though, believe this would be an example of ''out of the frying pan and into the fire.'' At a minimum, legalizing these substances is a high stakes gamble that is only partially reversible. There are other, safer alternatives to exhaust first (e.g., mending rather than ending prohibition) and more information that should be gathered about how legalization would affect use before seriously contemplating such a radical change.

Marijuana presents a quite different situation. Prohibition makes marijuana more expensive than it otherwise would be, but a daily habit is still only modestly more expensive than a two pack a day cigarette habit. Likewise, daily marijuana use is not a recipe for enhancing performance, but it does not preclude most daily functions (personal hygiene, holding down a job, etc.). So a ten-fold increase in use is a less likely outcome of legalizing marijuana than for cocaine, and even if it did happen, that outcome would be less catastrophic. On the other hand, the benefits of legalizing marijuana are far smaller than the benefits of legalizing cocaine, heroin, and methamphetamines because marijuana markets are less violent and marijuana users generally do not resort to crime to support their habit. There is no consensus about whether legalizing marijuana is wise. Some say yes. Most say no. What is clear though is that the risks, uncertainties, and potential benefits are all much smaller when considering legalizing marijuana than when considering legalizing cocaine, heroin, and methampheta-mines.

The last category is diverse, so general statements are difficult. It includes drugs that can be used as a weapon in sexual assault (e.g., GHB) and drugs used not for their mind or mood altering properties but to enhance athletic performance (e.g., anabolic steroids). Two general observations are possible, however. First, prohibitions are relatively more effective and relatively less costly when preventing the spread of substances that are not commonly used than they are at reducing the use of an established drug. Second, by definition, there is more to lose in terms of increased availability and use when altering the status of drugs that are now rare. By those principles, it would be easier to make a case for legalizing XTC or LSD, for example, than for PCP, but they are not frequently the focus of legalization proposals, which typically address just marijuana or all drugs collectively.

BIBLIOGRAPHY

KLEIMAN, M. A. R. (1992). Against excess: drug policy for results. New York: Basic Books. MacCoun, R. J. & Reuter, P. (forthcoming). Drug war heresies: learning from other times, places, and vices. New York: Cambridge University Press.

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A Disquistion On The Evils Of Using Tobacco

A Disquistion On The Evils Of Using Tobacco

Among the evils which a vitiated appetite has fastened upon mankind, those that arise from the use of Tobacco hold a prominent place, and call loudly for reform. We pity the poor Chinese, who stupifies body and mind with opium, and the wretched Hindoo, who is under a similar slavery to his favorite plant, the Betel but we present the humiliating spectacle of an enlightened and christian nation, wasting annually more than twenty-five millions of dollars, and destroying the health and the lives of thousands, by a practice not at all less degrading than that of the Chinese or Hindoo.

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