The tobacco harm reduction (THR) debate encompasses many challenging ethical questions—from the respective roles of misinformation, public health nonprofits and tobacco companies, to balancing the needs and rights of children and adults, especially the most vulnerable.
It isn’t hard, then, to see how my personal interests in THR and philosophy intersect. I’ve long wanted to ask a philosopher about THR issues through that lens.
Dr. Sridhar Venkatapuram, senior lecturer in global health and philosophy at King’s College London’s Global Health Institute, struck me as perfect for this conversation, so I reached out.
Venkatapuram trained in public health at Harvard University, and in sociology and political philosophy at Cambridge University, among others. In a career of over 25 years, he has conducted interdisciplinary research around health equity, helping to pioneer health justice as an area of philosophical inquiry.
His doctoral dissertation—which he later developed into his 2011 book, Health Justice—concerned the philosophical argument for a right “to the capability to be healthy.”
Back in the 1990s, Venkatapuram was a researcher for Human Rights Watch, focused on HIV-related human rights violations in India. He has since worked with or advised organizations including Doctors of the World, the international Minority Rights Group and the World Health Organization. He’s currently an ethics advisor for NHS London and chairs the International Resource Group for Global Health Justice, among other roles.
Dr. Venkatapuram kindly agreed to tackle some questions about tobacco harm reduction for Filter. Our interview has been edited for length and clarity.
Kiran Sidhu: Vapes and other safer nicotine products have been shown by research and lived experience to help many people quit deadly cigarettes. Most people who quit smoking in the United Kingdom, for instance, now use vapes to help them do so. As far as the evidence shows, safer nicotine products don’t kill people; a Public Health England review found vaping to be 95 percent less harmful than smoking. Yet the discourse around whether to ban or regulate safer nicotine products typically emphasizes the issue of youth use as a key driver of policies. How should we balance the needs of adults who smoke and those of youth who don’t?
Sridhar Venkatapuram: The first kind of statistical point, 95 percent less harmful, does not mean that 5 percent is harmless. So the question is, how much harm is still potentially happening? It’s definitely less harmful than smoking tobacco and all the stuff that they put in it. And so that’s one sort of question that we don’t really know, people haven’t really gotten a sense of that.
If there was a position that all vaping should be made illegal, then we would have a problem here—hindering people from doing something that’s 95 percent less harmful than smoking, and a possible path away from smoking.
Now, with talk about restricting vaping, we’re focusing on what’s happening to young people versus all (smokers and vapers).
There will always be young people who want to experiment with different kinds of substances; alcohol, different kinds of drugs, etc. There is no way that we are going to shut that down. Vaping is not just a singular thing. It’s part of a whole set of things that young people will aim to do.
The question we really want to find out is, what are the risks of long-term damage to young people if they start vaping early in life?
Is it wrong to make vaping illegal for the sake of stopping young people, because it would also hurt older people who are trying to quit tobacco? I would say that it’s wrong.
There is a worry here that being over-restrictive for the sake of protecting young people is not balanced with the help that it could provide to others who want to vape because they like it, or because they want to move away from smoking tobacco.
“Smoking is delivering various kinds of feelings that people like. The idea of swapping tobacco for vaping is basically giving and keeping that same sense to people, while lessening the harm.”
KS: Marginalized populations—people on low incomes, people experiencing homelessness, LGBTQ+ people, people with mental health diagnoses and others—smoke at far higher rates than the general population. Does this knowledge give us a special responsibility to prioritize availability of safer nicotine products for populations where the message of “just quit” has not done enough? The UK government has had a “swap to stop” scheme, giving out free vapes to predominantly marginalized people who smoke; do you consider this ethical?
SV: From a global health perspective, when tobacco restrictions started to come into place in rich countries, a lot of tobacco companies moved to low- and middle-income countries. So there’s a bigger picture going on here about how the harm is being shifted to poor countries.
We have done various things in order to reduce tobacco smoking in populations in rich countries. This has included increasing tax on tobacco so that it’s really expensive; we have tried to restrict advertising, require generic packaging, and other kinds of things.
What we have found is that there are some population groups that are continuing to smoke tobacco. And this isn’t just with tobacco. This happens with lots of other kinds of health harms, whether it be sexually transmitted diseases, or alcohol or drug use. And the question is to understand why.
What’s happening here with smoking tobacco is that it’s delivering various kinds of feelings that people like. Whether it’s true or not, they think it makes them feel better or it helps them. A lot of it has to do with complicated notions around pleasure and control. So you will find that very poor people smoke tobacco. And it’s shocking because it doesn’t make sense. Why would somebody who’s really poor be spending so much money on tobacco?
And some people get very moralistic and say these people are really dumb or irrational. But what you find when you look closer is that smoking is one of the few pleasures that they have in their life, and something that they do for themselves. So there’s this complicated sense of, This is something that is just for me and it feels good.
So based on that, the idea of swapping tobacco for vaping is basically giving and keeping that same sense to people, while lessening the harm that they’re at risk of if they carried on smoking. This would be the reason for it being something to support.
Something against it would be someone saying you are supporting addictive substances. And we should not at all be supporting anything that’s addictive, therefore either get them all off or don’t do anything.
I think from a public health perspective, and my own personal point of view, it would be much more right to support people in reducing the harms in their lives rather than saying it’s all or nothing—either you stop or we don’t do anything for you. My perspective here is based on appreciating and valuing each individual in their context, and helping them even incrementally reduce harms in their lives. It is not driven by being moralistic, or a rigid disease-control agenda.
“I think that the genie’s out of the bottle. Restricting flavors in order to reduce youth attraction is just not going to work.”
KS: The UK is about to implement a disposable vapes ban. The rationale is that disposables encourage youth uptake and cause environmental harm. On the other hand, disposables represent the lowest-barrier vaping option for people who smoke, due to their simplicity and low startup costs, and some companies are developing more sustainable products. Critics also point out that bans boost illicit markets (which already exist), meaning people using products without consumer safeguards or age restrictions. What’s your view of the disposables ban, and how would you consider these arguments should be balanced?
SV: Disposable vapes being bad for the environment is probably true. However, the amount of Nespresso capsules produced is enormous. No one talked about banning Nespresso as a result of the enormous metal that’s produced. In Switzerland, there are actually separate garbage containers on streets just for Nespresso capsules.
So I think a ban on disposable vapes is kind of unique to vape policy, because you’re not banning other things guilty of producing large amounts of waste. Think about water bottles. It sounds like “we’re going to go after vapes” policy.
The other thing is, it might be that disposable vapes are actually better for some of the concerns that people have about vaping; if you ask people to buy a long-term vape that you refill, you are actually making them invest into something.
Think about a comparison with disposable pens: You’re going to buy this fountain pen and you have to refill it, so you’re more likely to become invested in that pen than if you had a disposable pen. You’re really going to take care of it and use it, rather than say, I’m only going to use this for a while and then I’m going to throw it away.
We need to think much more about whether making disposables illegal actually commits people more to vaping. And then why not make disposable vapes more eco-friendly, anyway?
KS: Most adults who switch from cigarettes to vapes prefer flavored vapes, typically fruity or sweet. Many people say they found flavors critical to switching. Youth often prefer these flavors too, and this has led to calls for flavor bans, which have been enacted in many jurisdictions. Products like alcohol and sugary drinks come in many flavors, and in those areas age restrictions and parental discretion are considered adequate controls. How would you view all this?
SV: As far as I understand, there’s already an age restriction for young people for vaping.
I think that the genie’s out of the bottle: People know they come in flavors. So, if you go back to saying, okay, actually, there can be no flavors, then people will figure out a way to go and find the other ones that have flavors. Restricting flavors in order to reduce youth attraction is just not going to work. Someone will come up with a way to add flavors.
I think what would be better would be to treat everybody, whether young or old, as thinking, smart individuals, and say: Here’s the information. Tobacco smoking is bad for you, and long term, it’s really bad for you. Try to quit if you are smoking, and don’t ever start. Vaping is something that also has nicotine. It can come in a variety of attractive flavors, but it’s addictive. So do you really want it? Do you really think that the benefit is something that outweighs the potential for you to become addicted?
KS: Many governments, media outlets and even public health groups distort and exaggerate harms related to safer nicotine products. Often, the aim is to dissuade youth from using them. Would it ever be justifiable to be dishonest about risks for such a purpose?
SV: I don’t think you should lie to people, particularly if you are a government agency or a trusted health organization. If you’re knowingly dishonest, then you lose the trust of the people that you want to help.
I think it’s much better to provide the best available information that you know and to be able to say, This is what we know at present.
So, rather than being moralistic and saying, That’s bad and you’re bad and you’re doing something bad, I think sometimes when we don’t have the right amount of evidence, it’s okay to say, We don’t know, but we are erring on the side of precaution. That’s a different perspective than the moral high ground.
“People are so severely constrained in their lives that they are looking for these minimal ways in which they can make their life pleasurable, or show control. That’s a failure of us.”
KS: Part of the cultural and political backlash against vapes and other safer nicotine options has involved conflating them with Big Tobacco. It is true that some of these products are made by tobacco companies, but many are not. Should the role of tobacco companies weigh against supporting availability of products that can save lives through smoking cessation? Or, would you consider, given the unlikelihood of tobacco companies disappearing, that seeing these companies make profits from safer products rather than deadly ones would be an improvement on the status quo?
SV: I think it depends on what your role is and what your organization is.
If I’m a community-based health worker and I am working with people, I think that it would be very ideological for me to not support the use of vapes among people that I work with because I think that it would be supporting the tobacco companies.
It would be different if I was the NHS and I was putting in an order for vapes, and I buy it from a tobacco company rather than a non-tobacco company, right? So there, I would make a distinction between who it is that I want to be supporting in order to be able to do something like this.
At an international level as well, whose voice should we be looking at when we are thinking about vapes? Is it the big multinational tobacco company who’s pushing vapes, or is it other companies?
Eventually what’s going to happen is that the tobacco companies will buy up all the most successful vape companies anyway. It’s just the way late capitalism works.
KS: Do you consider that people have a right to use drugs if they choose, absent harm to others—and to decide for themselves what they put in their own bodies?
SV: I think in liberal, Western Europe Enlightenment societies, we tend to think people should be able to design and pursue their own lives. And I think that’s right.
I’m a big believer in this idea that individuals should be able to live the kinds of lives that they want to live. At the same time, we need to have minimum thresholds.
So, if somebody is on the street and they are clearly dying from being hit in the car, we save them. We don’t say, Well, you made the choice and therefore you’re on your own. So there’s something here about helping, making sure that people are not doing things that actually severely constrain their ability to live the lives that they want to live.
I think drugs is a weird word because white wine is one type of drug and people are drinking bottles of white wine every day, and we would never make that illegal.
I think what we should be having is a conversation about the different kinds of drugs, whether it be alcohol or stimulants. Should people be able to do it? Probably, yes. But what are the parameters for it?
Well, I don’t think that little children should be able to use drugs. I don’t think parents should be allowed to give their children drugs just because they can and it’s their children. I think there’s something of a social duty to protect children’s future lives.
In terms of adults, I think there are some parameters where we sort of say, you can live the way that you want to live. But, if it comes to a point where you are narrowing your life to something very, very minimal because of the use of drugs, then we should probably intervene. In something like a situation where someone is severely impaired from drug use, it’s much more of a self-harm situation that requires us intervening, rather than unjustly intervening into their positive outlook where they are saying, I’m living the life that I want to live.
And then there are the issues around tobacco and drug use being prevalent in some populations, like LGBTQ groups or people with mental impairments. That’s a failure of our society, not the failure of those people. People are so severely constrained in their lives that they are looking for these minimal ways in which they can make their life pleasurable, or show control. That’s a failure of us. So for us to say we should stop them from doing it, that’s hiding the problem of what is causing them to find pleasure, comfort or meaning in those behaviors.
Photograph (cropped) by Mustang Joe via Flickr/Public Domain