In fact, it is always driven by ordinary people who use drugs choosing to put harm reduction into practice. Yes, governments and experts can make it easier for them—or stand in their way. But ultimately, it’s individuals who take action to reduce harms they or people in their lives are facing. 

It’s largely because of this that I remain optimistic about the future of tobacco harm reduction as the 10th annual Global Forum on Nicotine (GFN) approaches—despite the many challenges it’s faced and the many obstacles it has yet to overcome. 

Tobacco harm reduction is based on a very simple proposition. If safer nicotine products are available, attractive, appropriate and affordable, most people who smoke will choose them. They will choose them over continuing to smoke cigarettes because most people are all too aware this is likely to lead to disease, disability or premature death. 

Despite snus in Scandinavia and some smokeless products in the United States, both of which had a relatively low public profile, smoking had always been the poor relation in harm reduction. That was because of a lack of suitable alternatives. 

Back in the 2000s, I thought we were on the cusp of an immediate breakthrough. I had overlooked the warning signs.

But the arrival of vapes from around 2007 brought growing realization that people could consume nicotine—including through inhalation, as many prefer—without the harmful effects of combustion. Since then, uptake has steadily risen in many countries. 

Back in the 2000s, I felt the excitement about the prospect of a big transformation in how people use nicotine, propelled by by vaping. I thought we were on the cusp of an immediate breakthrough. With safer nicotine products, if we played it right, millions of premature deaths from smoking could rapidly be averted. 

So in 2014, Paddy Costall and I organised the first GFN in Warsaw, Poland. The event was born of optimism. Rather than smoking and tobacco, it was the first ever conference to focus on nicotine and related scientific, policy, regulatory and consumer issues.

Reflecting on my comments at the time, I see that I was wildly over-optimistic about public health leaders throwing their weight behind an innovation which—unlike many public health interventions—could spread at no cost to governments. I had overlooked the warning signs.

Many medical and professional associations, health charities and foundations, governments, public health pundits and the World Health Organization (WHO) did not share my view. Many subsequently embarked on what amounts to a misinformation campaign, sowing fear and doubt about safer nicotine products—something which has not abated in 2023.

I’d worked on harm reduction and HIV prevention since the late 1980s. Making drug use and sex safer was both contentious and a struggle. But even that did not face the organized, well-funded opposition endured by proponents of making nicotine use safer.

The numbers paint a stark picture of global policy failures: One billion people smoked in 2000; one billion smoked in 2014; and one billion smoke in 2023.

This remains a huge frustration, especially when so many public health leaders who grasp harm reduction for other areas remain resolutely against it for tobacco.

Meanwhile, people who smoke continue to suffer ill health or premature death. Their numbers over time paint a stark picture of global policy failures: One billion people smoked in 2000; one billion smoked in 2014; and one billion smoke in 2023.

Over the last decade, it’s been surprising to see what a mess some countries can make of this issue. The US has a bizarre, cantankerous regulatory system with the perverse consequence that the vaping industry is being destroyed, while the cigarette industry isn’t. Australia—previously a leader on harm reduction—has made itself a case study in the impacts of prohibition for nicotine products. Politicians worldwide get agitated about vape flavors and exaggerated suppositions of dangers to young people—ignoring the implications for huge, often-marginalized populations of adults who smoke. 

But the last decade has also witnessed stunning examples of how, in the right circumstances, people who smoke will rapidly switch to safer alternatives. The United Kingdom, Norway, Sweden, Japan and New Zealand all now see tobacco harm reduction driving down smoking rates. The UK continues to lead: Its new plan to give out one million vaping starter kits to people who smoke has echoes of needle and condom distribution during the HIV/AIDS crisis.  

In the early 2010s there was optimism that the tobacco industry would be on a fast track to transformation, but—with some notable exceptions—this has not been achieved. The industry has severely neglected development of appropriate products for low- and middle-income countries, home to 80 percent of people who smoke. The advent of nicotine pouches may go some way to change this, but more action is needed from industry—and fast. 

Something that’s missing from the international response to smoking is broad-based engagement. GFN was born on our belief that a wide variety of organizations could and should contribute to hastening tobacco harm reduction, and would appreciate an opportunity for open discussion.

Our vision of multi-stakeholder engagement came from our previous work on drugs and HIV prevention. This brought together people who use drugs, sex workers, public health proponents, educators, law enforcement and ministries of health and justice in an atmosphere of mutual respect.

We believed then—and still do—that progress on tobacco harm reduction requires getting everyone around the table. This means consumers—the people actually using safer nicotine products—as well as policymakers, regulators, scientists and manufacturers.

Consumers have always been central to GFN. They are the people who are doing harm reduction. Yet at many conferences, their perspectives and experiences hardly get a mention, let alone a place on the program. We saw the need to galvanize energy and enthusiasm among consumers, and provide a platform for them to connect and build networks. The last decade has seen gradual growth in consumer advocacy in this space, although it remains fragile and underfunded.

We still haven’t managed to engage the WHO, where harm reduction has been deliberately ignored.

Our vision also means getting industry—everyone from independent vape and snus manufacturers to the major tobacco companies now producing safer alternatives—talking to others and, more importantly, listening.

GFN, therefore, is the only large-scale conference in the smoking, tobacco and nicotine space which welcomes everybody with a stake in tobacco harm reduction. Unlike many other events, no one is banned from attending or speaking. This open-door policy does cause challenges: Some people working in tobacco control are barred from attending by their organizations, for example. But we firmly believe that respectful debate involving all stakeholders is the way forward.

We still haven’t managed to engage the WHO. The WHO Framework Convention on Tobacco Control (FCTC) includes harm reduction as one of three pillars of tobacco control, alongside supply and demand reduction. But harm reduction has been deliberately ignored. And the WHO is not in listening mode. Paranoia about engagement with consumers and manufacturers permeates the biannual meeting of the FCTC; unlike other UN bodies, the WHO is actively working against engaging people affected by global policies. 

It’s not a matter of whether tobacco harm reduction will happen, but when.

But there is a pattern here. The WHO was behind the curve on harm reduction for other drugs at the early stages of the HIV response, banning staff from attending harm reduction conferences. Eventually, it was shamed into acceptance by other UN agencies. The WHO will eventually engage, far later than it should have, on tobacco harm reduction. It can’t ignore this forever. 

GFN is a microcosm of what should be happening globally. It’s exciting and energizing to hear consumers talking to parliamentarians, talking to regulators, talking to manufacturers—important conversations that don’t take place elsewhere. As GFN returns to Warsaw next month for its 10th edition, we will do all we can to drive tobacco harm reduction forward.

And I remain optimistic. What’s behind this is consumers. Ordinary people, doing harm reduction. Regulators, parliamentarians, legislators might slow this down or speed it up. Yet it’s not a matter of whether tobacco harm reduction will happen, but when.

Photograph via pxfuel/Public Domain

The 10th Global Forum on Nicotine – Tobacco harm reduction: the next decade is taking place in Warsaw from June 21-24. Many sessions will be livestreamed, and online participation is free to all registered at the event website.

Filter is an official media partner of GFN23, which is organized by KAC Communications. KAC Communications’ sister company, Knowledge∙Action∙Change, has provided restricted grants and donations to The Influence Foundation, which operates Filter, for projects unrelated to the conference. The Influence Foundation has received grants from the Foundation for a Smoke-Free World, which has also supported KAC. Filter’s Editorial Independence Policy applies.

The post Why I’m Still Fiercely Optimistic About Tobacco Harm Reduction appeared first on Filter.

Cigarettes are a harmful delivery mechanism for nicotine—and nicotine doesn’t cause tobacco-related disease. Options now available deliver nicotine at vastly reduced risk. More Swedes use snus than smoke cigarettes, resulting in the lowest lung cancer rates of any EU country. In the United Kingdom, vaping is supported by health authorities as a cessation tool. Around 7 per cent of adults (six million people) vape; a year-on-year increase in vaping is matched by a decline in smoking, and over a quarter of people who made a quit attempt in England in 2020 did so by switching to vaping. These products reduce harm at both an individual and population level.

For harm reduction advocates, much collective energy goes into discussing scientific and regulatory issues. It’s important, both to quantify and maximize the benefits of safer nicotine options, and because there are many countries where poor regulation or outright prohibition prevents access. Thirty-six countries currently ban the sale of nicotine vapes, 39 the sale of snus and 14 the sale of heated tobacco products.

A human rights approach offers us significant and as-yet unexplored opportunities for challenges to bad laws and policies.

In contrast, combustible cigarettes are widely available everywhere, and in 18 countries, the state is directly involved in, and profits from, the manufacture of deadly tobacco products. In Los Angeles, you can buy THC gummies in flavours like sour lemon and strawberry, and cigarettes in any corner store. But a new ban will mean you can’t buy flavored vaping products, which many vapers find essential to quitting tobacco completely.

However, it’s also important for us to consider the more fundamental basis of the argument for safer nicotine options. A strong case can be made that international human rights law supports tobacco harm reduction. A human rights approach offers us significant and as-yet unexplored opportunities for challenges to bad laws and policies.

The role of health rights in harm reduction was integral to my work on drug use and HIV/AIDS in the UK from the 1990s onwards. Drug control has primarily been viewed through a prism of bans, prevention and abstinence. In many countries around the world, it still is. Yet the focus on drug supply and demand reduction began to fracture with the arrival of HIV/AIDS, when the realization emerged that safer drug use, or harm reduction, could limit the spread of the virus.

Beginning in the early 2000s, organizations such as Human Rights Watch and the International Harm Reduction Association, which I led, campaigned to establish that harm reduction was about the right to health. These organizations worked with the UN Special Rapporteurs on the Right to Health, who argued within the UN system that interventions such as the provision of safer drugs and safer delivery systems—opioid substitution treatment and syringe access—were fundamental to the health rights of people who use drugs.

The parallels with tobacco harm reduction are clear. And the need is clear: There are 8 million smoking-related deaths a year. That’s three times more than the number of deaths from HIV/AIDS, TB and malaria combined. It’s 10 times greater than all deaths related to state-banned drug use.

One difficulty in developing these arguments with regard to tobacco is that human rights implications have long been ignored in tobacco control. While harm reduction is named as the third “pillar” in the World Health Organization’s 2005 Framework Convention on Tobacco Control (FCTC), alongside reducing supply and demand, the FCTC is not a human rights treaty, and a human rights framework was not incorporated into the text.

There was barely any consideration of human rights during the negotiations about the treaty. No delegate or NGO involved in the process raised the issue. Subsequent discussions about human rights in tobacco control have focused on the obligation of the state to protect people from the infringement of their rights by third parties, mainly identified as the tobacco industry. These address the demand and supply components of tobacco control and can be called a “freedom from” position. Political philosopher Isaiah Berlin called this concept “negative liberty,” describing the freedom from external constraints and influence.

We desperately need an alternative narrative to the dominant tobacco control view that human rights can only be about protection from tobacco.

Yet the right to health and the personal autonomy to take positive steps to protect one’s own health have been neglected. This is unsurprising, given the neglect and denigration of harm reduction by Parties to the FCTC, the FCTC Secretariat, and the WHO.

Ironically, the preamble to the Constitution of the World Health Organization (1946) that is recognized as the first statement of the right to health in international law. It states that, “the enjoyment of the highest attainable state of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition,” and “the extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health.”

In 1966, the International Covenant on Economic, Social and Cultural Rights (ICESCR) was ratified by 171 countries. Article 12 enshrines the right of everyone to “the enjoyment of the highest attainable standard of physical and mental health” and states that everyone has the right “to enjoy the benefits of scientific progress” (Article 15).

The pursuit of the highest standard of health includes enabling people to protect themselves. This can be called a “freedom to” or “positive liberty” position. Regarding tobacco, this would include the freedom to choose safer alternatives to combustible cigarettes or risky oral tobacco products, so as to avoid smoking-related disease and premature death. A rights-based approach that mixes both “freedom to” and “freedom from” elements is core to much public health thinking in other spheres. The exclusive invocation of negative liberty in tobacco control discourse is an anomaly.

This blind spot in tobacco control is costing lives—millions of lives—every year. The right to control one’s health and body is at the core of tobacco harm reduction. It empowers people to make safer choices.

We desperately need an alternative narrative to the dominant tobacco control view that human rights can only be about protection from tobacco. Times and technologies have changed since the FCTC came into force. Taking the right to health as the starting point, signatories to the FCTC and the WHO have a responsibility to take positive steps to ensure that safer alternatives are available to the 1.1 billion smokers worldwide.

Those of us involved in tobacco harm reduction need to build alliances with those working in human rights, explore challenges under international, regional and national legislation, and establish tobacco harm reduction as fundamental to the right to health. 

Photograph via PxHere

Professor Gerry Stimson will be discussing this topic on a panel, “Safer nicotine: human rights and legal challenges,” at the Global Forum on Nicotine 2022, taking place in Warsaw and online from June 16-18. The session is one of many from #GFN22 that will be live-streamed free to registered delegates. It is also the subject of a new Global State of Tobacco Harm Reduction (GSTHR) Briefing Paper, set to be launched in Warsaw on 18 June by Knowledge-Action-Change. The GSTHR, of which Stimson is project lead, receives funding from the Foundation for a Smoke-Free World. 

The Global Forum on Nicotine is organised by KAC Communications, the sister company to Knowledge-Action-Change. The Influence Foundation, which operates Filter, has received grants from both Knowledge-Action-Change and the Foundation for a Smoke-Free World. Filter is an official media partner of GFN. Filter’s Editorial Independence Policy applies.

The post The Right to Health Means the Right to Tobacco Harm Reduction appeared first on Filter.

I’m a public health social scientist. Until then, my career had mainly focused on research with people who use heroin and other opiates. Thanks to my experience, I found myself helping to develop and evaluate a harm reduction approach in the UK, before it was even named as such. My work became focused on helping people who inject drugs avoid HIV infection.

Only a few months before, it had run an anti-heroin campaign. Now it was giving out free syringes.

Early in 1987 the Conservative government took the radical decision to provide sterile injecting equipment to people who inject in response to the HIV crisis. Only a few months before, it had run an anti-heroin campaign. Now it was giving out free syringes.

I was asked by the UK Department of Health to evaluate the experimental needle and syringe program that was being rolled out. Things moved fast: In only a few weeks, the program and the evaluation were up and running across England and Scotland.

I soon developed a new program of research on HIV, which was oriented to community engagement. We were the first to hire people who used drugs—to conduct interviews with their peers and collect saliva and blood samples for testing.

As I became involved in developing the UK policy response to HIV, our guiding premise was that the risk of HIV infection was greater than the risks from drug use—and that’s harm reduction in a nutshell. By any standard, the UK response to HIV among people who inject drugs has been a significant public health success.

Fast forward a little over 20 years to the late 2000s, and I was still working in HIV prevention, human rights and drug harm reduction. I wasn’t involved in smoking cessation work, but I knew Michael Russell and so I knew millions of people “smoked for the nicotine, but died from the tar.” I also knew how many of the people who used drugs like heroin or crack were also smoking cigarettes.

Then someone told me about vaping. It was immediately clear to me that this new technology could offer a harm reduction solution for smoking—a safer product, enabling safer behavior.

All that remained, then, was to spread the word; I thought that smoking would be consigned to the history books within a few years.

Consumers could see the potential for nicotine without smoke as well. Little by little, vaping began to grow in popularity, in the UK and elsewhere. Along with long-established pasteurized snus from Scandinavia and, later, heated tobacco products, an entirely new front in harm reduction was opening up. Cut out the smoke, cut down the risk—as the research would later show, by as much as 95 percent for vaping.

All that remained, then, was to spread the word; I thought that smoking would be consigned to the history books within a few years. Given that many of my colleagues in UK public health are both pro-drug harm reduction and pro-drug law reform, I assumed that they too would see the huge public health potential offered by safer nicotine products.

But it hasn’t happened like that. Many public health leaders in the UK and abroad—with tobacco control hats firmly on—continue to oppose vaping. They invoke well-worn narratives of fear, uncertainty and doubt.

Some cling to a precautionary principle irrelevant when weighed against the well-known catastrophic harms of smoking. Others cast tobacco harm reduction as some kind of Big Tobacco conspiracy, no-platforming all who believe in its possibilities.

My theory? That it’s hard for many in public health to accept that there might be market solutions to public health problems. These interventions don’t require experts. They’re of minimal cost to the taxpayer.

There is one notable and important exception: Public Health England, an executive public health agency with responsibility for advising government. It conducted the first crucial evidence reviews on vaping, confirming the “95 percent less harmful” figure. The agency’s ensuing stamp of approval—received only after significant consumer uptake—has given tobacco harm reduction the chance to flourish here in the UK.

It’s only now that we are seeing prevalence reduction and falling cigarette sales that have never before been witnessed.

Since I began work in this field, conceiving of and developing the Global State of Tobacco Reduction project, there have been dramatic falls in smoking in the UK associated with the rise in the use of e-cigarettes.

Meanwhile Sweden has the lowest level of smoking in the EU due to the popularity of snus, and the lowest level of tobacco-related deaths in Europe. In Norway, smoking has virtually disappeared; among young women, 1 percent smoke while 14 percent use snus. Since 2016, when heated tobacco products (HTP) were introduced to the Japanese market, cigarette sales there have plummeted by a staggering 33 percent.

Despite years of pumping billions of dollars into tobacco control interventions, years of increasing tobacco taxes, years of stigmatizing people who smoke, it’s only now that we are seeing prevalence reduction and falling cigarette sales that have never before been witnessed, in countries where safer products are available and affordable.

In fact, the work we’ve carried out for our latest report, Burning Issues: The Global State of Tobacco Harm Reduction 2020, shows that globally, 98 million people have switched to get their nicotine from safer products instead of combustible tobacco. Of those, 68 million are vapers, 20 million are HTP users and 10 million are smokeless tobacco or snus users. It’s a consumer-led public health revolution.

The places where we are seeing these glimmers of hope are all rich nations.

We have the evidence: When they have the choice to do so, people quit combustible tobacco in huge numbers and switch to these products. People make the choice to improve their own health.

It would be easy for us to characterize this as a success. But the truth is, we’re nowhere near that yet. The places where we are seeing these glimmers of hope are all rich nations. Eighty percent of the world’s smokers live in low- and middle-income countries (LMIC)—where tobacco control measures are often only poorly or partially implemented, smoking rates are high or plateauing, population growth is increasing the number of smokers, and health systems are least able to treat smoking-related disease effectively or offer smokers support to quit. Manufacturers of safer products are not serving these countries well either, with limited or nonexistent rollout or price points that keep products out of reach of the majority.

We need to scale up, and fast.

1.1 billion people smoke worldwide. That total has remained unchanged for two decades. The WHO is predicting a billion smoking-related deaths by 2100. And our estimates suggest there are currently just nine users of safer nicotine products for every 100 smokers.

The barriers are significant. With millions of dollars from unaccountable philanthro-capitalists guiding the way, global tobacco control policymakers at the WHO are choosing to see tobacco harm reduction as a Big Tobacco ruse.

Burning Issues exposes the extent to which tobacco control policy both at the WHO and in individual nation states is being influenced by US foundations actively supporting campaigns against tobacco harm reduction. In countries where tobacco harm reduction already has a foothold, misinformation about vaping’s risks are impacting on consumer confidence—discouraging smokers from making the switch.

Will the WHO eventually see tobacco harm reduction as an individual and public health issue, as well as a right-to-health issue?

Meanwhile, LMIC governments are being encouraged to ban safer products in the name of tobacco control. Rising concern over the influence of these actors was echoed in the Philippines House of Representatives a few weeks ago, with calls for a congressional inquiry into the Filipino Food and Drugs Administration’s acceptance of funding from US-based anti-vaping groups. Yet all the while, combustible tobacco remains on sale in every convenience store on every street corner.

Will the WHO eventually see tobacco harm reduction as an individual and public health issue, as well as a right-to-health issue? It was reluctant to do so for both HIV/AIDS prevention and the right to health for people who use drugs, but it adopted harm reduction in the end. Indeed, the WHO’s Framework Convention on Tobacco Control treaty actually identifies harm reduction as one of three key tobacco control strategies, alongside supply and demand reduction. But in 2005 when it was drafted, no one imagined the choices that would be open to people who use nicotine just 15 years later.

And that’s where harm reduction has to reside. With the people who make choices to improve their own health and wellbeing. It’s impacted people who drive tobacco harm reduction—not experts. And tobacco harm reduction must leave no one behind.

Photo via Pxfuel/Public Domain

Knowledge Action Change, of which the author is a director, has provided scholarships to The Influence Foundation, which operates Filter, to support tobacco harm reduction reporting. Filter’s Editorial Independence Policy applies.

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