By Michael McGrady
Access to accurate health information about nicotine and products that contain it is a human right. A tobacco harm reduction approach centers this principle, in the same way that the United Nations justifies harm reduction for “harder” drugs. Unfortunately, UN institutions fail to recognize that international human rights treaties and conventions mandate governments to permit full access to information about every form of nicotine use.
Article 1(d) of the Framework Convention on Tobacco Control classifies harm reduction as a pillar of the global tobacco control agenda. Specifically, the treaty states the need for:
“a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke.”
This provision has been interpreted many times to include use of tobacco harm reduction products, like e-cigarettes or oral snus, and proper education campaigns about them. Yet harm reduction for tobacco is continually de-emphasized, and for countries across the world, these tenets have fallen to the wayside in favor of an entrenched “Quit or Die” mentality. Denial of accurate information about nicotine products has disastrous real-world consequences.
The United States, for example, has failed to understand the potential of vaping to cut smoking rates. Instead of taking an empirical approach, the country’s Food and Drug Administration (FDA) has manufactured fear by declaring a “youth vaping epidemic.”
Policymakers around the country have responded accordingly. San Francisco, long a beacon of progressive policy and drug harm reduction, has just banned the sale, manufacture and distribution of vaping products indefinitely—while leaving combustible cigarettes fully available.
Denial of accurate information about nicotine products has disastrous real-world consequences. A study published in JAMA Network Open this year showed that the percentage of Americans believing either that vaping is as harmful as smoking or that it is more harmful more than tripled from 2012-2017—to a combined figure of over 40 percent. People are similarly misinformed about snus.
In a country with over 34 million smokers, 16 million people living with smoking-related disease and almost half a million annual smoking-related deaths, what impact is this misinformation likely to have on people’s choices?
Research on long-term vaping impacts is still lacking, largely because vaping is so relatively new. But available evidence overwhelmingly shows that e-cigarettes are much safer than combustibles—about 95 percent less harmful, according to a 2015 review by Public Health England.
Harm Reduction Progress and Remaining Barriers
The UK is in an enviable position. Leading bodies like the National Health Service, the Royal College of Physicians, the Royal College of General Practitioners and the Royal Society for Public Health have all endorsed vaping as a harm reduction strategy. Many of these organizations recommend to medical practitioners that they should properly communicate all details about vaping to their patients—sensible advice that extends, for example, to people who are pregnant.
These attitudes are reflected on the ground: Of 3.2 million vapers in the UK, over 50 percent are ex-smokers; over 40 percent are current smokers at some stage of dual use.
Yet even in an environment that fosters such a huge win for public health, stigma and misinformation remain. And these problems are familiar to anyone who has worked in harm reduction in general.
“With HIV/AIDS there was a groundswell of support prompted by the stories of ‘innocent victims’ (absolutely awful to split people like this but it happened), whereas smokers and vapers get little sympathy from policymakers or the general public,” Louise Ross of New Nicotine Alliance (NNA), a UK charity that represents people who utilize tobacco harm reduction, told Filter in an email.
Ross has worked for years to introduce vaping to marginalized smokers, including the residents of a mental health hospital. “There’s a small and determined band of us trying to do this, but it’s a slow process, and any progress we make is often undone by negative publicity,” she lamented.
Tobacco harm reduction should prioritize ground-up leadership, media platforms and communications, and traditional word of mouth.
Drug-use harm reduction interventions like safe consumption sites and syringe exchange have been proven time and again to be effective in promoting public health, with the benefits outweighing the costs. Most of these programs around the world—despite fearsome remaining obstacles in many places—are supported by nonprofits or private-public partnerships that work with local communities to help at-risk populations. Many are led by current or former drug users.
These programs and organizations have become stigma-free forums for people who use drugs to get unfiltered information about substances and the ways they use them. Many of these organizations also advocate against societal stigma, driving social change to support agency and harm reduction for drug users.
Applying this community approach to tobacco harm reduction should prioritize ground-up leadership, media platforms and communications, and traditional word of mouth. Taking these approaches to find the right synergy between educating and inspiring action will best facilitate the spread of tobacco harm reduction to communities where smoking rates are highest.
Jessica Harding, NNA’s administrator, who has written for Filter about her vaping experiences and advocacy, agrees that innovation is needed to improve access to products and accurate consumer information. She notes some daunting obstacles.
“Smokers do disproportionately come from lower socio-economic backgrounds and often make sacrifices as it is to buy cigarettes—so many simply cannot afford to try vaping out,” she wrote in an email. “Other barriers to taking up vaping can include the steep learning curve—which is also where good information comes in—and also that people might not live near a vape shop or might not feel comfortable going into one.”
“People with mental health issues, people from lower socio-economic groups and prisoners tend to smoke a lot more than the general population,” she added, “and all face barriers to taking vaping up.”
Harsh Jurisdictions and a Ticking Clock
These barriers will significantly persist when many jurisdictions all over the world have rigid anti-tobacco advertising and risk-communication laws that cover vaping.
The US FDA, for example, prevents vape shop owners from communicating the relative risks and benefits of vaping to their customers—because vapes and liquid nicotine are categorized as “tobacco.” In order to accurately communicate the benefits of a particular product, shop owners and manufacturers are required to submit product applications through several, prohibitively arduous regulatory pathways ostensibly intended to allow the FDA to review the science.
Other jurisdictions are much harsher. Australia has banned liquid nicotine, characterizing it as an industrial poison, while people who vape in Thailand face up to 10 years in prison. Many laws will need to change if accurate health information is to be delivered as widely as needed.
Smoking rates in Africa are among the highest in the world. The public-health potential of tobacco harm reduction on the continent is therefore vast.
As the world continues to suffer 7 million annual smoking-related deaths, it’s particularly vital that community-led information and access campaigns are prioritized in the many low-income countries where smoking rates are highest.
According to 2018’s No Fire, No Smoke: Global State of Tobacco Harm Reduction report, most African countries, for example, have “no specific law” governing vaping. Smoking rates in Africa are among the highest in the world, with an estimated 77 million smokers—and rates are rising, even as they fall in rich countries. The public-health potential of tobacco harm reduction on the continent—despite cases like Ethiopia banning e-cigarettes—is therefore vast.
Yet here, too, stigma and misinformation pervade. At the recent Global Forum on Nicotine in Warsaw, Kenyan tobacco harm reduction advocate Joseph Magero, chair of Africa’s Campaign for Safer Alternatives, spoke of being ostracized from the tobacco control and public health community (he lost his public health job) when he began advocating for harm reduction. Lack of funding or locally applicable research are further problems.
Coupled with community-led initiatives, legislative efforts to legalize and spread reduced-risk nicotine products—and growing evidence of the long-term public-health impacts on countries that do so—should eventually force governments to tell the truth about nicotine. But every year of delay will result in millions more needlessly lost lives.
The Ottawa Charter and Vulnerable Populations
Until the day when nicotine and people who use it are not harshly stigmatized, all tobacco harm reduction efforts—including information dissemination campaigns—would do well to follow the tenets of the Ottawa Charter for Health Promotion.
This benchmark international agreement, signed by the parties of the World Health Organization’s First International Conference on Health Promotion in 1986, holds the autonomy of the individual to be essential for health promotion and harm reduction.
Regarding community activation, the charter declares:
“… health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities—their ownership and control of their own endeavours and destinies.”
With smoking a common coping mechanism for the hardships of life, vulnerable populations—already smoking at higher rates—suffer compounded disadvantages when policies restrict access to, or information about, safer nicotine products. These groups include, but are not limited to, people with mental health conditions, low-income populations, LGBTQ people, people who are homeless or incarcerated, members of the military who have experienced hardships, and Indigenous and minority populations. They should be prioritized in efforts to provide accurate nicotine health information and resources to all.
“Saying tobacco ‘isn’t safe’ isn’t incorrect, but it isn’t saying enough.”
As L.T. Kozlowski and B.Q. Edwards, both at the time affiliated with the Pennsylvania State University Department of Biobehavioral Health, argued in a 2005 paper for the Tobacco Control journal:
“Although harm reduction approaches to alleviating the burden of tobacco-caused disease incorporate science-based comparative risk information, the right to health information is a fundamental human right, distinct from harm reduction campaigns … Saying tobacco ‘isn’t safe’ isn’t incorrect, but it isn’t saying enough. Going beyond the no safe tobacco message to provide better information on the nature of risks from tobacco products and nicotine delivery systems is necessary to respect individual rights to health relevant information.”
For everyone—but especially for the most marginalized members of our societies—information is power.
Photo credit: Kristina Flour
Disclosure: The author is a recipient of the 2019 Tobacco Harm Reduction Scholarship administered by Knowledge-Action-Change (KAC). KAC is also the publisher of the No Fire, No Smoke: Global State of Tobacco Harm Reduction report by Harry Shapiro. KAC had no involvement in the creation of this piece. KAC has also previously funded Filter through a scholarship.