It was 1986 in the UK. Margaret Thatcher was Prime Minister, and in wood-paneled rooms near the Houses of Parliament, ministers were being briefed on a significant public health threat: HIV.
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.