How Can We Integrate Nicotine Into Harm Reduction Programs?

    Vaping and forms of smokeless tobacco have gained popularity as harm reduction options for millions of ex-smokers around the world. Evidence shows that such products are both vastly safer than cigarettes and effective ways of quitting them. But in the last few years, we have simultaneously seen a dramatic increase in fear-mongering around these options, led by national and local governments, well funded nonprofits and the World Health Organization.

    In the United States, the political and media fixation has been on a supposed youth vaping “epidemic,” despite a steep recent decline in youth vaping. This narrative ignores the predominantly marginalized adults who are dying of smoking-related causes at a rate of almost half a million a year. Yet to many opponents of tobacco harm reduction (THR), nothing other than abstinence from nicotine should be our goal.

    Surely it would make sense for every smoker who benefits from syringe access to be offered vapes as well?

    As a harm reductionist, I am particularly perplexed that many harm reductionists and harm reduction organizations do not fully embrace vaping. I recently reported, for example, on the anti-vaping positions of some syringe programs in Colorado. Surely it would make sense for every smoker who benefits from syringe access to be offered vapes as well? Yet THR has been sidelined in wider harm reduction discourse and provision.

    How can we do better at integrating THR into “drug” harm reduction programs (HR)? I put this question, among others, to three people with different expertise and experience.

    One of them has an extensive background of working in harm reduction and grassroots drug-user advocacy; his current position at a state health department means that he spoke on condition of anonymity. We’ll call him “Mike.”

    I also spoke with Art Way of Equitable Consulting; before becoming a drug policy consultant, he advocated around cannabis and criminalization, among other issues, for the Drug Policy Alliance. Finally, I put these questions to Kat Humphries, a well known harm reductionist who is the programs director of the Harm Reduction Action Center in Denver. Their responses have been lightly edited for length and clarity. 


    Kevin Garcia: What made you start thinking that we needed to pay attention to THR?

    Mike: It’s something I’ve thought about here and there. I first became involved in the international THR scene about 15 years ago and was exposed to some Australian work. In the States, I’ve been engaged with service delivery and a group of us conducted a THR group for people using cocaine. 


    Art Way: Nobody wants to represent the tobacco industry or users, and the death of Eric Garner [killed by the NYPD in 2014 after being accused of illegally selling “loosies”] was problematic. At that time, I worked with the Drug Policy Alliance. It was about police accountability, marijuana legalization and menthol bans. 


    Kat Humphries: I don’t typically think of harm reduction in terms of specific substances, but rather as a movement to support and empower the safety and wellbeing of all people who use drugs. THR hasn’t been a prominent component of my harm reduction career; however, I absolutely believe people deserve access to tools that allow them to use substances in a way that lowers negative health outcomes. Many harm reduction agencies have historically prioritized opioid-centric harm reduction, but ensuring appropriate harm reduction tools are available for all people who need them is imperative.  

    “Harm reduction tends to work well by maximizing pleasure, not just minimizing harm.”

    What would bringing THR to HR look like for you? How can we bridge the gap?

    Art: That’s what I’m trying to do. I don’t know if it can happen in regards to organizations right now. We need to build a base of harm reductionists as individuals to advocate for THR. Harm reductionists within the public health space, willing to cut through politics and stigma. 

    Kat: Education! I think the biggest barrier to implementing THR is the lack of education around the options. The evidence is definitely out there, but a lot of misinformation has also been pervasive, causing confusion about the facts. Harm reductionists respond well to evidence, and I love that you’ve taken on highlighting the importance of THR.

    I would start by defining the most effective THR options for people interested in implementing them, providing different levels of potential interventions for already-existing harm reduction agencies to integrate (with a focus on low-barrier, low-cost options for severely underfunded organizations or [those that] receive no formal funding), and working to provide sustainable long-term funding for those interventions. Further, I would define a specific population that is interested to start applying those interventions, and then scale up. 


    Mike: Good HR gets the approach of putting drug use in context with life. Also HR tends to work well by maximizing pleasure, not just minimizing harm.

    Smoking after a long time comes with lots of side effects. There’s no naloxone for cocaine or meth, so what do we do? Cardiovascular health education for people who use stimulants, hypertension screening, linking people to care. Providing access to nicotine replacement products, including vapes [works on the same principle].

    Have THR integrated into health promotion groups and counseling. Provide real options for people, like free access to nicotine replacement that is desirable to them. Link THR to other drug harm reduction information: [for example] lung health is important for avoiding fatal overdoses. 


    Where would be a good place to start?

    Mike: States are giving out safer smoking kits for meth and crack using federal funding. The same could probably be done for vapes. States that have embraced harm reduction and have committed to resources like naloxone access would be the best places to start.

    Art: It comes down to having the will to advocate on behalf of users of these products. A will to go beyond the politics surrounding the tobacco industry. Organizational perspective can get tricky, but it’s doable from an individual perspective.

    “Providing education about low-barrier options for trying out THR could mitigate some of the resistance.”

    Do you see any potential issues or complications with integrating THR into HR? If so, do you think they can be mitigated? 

    Kat: In spaces that have historically been underfunded, there will always be resistance to change from people who have had to sacrifice for resources and make hard decisions about what to prioritize. Providing education about low-barrier options for trying out THR could mitigate some of the resistance.


    Mike: It bugs me that HR in some ways carries over weird vibes from rehab culture, and doesn’t have an issue with people smoking. I smoked for 25 years. When I quit, I used vape pens as a bridge to stopping; [for me] it was more effective than anything else, with the partial exception of Chantix. 


    Art: A lot of it comes down to [Michael] Bloomberg and the financing of nonprofits and the Democrats. It’s not within political whims to stand up for vapers and people looking to reduce harms from tobacco use. Bloomberg’s main goal is prevention for youth and hurting the tobacco industry. They have a blind spot with young adults and smokers. It’s a punitive approach. It won’t help in the long run with prevention. If you strengen the illicit underground market, what does that mean for youth prevention? When you have people selling products for supplemental income,they don’t care how old you are. It isn’t a solid move towards cessation and it’s just a lazy policy. 


    Drug decriminalization movements are gaining traction, but with nicotine it’s going in the opposite direction. What are your thoughts on the cause of this? How does it harm THR efforts in HR spaces?

    Art: It’s unfortunate. It speaks to the fact that we can’t be universal and fundamental in our approach. So called “hard drugs” policy goes in one direction. But when it comes to Democrats specifically, because of Bloomburg, momentum is going the other way and restricting nicotine products. They’re following the money.

    Bans and prohibition aren’t the way. We need to focus on demand. Public health and law enforcement always focus on supply and the users are left out of the approach, unless they’re first criminalized. We don’t have a public health infrastructure that isn’t connected to law enforcement. We need to decriminalize drugs … you have to deal with the demand and you have to deal with the user. 


    Mike: Anti-vaping hysteria has taken important tools off the table. It’s 100 percent true that we’ve had a whacko, unregulated vape market. That doesn’t mean you can’t make it saferespecially safer than tobacco.


    Kat: Prohibition has always disproportionately impacted communities of color in the United States. And taxation as a form of reducing access to a substance is only a preventative measure for people without expendable incomemeaning that I think ultimately it’s both racist and classist to deny evidence-based harm reduction interventions for certain substances if people are seeking those resources, particularly while advocating for the decriminalization of other substances.


    What are your thoughts on overcoming public health’s blind spot concerning THR?

    Kat: I think a lot of people have historically used tobacco, and cigarettes specifically, to self-soothe and help manage stress, anxiety, and a myriad of other mental health conditions. In my time working in harm reduction, I haven’t had participants regularly ask me for harm reduction resources to reduce their smoking, but we’ve had things like nicotine gum available and would certainly expand that if requested by the population we serve.

    However, until we start the conversation about other options, people may not be prioritizing lessening tobacco consumption (from the perspective of someone working in a syringe exchange), or they might not have considered it as an aspect of harm reduction. Alternatively, they might not see it as a realistic option when over 75 percent of people we serve are experiencing homelessness and are often victims of theft, which makes holding onto anything of value challenging.

    I think starting the conversation is an important step, to see how it is received, which populations might be most interestedand to provide non-judgemental information and access to those interventions … or walking public health and community-based harm reduction organizations through accessing sustainable funding for those interventions.

    “We need to adopt an approach like the UK, which has a reality-based nicotine policy that accepts vapes alongside other options.”

    Art: My whole goal is to avoid blanket bans, and to take a scalpel to the issue of youth prevention, as opposed to a sledgehammer. Things have gotten better in public health in the last 20 years or so. About 33 million fewer are smoking tobacco [than 50 years ago] and it’s a slow step in the right direction.

    We need to adopt an approach like the UK, which has a reality-based nicotine policy that accepts vapes alongside other nicotine replacement options. The US needs to get off of the prohibition approach. We’re doing it with the decriminalization movements but it’s a slow process.


    Mike: FDA-approved [vaping] products would be ideal. It would be a big breakthrough in THR for medical and public health purposes. 



    Photograph by Lindsay Fox via Wikimedia Commons/Creative Commons 2.0

    The Drug Policy Alliance previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship. Art Way’s consulting clients have included Reynolds American, Inc, which has also provided unrestricted grants to The Influence Foundation.



    • Kevin is a tobacco harm reduction fellow for Filter. He began working in harm reduction as a health educator, providing street-based syringe access services for people who inject drugs. He was later a bilingual medical case manager, providing case management for people living with HIV/AIDS. He has also been a chapter leader and member of the board of directors at Students for Sensible Drug Policy.

      Kevin’s fellowship is supported by an independently administered tobacco harm reduction scholarship from Knowledge-Action-Change—an organization that has separately provided restricted grants and donations to support Filter.

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