The tobacco harm reduction movement has long needed doctors to unapologetically make the case that it’s a matter of life and death to get safer nicotine products to the most vulnerable groups of people who smoke. Mark Tyndall is the ideal doctor. He has the bonafides and he brings the receipts.
For decades, Tyndall’s medical practice with people who have HIV and/or use drugs has been based on the philosophy of harm reduction, of meeting people where they’re at. In Canada, he was on the frontlines of the HIV/AIDS epidemic in the 1980s and ‘90s. More recently, he worked with people who use drugs in Vancouver’s Downtown EastSide, amid the devastating opioid-involved overdose crisis.
To address these public health emergencies, Tyndall was an early supporter and promoter of syringe programs, overdose prevention sites, expanding access to methadone, and safe supply—for which he founded a pioneering, innovative program.
For Tyndall, safer nicotine products are safe supply for people who smoke.
Now Tyndall has turned his attention to another public health problem, smoking, which is responsible for more deaths than overdose and HIV combined. His new, vitally important book, Vaping: Behind the Smoke and Fear makes an urgent case for tobacco harm reduction and for the medical community to recommend the use of safer nicotine products to their patients. It chronicles the toll of smoking-related disease and death that he has witnessed in his long career working with people who use drugs.
For Tyndall, safer nicotine products are safe supply for people who smoke. In Vaping: Behind the Smoke and Fear he argues that getting these products to the groups with the highest rates of smoking—people who use drugs, who are unhoused, who have mental health conditions—is a matter of health equity and social justice.
Chapters explain the benefits of nicotine, the “group think” that hasn’t allowed the medical community to adopt the use of safer nicotine products, and community-driven vaping advocacy. You can read an exclusive excerpt here.
Tyndall is that rare doctor who will forcefully stand up and speak out about the necessity of integrating tobacco harm reduction into health care. We need more of them, and this book will help in that effort. I asked him about the experiences that inform his thinking.
Helen Redmond: You’ve worked with people who use drugs in the Downtown Eastside in Vancouver using a harm reduction approach for decades. You founded the MySafe Project to offer safe supply through vending machines. How has that experience informed your work around tobacco harm reduction?
Mark Tyndall: The way I think about tobacco harm reduction is totally because of all my experience with other forms of harm reduction. And I tend to think of all medical prevention as harm reduction. I’ve just seen it work for a long time. Giving people a clean needle and a supervised injection site where their drug use won’t kill them, it just seems so obvious to me.
But it takes a long time to convince people that harm reduction is the right way to go, because they’ve vilified it so much that they can’t really see beyond anything but prohibition and abstinence. Cigarettes are much the same. My public health colleagues have been so socialized and educated into the harms of cigarettes and that people have to quit, they have a lot of difficulty putting their heads around the idea that there should be a safer option. There are groups of people who just will not quit. We’ve had decades to find that out, so it should be no surprise.
We’ve taken most of the health risks out of smoking if people vape or use other safer nicotine products. It’s such a brilliant way to do it, and it’s so frustrating that a lot of people don’t see it that way.
“I knew a lot of people who were very sick and should have been in hospital, and they left against medical advice because of the smoking ban.”
HR: Can you tell me about your experience working in the hospital, and with patients smoking on 10 C Ward?
MT: I arrived in Vancouver in 1999 and started working on what was called the 10 C Ward, which was designated for HIV-positive patients. When I first got there 75 percent were gay men. Back then we saw all kinds of opportunistic infections, the treatments available were not that great, and adherence was difficult because of the toxicity. So a lot of people were in and out of hospital. As time went on, more and more of the clientele were people who used drugs intravenously and shared needles. That’s how they got infected. So the clientele changed.
But what was the same about both groups was that the smoking prevalence was very high. The hospital allowed smoking in designated areas. The 10 C ward had an actual room right on the ward, because we didn’t want people wandering around the hospital. So at the end of the hall there was a room with a nice balcony; a smoking lounge. When I go up to the floor in the morning to do rounds, most people were in the smoking lounge. And when they weren’t in their rooms, that’s where they were. And it was a very social place.
Around 2007 or 2008, hospitals passed bylaws that they’d be no-smoking facilities, and that room was closed. All of a sudden, the community part of the ward disappeared. Many patients that I was looking after were very angry that they couldn’t smoke, and many were not allowed off the ward because of the infectious diseases they had. So they were basically forced into quitting smoking, and for quite a few people that was just too big a deal.
They would sign themselves out of hospital. I knew a lot of people who were very sick and should have been in hospital, and they left against medical advice because of the smoking ban. There were many people that I saw in the community who I was trying to get to go to hospital because they really needed to be admitted, and their biggest reason not to go was that it was a no-smoking facility and that they couldn’t see themselves without a cigarette. So it had a huge implication for patient care.
HR: You also use the example in the book of patients who smoked in a psychiatric hospital.
MT: The hospital had beautiful grounds, big trees and tables outside. They did some of their counseling and therapies outside but they were not allowed to smoke. A beautiful park area beside the hospital and in the morning, totally empty, except for security guards making sure that nobody smoked on the property. People were all lined up on the other side of the fence next to traffic, smoking cigarettes. You couldn’t think of a more humiliating thing to do to patients than that.
HR: Tell me about “contraband” in the hospital.
MT: I was part of the leadership team for the health authority for the BC province. I was representing public health. There was a meeting with the head of the cancer agency, the head of pediatrics and other staff. One of the roles of the health authority was to give approval for different expenditures. A group of security experts were at the meeting, and they had a plan to stop contraband from getting into the hospital.
I found out that the contraband they were talking about was tobacco. The economy of this hospital was based around it. Loose tobacco and cigarettes were smuggled in, and were very valuable because pretty much all of the patients in this facility smoked. They had decided that all this contraband being sneaked in was a big problem, and they had a $7 million proposal to reinforce the fencing, put in more security cameras and take out this massive tree that was on the property. Apparently people were hiding behind it and they couldn’t see them.
I thought the proposal was crazy. Somehow they believed that it was a good use of $7 million to make sure that there was less loose tobacco getting into the hospital.
This ridiculous idea shows what lengths people will go to in order to prohibit people from getting a cigarette. When you think about what you could do with $7 million for that institution… My thing was just give patients safer nicotine products like vapes and the contraband problem would go down substantially. You’re not going to stop it by cutting down a tree! I wasn’t there for the final decision, but heard that they ended up approving the security experts’ proposal.
Dr. Tyndall speaking at the Global Forum on Nicotine in June 2025
HR: Rates of smoking among Indigenous people are very high in Canada. In your book you give the example of the Inuit. Can you discuss the impact this high rate of smoking has had, and the impact of taxes?
MT: If you look at the prevalence of smoking among First Nations in Canada, it’s probably three or four times what the national average is. It depends what province and what community, but the adult smoking rate is probably 25 to as high as 80 percent in the Inuit population. There are huge problems with the economy because everything has to be imported. The cost of food and medical care is super-high, and the price of cigarettes is exorbitant. It’s $30 a pack; most of the cost is taxes and transportation.
So if you have 80 percent of the population smoking, and they pay $30 a pack, it has a huge impact on their household income. Can you imagine if you have an extended family and 10 people in the household are all smoking at $30 a pack?
There’s quite a lot of bootleg cigarettes around and the government spends a lot of time trying to intercept that and to shut it down. They overtax cigarettes in the hope that people won’t buy them. But they do. Instead of reducing the taxes, we put all our money into enforcement to try to make sure that people can’t buy cheaper cigarettes. It really makes no sense.
“Michael Bloomberg got Vietnam to ban vaping. It’s outrageous. That just shouldn’t be allowed to happen. It’s colonialism.”
HR: You lived in Bali for two years. Can you describe how widespread smoking is and the impact on the population?
MT: I went to Bali for family reasons, and to write this book. I had no idea I would be living in the heart of the cigarette world. It was like going back to the 1960s in Toronto, where I grew up. In Indonesia, smoking is just so ubiquitous and part of the culture and society that it’s really not thought of the same way we think of smoking here. People who smoke cigarettes in Canada know it’s bad for their health. I’m not sure in Bali that most young men I saw smoking know that.
There were villages I visited in Bali that had no advertising at all, except for cigarettes. Every shop has a cigarette advertisement. Everybody sells them, not just little convenience stores, but food stalls sell individual cigarettes. They’re very cheap.
You could switch the whole game very quickly in Indonesia by incentivizing alternative nicotine products. Make vaping way cheaper and incentivize it way more than cigarettes, and I think a lot of people would switch very, very, quickly. With such a young population they could add 10 years to life expectancy.
So it’s kind of exciting in some ways. I’d love to talk to the president of Indonesia and say, “Look man, this is such a massive opportunity for your country. Cancer rates are just enormous, you could really make a huge difference to your whole country by promoting safer nicotine products.”
And you see a country like Vietnam, with a smoking prevalence rate that is similar to Indonesia. I have visited Vietnam a number of times. Michael Bloomberg got them to ban vaping. It’s outrageous. That just shouldn’t be allowed to happen. It’s colonialism.
HR: How does nicotine affect the brain? What are the benefits of nicotine?
MT: I’m not a nicotine expert, but what I have found both from reading research and talking to people, it’s a very useful stimulant. It’s like caffeine, only more addictive as far as cravings go. It’s a fascinating drug that is so ubiquitous.
We think of people who smoke cigarettes as just being chained to this terrible addiction. If only they could quit nicotine. But when they’re having a cigarette, it’s an enjoyable and helpful experience. When people get up in the morning and need a cigarette, the nicotine is very useful to them and helps them to get going and concentrate. There are positive effects on people as far as their attention span, memory and reducing anxiety. I think we’ve lumped it in with cigarettes so much that people don’t know about the benefits of nicotine.
It’s crazy to me that the anti-tobacco lobbyists have turned their attention to not only a smoke-free society but a nicotine-free society. I think it’s quite reasonable with safer nicotine products that we could look at Canada or the United States reducing the rates of smoking to less than 5 percent of the population by 2035. But if the goal is to get nicotine use below 5 percent of the population, forget it. That will never happen.
“Smoking has such massive global implications. If we could take half of the billion smokers and switch them off a deadly cigarette to a vape it would change health care systems around the world.”
HR: Many doctors are opposed to the use of safer nicotine products. What will it take to convince them that tobacco harm reduction works and can save the lives of their patients?
MT: I think that doctors are, for the most part, group thinkers. Cigarette smoking has been around so long that very few physicians want to hear about it or take it on. They’ve been so used to telling patients to quit smoking and to use a nicotine patch, and they don’t. Doctors haven’t really taken the time to look into the alternatives.
Most of my colleagues, when I sit down and talk to them about it, are actually surprised that vaping is safer. It’s kind of just being lazy. When big organizations like the CDC, the WHO or Johns Hopkins University come out with statements against vaping, they don’t really question them. I think most doctors don’t even care if nicotine doesn’t cause cancer. They know it’s associated with tobacco and if that’s the message out there—that nicotine causes cancer, all the better because it makes a stronger argument for people to stop smoking. It’s really horrible and tragic.
Smoking has such massive global implications. If we could take half of the billion smokers and switch them off a deadly cigarette to a vape it would change health care systems around the world. Instead, we’re diddling around with whether we should ban flavors or not. It’s missing the whole point of what vaping can offer people to help them quit smoking.
Photographs by Helen Redmond
