Tobacco Harm Reduction: Time to Change Attitudes

In a speech I gave to the Global Forum on Nicotine in June, I noted that when it comes to harm reduction, policy lags far behind the science. For years, decades, even, politicians and health authorities who should know better have ignored, derided and undermined such measures, stuck in a past in which the tobacco industry played a big, bad role. The result is that much of the public wrongly believes that nicotine causes cancer, e-cigarettes are more dangerous than combustible ones, and there is no leeway between the extremes of ‘quit or die.’

This is tragic because important sectors of the industry are in the process of transformation and investing heavily in research that is helping to create one of most profound public health shifts in history, namely, the elimination of combustible cigarettes altogether. With over 1 billion smokers around the world, most of them in low to middle income countries, the challenge is daunting. As Michael Russell, the late pioneer in the study of tobacco dependence and harm reduction, noted: “People smoke for the nicotine but die from the tar.” But a concerted, coordinated effort by governments, health authorities and the industry to promote and regulate THR initiatives as a key component of tobacco control could save between 3 to 4 million lives a year by 2060 — this as all the parties continue the fight to end combustible smoking.

The World Health Organization and its landmark Framework Convention on Tobacco Control have stalled, failing to have significantly reduced the number of adult smokers, and to take steps to deal with that failure. Rather than embrace newer forms of THR as part of a continuum to help stem the estimated 8 million deaths each year from combustible tobacco-related diseases, it warns against them, preferring to concentrate on the supposed threat they pose to vulnerable groups such as young people.

Of course, bucking against harm reduction measures meant to improve the quality of life for all is not a new phenomenon, with protests over the mandated wearing of protective face masks during the pandemic only its latest iteration. When Ford Motors introduced seatbelts in 1959 as an option in its automobiles, for example, a mere 2% of new car buyers took it — and it was only in 1984 that New York became the first state to make them mandatory.

The same has largely held true for drug abuse, too. In a way, the debates over tobacco and drug harm reduction are mirror images of each other, with a chorus of politicians and interest groups charging that harm reduction enables drug addicts; that they are the weak-willed authors of their own misfortune and should be able to quit outright.

In 1971, Richard Nixon, the U.S. president at the time, declared drug abuse to be “public enemy number one,” thus launching the modern-day “War on Drugs,” a classic conflict that has revolved around eradication, prevention and incarceration. There has been a revolving cast of good guys and bad, with little middle ground, save for former president Barack Obama, who preferred to emphasize recovery and rehabilitation over prison.

Former first lady Nancy Reagan spearheaded the simple campaign aimed at kids with the tag line, “Just Say No,” while the public service announcement that featured an egg being cracked into a sizzling cast-iron fry pan as an actor with a military mien states “This is your brain. This is your brain on drugs. Any questions?” still reverberates today.

Now, for the first time in history, U.S. President Joe Biden has made harm reduction a part of his administration’s drug policy measures, devoting $30 million to evidence-based efforts that include the provision of sterile needles and syringes, counsel for addicts and support for front-line staff.

It is a start.

As the world begins to emerge from its isolation during the COVID-19 pandemic, as it mourns the loss of family and friends, of jobs and homes and a sense of community, drug addicts have been among the hardest hit of all. Already marginalized by society, their safe harbor was often found in the drop-in clinics that had to shutter in the spring of 2020.

According to provisional data from the Centers for Disease Control drug overdose deaths increased by nearly 30% over the 12-month period ending in November 2020, giving the situation an increased sense of urgency.

There is pushback. As the New York Times reported in June, West Virginia, which is currently seeing a surge in H.I.V. cases driven by intravenous drug use, recently passed a law that makes it harder for sterile syringe services to operate in the state. In North Carolina, proposed state legislation seeks to ban mobile exchanges, require engraved needles and background checks, and have addicts who make use of the service sign an agreement to enroll in substance abuse treatment. This goes against the very principle of harm reduction: to minimize the health, social and legal impacts associated with drug use, policies and laws without using coercion, judgement or discrimination.

In an interview I did last year on the Global Health Perspectives podcast, Ethan Nadelmann, a founder of the Drug Policy Alliance, a U.S. group that pushes for policies grounded science, commonsense and compassion, recalled how he was drawn to the subject in the 1980s as a graduate student.

“The more I read about the issue, the more I realized that if you followed health and science, drug policy should go in one direction whereas public opinion, the laws and politicians were going in the other,” he told me. “The core principle involved here is that nobody deserves to be punished or discriminated against for something we put in our bodies.”

Since those graduate days, Nadelmann’s cri de coeur has grown to encompass harm reduction measures surrounding nicotine as well. From a simple moral issue, he said in that same podcast, it is despicable to see how anti-tobacco activists approach the issue, negatively judging people who get pleasure from nicotine while tossing out the science and citing the risk of young people being drawn to the habit.

During my latest visit to Geneva, these truths were brought home to me in conversations with three ambassadors who focus on issues of national security, World Trade Organization disputes and human rights, and with diplomats whose work straddles the same issues and the FCTC. As Gregory F. Jacob noted in 2018, the challenge is to make negotiations and the convention’s implementation process, which has drifted in recent years from established norms of international law, more transparent and inclusive.

The failure lies, not in linking smoking with the notion of an epidemic, as the WHO has termed it, but in the refusal to accept the latest science-driven measures that reduce the harm incurred from the habit. It lies in the blind assumption that we can somehow control what people put in their bodies with strict laws, high excise taxes and grisly pictures on cigarette packages. It lies in the WHO’s ominous call for boycotts with no scientific basis, and in the decision of authorities, from Australia to India, to severely restrict or ban the sale of THR products altogether, and thus deny adult smokers the opportunity to make their own choice.

The failure also lies in the character assassination of highly principled scientists, epidemiologists and physicians who believe in the benefits of harm reduction, thus are banned from attending conferences, their valuable insights and research papers ignored because they are seen to be working in concert with the tobacco industry. The WHO is guilty of this, as are wealthy individuals such as former New York mayor Michael Bloomberg, who has campaigned and written against e-cigarettes under the aegis of his organization, Bloomberg Philanthropies.

How can you have a constructive tobacco-control policy when, in effect, anti-tobacco activists are scaring adult smokers into sticking with cigarettes, which is the most dangerous product of all? When they misinform the public about a since-retracted study that erroneously linked e-cigarettes to a serious pulmonary illness?

How do you overcome when scientists interested only in dispassionate, careful research are pressured to take one side in the issue, or else have their work sidetracked, as Dana Mowls Carroll and several of his graduate students have so evocatively written about?

With stubbornness. With science. With a cascade of research papers, patents and both data-driven and anecdotal evidence of change that is already happening. And with engagement, sharing of information and civil dialogue between all parties, no matter what has happened in the past. After all, nearly 100 million people around the world now use such products, from snus and tobacco-free nicotine pouches to e-cigarettes and heated tobacco products. They have made the informed choice for themselves. And weave in –with dialogue and engagement especially with those who disagree.

As with seatbelts, which are now rote, the number of users will continue to grow.

Change does happen. It is happening. To wit, the decisions in 2019 and 2020 by the U.S. Food and Drug Administration after exhaustive reviews of the evidence to grant permission to Swedish Match and Philip Morris International to respectively market snus and IQOS heat-not-burn sticks as Modified Risk Tobacco Products (MRTPs). And the UK’s Royal College of Physicians Report on Smoking and Health 2021 emphasizes the need for a proactive approach to the regulation of THR products, and states that their use in place of combustible ones should be encouraged.

Back in 2001, as the G7 conference prepared to concentrate on global health issues, US Surgeon General C. Everett Koop spoke in prescient fashion at a seminar at Dartmouth University about the importance of technology and accurate information, and the neglect by wealthier countries of LMICs — issues that to this day still pose major global health challenges.

I remember because I was there, too, at the time an executive director of the WHO and a key player in the formation of the FCTC. I remember him saying he was convinced the internet would change the way medicine is practiced in LMICs because knowledge empowers people to make decisions alongside their doctors.

“Our greatest need for a foreign or international health policy is illustrated by the history of AIDS and polio. Discoveries in the west eliminated those problems domestically but not abroad where the need was greatest,” Koop continued, adding that those charged with bringing health information to the public should be well-informed about every angle of a medical issue so as to enable people to make better-informed decisions for themselves.

“Let each one, teach one,” was the motto Koop hoped would dominate world health policy, and his words ring as true today as they did when he delivered them.

We must all learn from the past and admit our mistakes in order to move on. Consider that Michael Bloomberg, the former New York City mayor who, through his philanthropic organization is leading the attack against e-cigarettes, has admitted as much. During his attempt to become the presidential candidate for the Democratic Party in the 2020 election, he was asked about a controversial “stop and frisk policy” he championed as mayor, in which Black and Latino men were unduly targeted.

“I can’t change history,” he replied. “However, I want you to know today that I realize back then I was wrong.”

That is why I know that one day, policy will catch up to science. Millions of lives may be lost in the interim to grisly tobacco-related diseases that take years to develop but it will happen.

It already is — one step at a time.

President of the Foundation for a Smoke-Free World and former World Health Organization (WHO) cabinet director for noncommunicable diseases and mental health.