“It’s time drug treatment and harm reduction services got involved with tobacco harm reduction,” Gerry Stimson told the audience.
Stimson, a public health social scientist and emeritus professor at Imperial College London, was speaking at the Global Forum on Nicotine (GFN) in Warsaw, Poland, in early June. He emphasized the extremely high prevalence of tobacco smoking, and related harms, among people who use banned drugs.
“Smoking rates amongst people who use drugs or people in drug treatment are two to four times higher than the general population,” Stimson said. Of 100,000 people who used heroin in the United Kingdom, according to research he cited, 63 percent were projected to die before the age of 70, compared with 16 percent of the general population. While 27.6 percent of the projected premature deaths were attributed to factors around banned drug use, 23.6 percent were attributed to smoking.
“We’re all aware of drug-related deaths,” said Stimson, who helped pioneer harm reduction approaches to drug use in the UK in the 1980s. “But the fact is, in this population, there are nearly equal numbers of deaths from smoking.”
Such figures are “stunning,” Stimson said, yet remain “invisible.”
“We can’t talk about harm reduction without tobacco harm reduction.”
The GFN panel, titled “Drugs and Tobacco Reduction: Shared Challenges, Shared Solutions,” highlighted how ignoring this intersection is one major way in which people who use drugs are denied the right to health. And the relationship is so obvious.
Nicotine use and use of other drugs go together so often that, “We can’t talk about harm reduction without tobacco harm reduction,” said panelist Magdalena Bartnik.
Bartnik is the founder and director of PREKURSOR, a Polish organization providing harm reduction services and advocacy for people who use drugs. She sees safer nicotine products as essential resources. “Cigarettes are an important part of people’s lives, a way of coping with stress,” she told the audience, “so tobacco harm reduction allows for the mitigation of health risks without the need to quit using nicotine.”
Marianna Iwulska, another of the panelists, has first-hand experience of that. She’s a drug-user activist who chairs the board of EuroNPUD, and a peer worker at PREKURSOR. She switched from cigarettes to vapes, and said her health has improved immeasurably as a result. But she did so without any encouragement from those who should be looking out for her health.
“When it comes to tobacco harm reduction, I have déjà vu. I am seeing the same arguments thrown about as with opiate substitution therapy.”
“No doctor ever asked me, even, if I am smoking, throughout my 26 years of [opioid] substitution treatment in Poland,” Iwulska told the audience. And that silence reflects what she described as a culture of hostility towards safer nicotine options, similar to that seen against medications for opioid use disorder.
“When it comes to tobacco harm reduction, I have déjà vu,” she said. “I am seeing the same arguments thrown about as with opiate substitution therapy, when people were saying, ‘It’s the same, it’s like drug use, you are not recovering at all.’ But harm reduction is about meeting people where they are, not expecting miracles—not, ‘You have to stop first, then we treat you.’ I think it will be very, very beneficial to drug users to implement tobacco harm reduction to services.”
There have been some signs of momentum, with more groups concerned with drug-user rights and health recognizing the importance of tobacco harm reduction in recent years. In the United States, for instance, the National Harm Reduction Coalition has been working on it, as has the Urban Survivors Union, among others. Prominent supporters include Mark Tyndall, a Canadian physician with a long background in “drug” harm reduction.
A recent briefing paper from Global State of Tobacco Harm Reduction (GSTHR)—a project of Knowledge-Action-Change (KAC), which Stimson co-founded—highlights some of the reasons nicotine and other drugs often go together.
“One of the problems is that drug services are often in a different silo, with different budgets from smoking cessation.”
Many people find nicotine relieves symptoms of withdrawal from other drugs, the paper notes. Smoking cigarettes before and after can be part of people’s ritual of drug use, “reinforcing both habits,” while nicotine may enhance people’s experiences of using drugs such as cocaine or opioids, as it “increases the body’s uptake of one or both substances.” Yet at the same time, data show that many people—including up to 80 percent of those in substance use treatment—do have a desire to quit smoking.
An accompanying GSTHR briefing paper offers ideas on how drug services could incorporate tobacco harm reduction to help people who smoke—by displaying information on safer nicotine options, for instance, and creating a smoking-cessation community that shares the same goals.
This kind of integration would be fairly straightforward and wouldn’t cost much. “It’s a lot simpler than trying to persuade governments that you want to prescribe methadone, or persuading governments that you want to give out needles and syringes,” Stimson said.
So why is tobacco harm reduction not already routinely included in most harm reduction and drug treatment services?
“One of the problems is that drug services are often in a different silo, with different budgets from smoking cessation, and people are focused on their own targets and priorities,” KAC Director David MacKintosh told Filter.
Harm reduction services are typically very stretched, dealing with acute crises such as overdose with scarce funding, he acknowledged, “so it’s understandable it’s not the priority, even though it will kill half of those who continue to use combustible nicotine.”
“I think the way to bring change is within community-based organizations upwards.”
Change requires support from leadership. MacKintosh moderated the GFN panel, where he said the idea of tobacco harm reduction remains “abstract” for many, and needs to be made more concrete in decision-makers’ minds.
“Whether you’re working with national politicians, public health people, whoever it is, they have their own interests,” he told the audience. Advocates, he said, need to appeal to those interests, to sell the idea of tobacco harm reduction and its benefits for individuals and local communities to the people who fund harm reduction services.
“We have to build from the ground up and help policymakers and public health leaders find their confidence to do what’s right around THR, rather than ignoring the potential, which can seem safer and easier,” MacKintosh told Filter after the event.
This grassroots approach is something Stimson agrees with. He told the GFN audience that getting THR into drug services can be a “bottom-up way to influence donors and international organizations.”
“I think the way to bring change is within community-based organizations upwards,” he said.
Photograph by Irina Iriser on Unsplash
The Influence Foundation, which operates Filter, has received donations and grants from KAC and from GFN Ltd. Filter‘s Editorial Independence Policy applies.