The 13th National Harm Reduction Conference took place in San Juan, Puerto Rico in mid-October. It involved around 2,800 harm reductionists from across the United States and beyond, and its myriad important themes included overdose prevention, drug checking, racial justice, sex work and much more.
There was also one panel about tobacco harm reduction (THR), in which I participated. Its inclusion was significant, given the divisions sometimes seen between THR and the rest of harm reduction, and conversations about how to align the two.
So I took the chance to ask some of the folks at the conference for their thoughts. The responses they were kind enough to share with me reflect some of the issues that impede better understanding, some personal THR experiences, and some really encouraging interest in including THR in their work.
“Vapes? Those things are horrible for you.”
“Vapes? Those things are horrible for you,” said one conference attendee, who was smoking a cigarette and asked to remain anonymous.
The evidence shows that vaping, while it may not be entirely risk-free, is exponentially less harmful than the cigarettes it typically replaces. Harms from long-term vapor inhalation are “unlikely to exceed 5% of the harm from smoking tobacco,” states the UK’s Royal College of Physicians, for example. Other reduced-risk THR options include oral snus and “heat-not-burn” tobacco products.
Nathan Smiddy, a harm reduction educator at A New Path in California, was unclear on some health questions, though he vapes himself. “I don’t know if popcorn lung is a real thing. I’ve never researched it,” he told Filter. (The idea that vaping causes “popcorn lung” is a myth.)
Still, “for me, vaping saved me money [compared with smoking] and I feel better,” Smiddy said.
The fact that Smiddy’s principal motivation for switching was financial is instructive, regarding debates over the taxation of vapes and cigarettes. “To be dead honest, cigarettes are very expensive … and I was like, I can’t afford this right now. So I just bought a vape and I stuck with it,” he related.
“I’ve been smoking/vaping since I was 15,” he continued. “I’m 30 now … I feel like I would say yes, it’s safer, but I don’t have the evidence to prove that. I feel like my overall health and quality of life just from switching is better. I don’t wake up and cough up phlegm.”
The harm reductionists I spoke with tended to be refreshingly frank about what they didn’t know about THR, which is a great starting-point when you’re interested to find out more.
“I have a lot of clients who switch over to vaping instead of smoking cigarettes.”
“I don’t really know a whole lot about the science of it, just to be straight-up,” said Gillian Garton. She works as a medical case manager at the Red Project in Grand Rapids, Michigan, and emphasized that she was speaking purely on her own behalf. “I do know that there are people … who use vaping to cut down on their cigarette consumption or completely switch over, because I know that there are some health aspects that do change … I have a lot of clients who switch over to vaping instead of smoking cigarettes.”
In fact, she did the same. “I used to smoke cigarettes a lot and started when I was about 15,” she told Filter. “I had been trying to quit for a long time so I switched over to vaping mostly for my own health aspects.”
Garton was also aware of the tide of vape bans in recent years and the likely detrimental consequences. “I do know there’s lots of legislation that is trying to ban vapes,” she said. And she noted that people’s reactions could well be, “I don’t have access to this vape, so maybe I’m gonna have to go get cigarettes because I still have cravings for, like, the oral fixation or the nicotine.”
“I see no positives and only negatives when it comes to bans. That’s across the spectrum of drugs,” Presto Crespo, a Bronx resident who identifies as a drug user and coordinates support services for NEXT Distro, similarly told Filter. “People are just gonna revert back to smoking cigarettes … or people are gonna make their own stuff; sometimes they’ll get it right and sometimes it can be extremely harmful.”
After our panel, in which we debunked myths and discussed the need for THR’s integration in the wider field, some people who attended said they were considering these questions more.
“Before the panel I definitely didn’t think about it too much,” Crespo said. “I think I [had] succumbed to some of the misinformation about vapes, but, I mean, just being a skeptical person in general, I was like, Some of that obviously cannot be true.”
“But I did agree to this idea that this is Big Tobacco’s way of getting a new generation hooked on their products,” they continued. Yet this was countered by the experience of seeing their roommate switch from smoking to vaping: “It was helpful and he felt his lung capacity was larger. He wasn’t coughing and spitting up phlegm all the time.”
Still, when it came to the evidence, “I didn’t know that there was a harm reduction aspect to transitioning from cigarettes to vaping,” Crespo said. “Vapes are everywhere. If they were still exploding … literally everybody would be on fire. They’ve improved the technology, you know?”
“I know one individual that can’t do other drugs because they’re being drug tested because they’re on methadone,” they continued. “Cigarettes are the only option for them. I talk to that individual about vaping and they tell me no, because it’s going to explode in their face. So that person has come to the misinformation; meanwhile they’re ingesting these packs of cigarettes.”
“After the talk, it made so much more sense as to why this is very squarely within the realm of harm reduction.”
“I don’t regularly vape or smoke,” said Dan Coello, program director at NEXT Distro, which ships vital harm reduction supplies like naloxone and syringes online and by mail. “Going into the panel, I had next to zero knowledge about THR … I think a lot of the risks we’re dealing with [in the harm reduction movement] are very immediate overdose or overamping risks. After the talk, it made so much more sense as to why this is very squarely within the realm of harm reduction.”
If so, what about the prospects for integrating THR into harm reduction services for people who use state-banned drugs? After all, nearly half a million deaths are related to smoking in the US each year—more than for any other substance. And people who use illegal drugs smoke cigarettes at high rates.
“Yeah, people don’t see it,” Coello told Filter. “I mean, humans are just very hardwired to look at immediate gains and immediate risks. And long-term thinking is not something we’re very good at. And so I think, this theoretical thought of, like, so many people dying in the future because of lung cancer, can feel not as important as the immediate risk of people overdosing.”
“With anything, especially in America, our first thing when we talk about people who use drugs is complete abstinence, you know what I mean?” Smiddy pointed out. “It’s not ideal for a lot of people. Most people aren’t going to go that route. …. With the HR community I would say, especially with fentanyl and the ever-changing drug supply, we’re always so focused on that, that [THR] is left on the backburner.”
“I would say that tobacco isn’t a priority for people [in the harm reduction movement],” Garton concurred. “Additionally, stigma with smoking tobacco is nowhere near the stigma for people who use … other substances. Focusing on the issue where it’s more stigmatized is where the disconnect is from. It’s not that I think that harm reductionists don’t care about THR, I think it’s that we have a bigger problem at hand with stigma when it comes to other substances.”
“I feel like THR has to be taken more seriously amongst the HR community,” Crespo said. “We’re very much focused on the situations where an overdose happens, where it’s rapid onset and we’re trying to prevent those things from happening, but we also have to focus on long-term HR as well. I don’t think it’s discussed enough.”
“Even in NEXT specifically, I think there needs to be a wider role to be played,” they continued. “Because you know, people who use drugs are polydrug users normally, so if you’re doing whatever your drug of choice is and you’re also smoking cigarettes… Alcohol and tobacco are the underlying drugs that don’t get talked about too much in HR and … are more prevalent than some of the other drugs we focus on. For me, I just totally forgot that nicotine is a drug, and if it’s a drug, there are HR tactics that can be used.”
“Communicating with people who use tobacco is something we can very much pivot into.”
“I think the call to action within the community isn’t fully fleshed out yet, like what exactly we can do,” Coello said. “What we can start doing is just linking up to like, these two kind-of separate worlds. Like there being communication between people who are very invested in tobacco harm reduction and the other wings of harm reduction …. So first, I think that solid communication and camaraderie needs to be there. And then, I think aligning values of reducing harm overall, despite the legal status of the drug … Everyone needs to be on the same page about what it is and what can be done to reduce harms.”
“We already know and understand how to communicate with people who use drugs, and communicating with people who use tobacco is something we can very much pivot into,” he continued. “I’m sure a lot of our participants smoke or use vapes; we can leverage our ability to reach those folks and provide safer alternatives to smoking or combustion-based methods of using tobacco or getting nicotine.”
“I personally want to learn more and better understand THR, and how NEXT specifically could start doing things like this,” Coello concluded. “I’m not sure we’re at a point yet where we can make meaningful changes, but I’m hopeful in the future NEXT can play a role.”