“I am an accidental voice in the vaping world,” began Dr. Mark Tyndall, a professor at the University of British Columbia School of Population and Public Health. “For the most part, my world of harm reduction did not include cigarette smoking.”
Yet the epidemiologist’s world of harm reduction has been a big one throughout a long career: Some of his key contributions from his home city of Vancouver, Canada have included being the co-lead investigator in the evaluation of Insite, North America’s first sanctioned safe consumption site, and pioneering the safe supply of opioids, including through a “vending machines” project on which Filter has reported.
To those who support both tobacco harm reduction and harm reduction in general—and who see how the former is sometimes siloed—Dr. Tyndall’s address to the Global Forum on Nicotine was therefore particularly welcome. The annual event, moved online due to pandemic travel restrictions, took place on June 11 and 12, attracting over 1,400 remote delegates to hear dozens of international speakers.
“In fact, I always considered that smoking cigarettes was a form of harm reduction,” continued Tyndall (whose full presentation, courtesy of conference organizers Knowledge-Action-Change, can be watched above). “Among the thousands of people I have met who inject drugs, essentially everyone smokes cigarettes. For them, nicotine was a way to fill the time and calm the nerves in between fixes.”
“However, at the same time, it was painfully obvious that cigarettes were killing people—more than HIV, more than hepatitis C, and even more than the catastrophic overdose epidemic that has been sweeping through North America.”
Tyndall noted that the threat of “slow, insidious” death from smoking was not a great change-motivator for populations with more urgent concerns, and that “another reason to avoid the topic of smoking was because, at least until vaping, there was not much to offer.”
“It should have been a slam-dunk. By now, leading public health authorities around the world should have launched global campaigns to rid the world of cigarettes through vaping.”
“Around 2012,” he continued, “I heard about vaping. This was the very definition of harm reduction: taking an inherently risky activity and making it way less risky. … The amazing thing about vaping was that for many people, it was even more attractive and satisfying than cigarettes.”
“Yet eight years later, who would have thought that throwing a lifeline to people who smoke cigarettes would be so contentious? It should have been a slam-dunk. By now, leading public health authorities around the world should have launched global campaigns to rid the world of cigarettes through vaping. But that just hasn’t happened.”
Tyndall went on to outline typical arguments used against all forms of harm reduction—including moral arguments and the aspiration to a drug-free society, “enabling” arguments, youth messaging arguments and NIMBY-ism. He then turned to some obstacles specific to vaping.
“For one thing, it runs against a very well established cessation narrative. Many countries believe that they are on the right track, as they see the prevalence of smoking slowly declining. According to this narrative, the status quo is working already, and vaping just complicates things.”
“Well in fact,” he countered, “this downward trend in smoking prevalence is driven by people who are dying prematurely from smoking. Of course the prevalence is slowly going down as we watch people die. That’s not a victory when we have the opportunity to save lives. Progress should actually be declared when we see the prevalence of nicotine use go up, and that means less people are dying.”
Tyndall additionally criticized public health bodies for “irresponsible reporting” about the 2019 outbreak of lung injuries in the US, attributed—wrongly—to nicotine vapes. “The CDC and the WHO used this tragic event and the moral panic that followed to undermine the fact that vaping was much safer than smoking … their response caused people to go back to smoking cigarettes.”
Tyndall further identified “the tired old narrative, used by many of my public health and medical colleagues, that we just don’t know if vaping is safe: Where are the long-term prospective studies? Sure, we need studies—but only time will provide this. While we wait for these studies, it doesn’t mean that we shouldn’t do anything. In the case of smoking, we know that 50 percent of people die from chronic use. That prospective data is what we should be focusing on.”
“At the end of the day, access to vaping is simply a human right.”
The final obstacle he cited was “the fear of Big Tobacco,” meaning companies that manufacture both cigarettes and vapes. He explained: “No one should be defending the deadly, profit-driven strategies of tobacco companies, but taking some moral high ground when so many lives are at stake only hurts the people who are dying from smoking. If we truly want to shift away from cigarettes in any reasonable period of time, we must engage tobacco companies. … We can do this while continuing to tighten controls around global cigarette production and promotion. It should be noted that some of the most respected voices in the vaping movement are people who have spent their lives fighting tobacco companies. But understand that no engagement means no progress.”
Tyndall summarized some broad lessons from his life in harm reduction as the need to center robust scientific evidence, and knowing that legal challenges to restrictions on harm reduction, as with Insite, can be effective. But most importantly, he said, “I have learned that change comes from the bottom up. The role of drug users and direct community action has been critical to the harm reduction movement. For vaping, the passion shown by people who have truly had their lives changed must be heard.”
“At the end of the day,” he said, “access to vaping is simply a human right. People have the right to access a safer product, much like they have the right to supervised injection sites and HIV medications.”
Knowledge-Action-Change has provided a restricted grant, through a scholarship program, to The Influence Foundation, which operates Filter, to support tobacco harm reduction reporting. Filter‘s editorial independence policy applies.