As a community-based researcher, I always tried to involve community members in the planning, conduct and presentation of the research. Over the years I learned to embrace the “nothing about us without us” philosophy. I know from my researching drug use and harm reduction that the success of the studies was greatly enhanced by the community connections and relationships. After all, they were the people who were using the drugs and would be in the best position to know what would work and what interventions were just wishful thinking.
When I arrived in Ottawa in 2010, my research focus was people who used illegal drugs and how to reduce the health and social harms. As a first step I wanted to establish a community advisory group in Ottawa to identify priority areas of research and advocacy. I initially contacted Sean LeBlanc, who was a community leader and organizer. Sean had just launched an organization called DUAL (Drug Users Advocacy League) that advocated for people who use drugs in Ottawa. Sean agreed to help me create a community advisory group that would assist in designing and overseeing the work.
Not unexpectedly, the people who agreed to participate in the committee smoked cigarettes, in addition to using other drugs. When we had our first meeting to discuss how the group would operate, it was clear that cigarettes were on everyone’s mind. Could the group members smoke inside the building when city bylaws prohibited indoor smoking? Could the committee members smoke during meetings? How long would a smoke break be? Could study participants smoke during research interviews? Could we use cigarettes as an incentive for people to participate in the research?
Within the first three months of forming the advisory group, we lost three out of eight members to smoking-related diseases.
During that first meeting we could only go 10 or 15 minutes before someone needed a cigarette break. Once one person wanted to smoke, everybody else decided they needed a cigarette too. At first, we held our meetings outside to avoid conflicts with the indoor smoking ban, but as the Ottawa winter came on this was just not possible. But the real impact of smoking extended far beyond ignoring bylaws and being exposed to secondhand smoke.
Within the first three months of forming the advisory group, we lost three out of eight members to smoking-related diseases. One member had a debilitating heart attack, one was diagnosed with advanced lung cancer, and one was confined to his room because he was reliant on home oxygen due to COPD. All would die within the year. It was a big loss for the group and led to a lot of probing discussions around why people smoke. It also got me thinking about the human cost of smoking and nicotine addiction among people who are using illegal street drugs.
My research and clinical work had primarily focused on the health impacts of HIV and hepatitis C. Like smoking, HIV and hepatitis C are chronic, progressive and relentless diseases that ultimately kill. What is strikingly different is that effective and well-tolerated treatments are now available for these viral infections. In contrast, virtually nothing was being done to help manage nicotine dependency and cigarette smoking among people who use drugs. I started questioning why I would put all this effort into studying the natural history of HIV and hepatitis C among people who were on antiviral treatment, when most would die of smoking-related causes.
I was immediately struck by the concept. E-cigarettes were the very definition of harm reduction, taking something inherently dangerous like cigarettes and making them less so.
It was during my time in Ottawa that I first heard about electronic cigarettes. I was immediately struck by the concept. E-cigarettes were the very definition of harm reduction, taking something that is inherently dangerous like cigarettes and making them less so. In keeping with the harm reduction interventions that I spent decades advocating for—clean needle programs, supervised injection sites, methadone maintenance treatment and safer drug supply programs—vaping was a direct response to reducing the risk of cigarette smoking. People could get the nicotine that they craved and enjoyed with far less risk.
The implications were enormous because of the millions of people who smoked. In June 2014, I published an op-ed in the Ottawa Citizen that outlined the merits of e-cigarettes and the need to establish vaping as a harm reduction intervention. At the time the response to my article was generally positive, and I thought that e-cigarettes would catch on quickly. Sadly, over a decade later we are even further away from promoting safer nicotine delivery products.
The global tobacco epidemic requires a seismic shift in perspective. Harm reduction offers a pragmatic approach that doesn’t abandon smokers to an all-or-nothing choice between abstinence and continued smoking. The adoption of safer alternatives can reduce harm substantially. This has been demonstrated by decades of evidence in other health fields. While vaping may not be entirely risk-free, it presents a far less harmful alternative to smoking, and for many individuals it can serve as an effective bridge to quitting nicotine.
They’ve already gone to great lengths to discredit vaping. At this point, a change would be an admission of failure and public health institutions fear this above all else.
While governments and health authorities remain focused on traditional, abstinence-only models, the global epidemic of smoking-related diseases rages on. Each day that passes without a reduction and cigarette consumption, thousands more people develop preventable chronic illnesses. Lung cancer, COPD, heart disease and stroke continue to take an enormous toll on public health, yet many medical and policy leaders are hesitant to discuss the alternatives.
At some level, it is understandable for governments, health officials, medical leaders, and influential journals to reject vaping’s potential health impact. They’ve invested heavily in absence-only messaging and fear-based warnings over decades. They’ve engaged in a campaign to punish and take down the tobacco industry. They’ve already gone to great lengths to discredit vaping and safer nicotine products. At this point, a change would be an admission of failure and public health institutions fear this above all else. Vaping has become a threat to their very existence.
In my experience as a physician, I’ve seen first-hand the toll that smoking takes on people’s lives and the deep frustration many feel in their failed attempts to quit. The stakes are too high not to act. While smoking rates are declining in many countries, it will take years, if not decades, to see those reductions translate into broad improvements in health outcomes. Meanwhile, millions around the world will continue to develop preventable illnesses. The time to rethink our approach is now.
This article is an excerpt from the book Vaping: Behind the Smoke and Fears, by Dr. Mark Tyndall, published in May 2025. Dr. Tyndall was recently interviewed by Filter.
Top photograph by Andres Siimon on Unsplash
