When it comes to tobacco harm reduction, whose opinions and voices should be heard? The question was put to a host of experts at the Global Forum on Nicotine, which took place in Warsaw, Poland from June 19-21.
A session titled, “Who else should be in the room?” was pertinent to this year’s conference theme of effective communication for tobacco harm reduction (THR).
The jury is no longer out: Safer nicotine products (SNP), like vapes or pouches, can save lives by helping people quit cigarettes who would otherwise not be able to do so. But most people, subjected to reams of misinformation from sources that should be trustworthy, don’t know this.
This knowledge gap is especially damaging for marginalized populations with the highest smoking rates, including people experiencing homelessness or incarceration, people who use banned drugs and people with mental health conditions, among others. At a conference that amplifies consumer voices, it was fitting that “Who else should be in the room” featured speakers dedicated to working with a number of those populations.
She was told by the respiratory specialist that “under no circumstance” should she use vapes, because they’re “no different to smoking.”
Garret McGovern is a doctor in Dublin, Ireland, who specializes in addiction medicine. He told the audience how one of his patients, who had smoked heavily and “never really cracked her cigarette habit,” had to have her lung removed.
The woman, who was on ancillary oxygen and nebulizers, was seen by a respiratory specialist. Even though the patient had expressed a dislike for nicotine gum and pharmaceutical smoking cessation options, she was told by the specialist that “under no circumstance” should she use vapes—which are, in fact, more effective for smoking cessation than NRT—because they’re “no different to smoking.”
“This is somebody very experienced in lung health and the damages of smoking—and this authoritative person gave that information,” Dr. McGovern said. “How could anybody give that advice to somebody, particularly someone so vulnerable who had lost their lung, has COPD, who’s a heavy smoker?”
Dr. Sharifa Ezat Wan Puteh, a public health physician and consultant to governmental bodies in Malaysia, noted how that story underlined the importance of consumer agency. “They have a say,” she said, “and sometimes we have to liaise with them and say, this is your right to demand certain extra options that are available, other than the traditional NRT.“
Consumer voices have so often been excluded when tobacco and nicotine policies are under discussion—the very voices that are most effective in getting the THR message across. It’s a case of “plenty about us without us.”
“Who should be in the room? Consumers are the most important stakeholder in any proposed THR/SNP policy,” McGovern told Filter. “They were forgotten in the recent tobacco bill here in Ireland—and it showed!”
McGovern’s work encompasses a range of substance use disorders. And THR and “drug” harm reduction ought to be one and the same thing—something various organizations are working towards, even if the two have too often been placed in separate boxes.
“Tobacco should be part of the [harm reduction] conversation just like opioids, stimulants, alcohol and many other substances.”
Adriana Curado understands this need, when people who use banned drugs smoke at very high rates. She’s a harm reductionist and researcher who has played a key role in designing and implementing interventions around high-risk drug use in Portugal, where she was previously a coordinator at a mobile overdose prevention center. She reflected on how the obvious intersections between tobacco and drug harm reduction haven’t automatically produced alliances, saying that while drugs have always been surrounded by misinformation, “tobacco harm reduction is newer and less understood.”
“There’s this idea that no product from the tobacco industry can ever be part of harm reduction,” Curado told Filter. “But we manage to regulate medicines and other products from powerful industries like pharmaceutical.”
“Tobacco should be part of the conversation just like opioids, stimulants, alcohol and many other substances,” she told the audience.
McGovern agreed, and said he was surprised THR has not caught on more in the wider harm reduction space, when “these people have been warriors for harm reduction for decades.” One factor in this, he continued, is that harms related to tobacco and those related to other drugs can play out differently. “If you look at the other drugs, people’s lives can unravel very quickly in a way it doesn’t with smoking.”
Harms of all kinds are acute in prisons, where there’s a high concentration of people who use drugs and people from marginalized and low-income backgrounds—communities with high smoking rates.
In 2018, concerns about staff exposure to second-hand smoke led to tobacco being banned in all Scottish prisons. Critically, however, vapes are available and switching is encouraged.
“There was no reaction to the removal of tobacco, and vapes were readily and immediately adopted in the prison—it has continued to be a success.”
Michael Stoney is the governor in charge of Scotland’s largest prison, HMP Barlinnie, which holds over 1,400 men. He told the GFN audience that the initial introduction of vapes that prisoners could buy was not driven by harm reduction as such. Rather, it was just seen as an alternative to cigarettes that would adhere to the new smoke-free policy.
With tobacco a longstanding part of prison culture, he explained, there were fears of increased violence when it was removed. There was also concern that the removal of nicotine could exacerbate mental health issues for the high proportion of prisoners with such conditions.
But because vapes were available right away as a nicotine alternative, “What we saw, remarkably, was no backlash in the prison whatsoever,” Stoney said. “There was no reaction to the removal of tobacco, and vapes were readily and immediately adopted in the prison, which was a great surprise—and it has continued to be a success.”
Within one week of vapes becoming the main source of nicotine, there was an 81 percent reduction in fine particulate matter in the prison air, Stoney reported; within six months it was down 91 percent. Other wins from the mass switch to vapes, he noted, included a 9 percent reduction in prescriptions for respiratory issues among prisoners.
As for the mental health concerns, “we’ve seen no increase in mental health referrals or prescriptions post-smoking ban.” Stoney said. “Vapes have given us the exact impact we were looking for.”
Stoney confessed that he’d wondered why he was in the room at the GFN session. But his experiences had unexpectedly made him aware of THR and how it relates to wider society. The session, he said, “has been very timely in considering prisoners’ reintegration back into the community” as people who vape, rather than smoke.
“Bearing in mind how negative the medical profession has been about vaping, there could be an argument for keeping them out of the room.”
Prisoners’ voices are among many that have not been heard, but should be, in tobacco and nicotine discussions.
Curado said it was obvious that vulnerable groups who smoke, more broadly, have been missing from the conversation—and also, perhaps more surprisingly, health care professionals. “It’s striking, people really trust [health care professionals],” she said, “but many don’t feel informed or safe enough to talk about SNP—that’s a huge missed opportunity.”
As a doctor, McGovern has a dim view of most of his colleagues when it comes to THR. “Bearing in mind how negative the medical profession has been about vaping, there could be an argument for keeping them out of the room,” he told Filter.
However, “Probably the worst culprits of all are the policymakers who view noncombustible nicotine products with deep suspicion, and make it harder for smokers to quit.”
Photograph (cropped) by Marissa Lewis on Unsplash
Filter was an official media partner of GFN, and received assistance with travel and accommodation to attend the event. Filter’s Editorial Independence Policy applies.