Why is Harm Reduction such a Hard Sell?
How the activist campaign against vaping has stigmatized harm reduction strategies (Part 1 of a Three-Part Series on Harm Reduction)
Harm reduction is a core strategy in decision theories and health risk management. It is a common sense, pragmatic approach that treats the patient with respect and compassion. So we should not be surprised then that most healthcare advocates speak out against harm reduction as a health policy strategy (especially in the field of tobacco harm reduction approaches). This three-part series will look at the challenges for harm-reduction advocates to get the interest of the patient heard over the puritan dogmatic ideologies of the supposed health leaders.
The basic premise of harm reduction is that as we cannot stop certain risky behavior, we should strive to reduce the harm of the consequences. Harm reduction is common sense and can be seen in decisions like wearing a seatbelt in a car or a helmet on a bicycle. It should in no way ever be an issue of contention in health decision-making.
Some examples of harm reduction health policies include distributing free needles for drug users or condoms at music festivals. If risk equals hazard times exposure, risk management is about lowering exposure to harmful hazards to as low as reasonably achievable (ALARA). Harm reduction is reasonable policy, reasonable behavior and reasonable public health strategy.
People who take a value-based (righteous) approach to health policies have been fighting against institutionalizing harm reduction strategies. Rather than free needles for addicts, people should stop using drugs; rather than free condoms, people should abstain from open sexual relations. There is no need for harm reduction measures, they argue and we should not condone risky behavior.
The public health community takes the same position against tobacco harm reduction alternatives like vaping, snus or nicotine pouches. You don’t need these new products, you just need to stop smoking … simple.
Just quit using nicotine
The policy campaigns against vaping and other reduced harm alternatives to smoking combustible tobacco products is the most recent case where risk reduction strategies have been badly misunderstood. If the “old warrior” anti-tobacco activists continue to distort the issue and drive the focus away from harm reduction, success in reducing deaths from tobacco use will decline, especially in developing countries where smoking cigarettes is still widespread.
It is troubling to see such political opposition to regulatory strategies that seek to limit exposure to negative consequences from risky behavior. The worst offender of this misguided approach is the scientific community working under the World Health Organization umbrella. Since 2012, activists have used the WHO to advance their crusade against vaping and other innovative nicotine products.
What are the main reasons health campaigners attack any harm reduction strategy?
It encourages or destigmatizes risky behavior
It promotes gateways to other riskier products or behaviors
It goes against the strategy of promoting a safe society
There is no certainty that the reduced harm alternatives are actually safer or would make a difference
Any addictive behavior or products must be resisted
Health idealists cannot accept a compromise to any level of unhealthy behavior
For the health zealots, “Do no harm” is thought to be incompatible with the pragmatic “Do less harm”.
But the policy actions against reduced harm approaches have also led to bad policies and poor governance. In the case of e-cigarettes or vaping, nicotine pouches and snus, restrictions on use, sale and product or flavor varieties have flouted any evidence-based policy approach, classed vaping under the same category as smoking combustible tobacco, vilified vapers, refused to consider relative or comparative risk analyses, and have created mixed and confusing communications on the benefits of vaping over smoking tobacco.
As a result, too many people continue to smoke combustible cigarettes, exposing themselves to higher risks. The problem is amplified in developing countries where anti-vaping misinformation campaigns have led to a boom in tobacco use.
Harm Reduction and Policy
Harm reduction is a compassionate approach to health policy. As the saying goes, the reduced harm approach meets the patients where they are and tries to move them to a better place (rather than lecturing the patients for their vulnerabilities). It is built on respect for the patient in the search for a pragmatic solution, rather than imposing some ideology of what a privileged, affluent health activist has determined to be a “healthy lifestyle”. Harm reduction seeks improvements rather than blaming others for their weakness.
To the public health policymaker, this harm reduction question should be a no-brainer:
No one will deny there are serious health consequences linked to smoking tobacco products.
Cigarettes are addictive and smokers are twice as likely to be able to quit via vaping than through the use of patches and gums.
Eliminating tobacco smoking will have a positive effect on the environment, waste management and the organization of public spaces.
Sweden, where snus is popular, has just become the first tobacco-free country in the EU and the health statistics show a dramatic decline in tobacco-related illnesses (almost 40% lower tobacco-related deaths than the EU average).
These millions of vapers are all telling public health success stories and should be promoted to justify further reduced harm health strategies. Such reduced harm achievements should be celebrated and emulated across other public health issues, from obesity to drug abuse.
Instead, vaping advocates are stigmatized and vilified even more than Big Tobacco with institutional misinformation campaigns widespread.
Save the Children
During the time of Malala Yousafzai media mania, I wrote an article called: How to Use a Child, that questioned the ethics of running lobbying campaigns with children in the lead. Using children to run campaigns now seems to be a morally-accepted exploitation tool (the MAHA movement in the United States has put children front and center via the Moms Militia health advocacy groups). The campaigns against alternative nicotine products ignore the success stories of the millions who have managed to stop smoking while attempting to deflect the debate toward the concern that young people, who have never smoked, take up vaping instead, exposing this vulnerable population to high levels of nicotine.
Much of the misinformation spread about vaping risks (popcorn lung, poisoning, chemical toxicity on brain development) is designed to scare the kids. Health authorities may be concerned that the Big Tobacco Playbook is being played out again, building lifelong addiction from the playground fence. They fear that vaping would become a gateway to young people then starting to use cigarettes as an alternative to vaping. They fear that there are risks of unknown health consequences of a new technology over the long term.
But these fear and misinformation campaigns imply that the health authorities have learnt nothing in the last 75 years about regulatory tools to prevent substance abuse within vulnerable populations. Most of these fears are overblown and can be managed through communications. Rather than working with e-cigarette advocates, most of whom know full well how hard it was to quit the tobacco addiction, the public pressure and campaigns against vapers have, if anything, made the practice more attractive to a younger population seeking rebellion.
Young people want to act out and push risks as part of growing up. Cannabis and harder drug use has replaced tobacco, alcohol is widely used and black markets of prescription-based stimulants are widespread among many Western youth populations. Mental health, self-harm and aggression are having a profound effect on the youth. Is vaping that significant of an issue? Don’t our health authorities have better things to do with their time?
Who are the public health leaders?
The WHO is spreading wrong, confusing misinformation on non-combustible nicotine products and is relying on these blatant lies in their guidance to policymakers to not authorize reduced harm alternatives to tobacco. They are not acting in the interest of public health as their misinformation spreads and leads to fewer smokers switching to vaping or pouches.
Activist health NGOs are parroting the WHO’s misinformation as part of their anti-industry, post-capitalist campaign. It is interesting how groups like the European Public Health Alliance support other reduced harm strategies but fall in line with the WHO even though almost one in five Europeans still smoke.
The pharmaceutical industry will not stand up for reduced harm nicotine products that are eating into their smoking cessation patches and gums (products that have a very low success rate).
The media has not bothered to do the homework to see how the NGOs, WHO and certain academics are flat out lying on vaping risks, so they simply amplify the misinformation confusing consumers even more. Many reporters are getting funding from anti-vaping activist philanthropists like Michael Bloomberg, so little actual news will see the light of day.
So who, then, in this debate, are the real public health leaders?
The vaping community has a number of passionate advocates and academic researchers trying to ensure that their products are allowed to stay on the market. Some are long-time smokers who were only able to regain their health via e-cigarettes, others are owners of vaping shops fighting to keep a product they believe in on the market. They have very little funding, even less political experience and are doing impressive things on the basis of their passion alone.
These part-time pro-vaping activists do not welcome corporate funding since any association with tobacco companies closes access to policymakers. Meanwhile foundations like Bloomberg Philanthropies are pumping millions into the anti-tobacco (anti-vaping) NGOs to regulate these products off of the market. See the image below that puts the David v Goliath struggle into context.
So the next time you hear some anti-tobacco NGO claiming that the tobacco industry is secretly funding campaigns, your question should be: How much exactly and where did all of this money go?
It seems like a bad joke that a small group of passionate vaping advocates who fought hard to quit smoking and regain their health, and who even resent the tobacco industry, find that the organizations charged with protecting public health have packaged up their reduced harm product with tobacco and consider them as tobacco industry lobbyists.
This is not the first time that the activist NGO/foundation/media nexus has made a poison cocktail of emotion, misinformation and dogmatic campaigning that resulted in countless more deaths (just Google the term: “agroecology”). This is not the first time their narrow-minded fear-mongering is harming rather than helping public health. Many policymakers are getting pulled into their campaigns rather than having the courage to promote an effective, reduced harm alternative and start showing some compassion and respect for those struggling to stop smoking cigarettes.
Part 2 of this analysis will look at how and why the self-proclaimed health leaders got the issue of tobacco harm reduction so badly wrong. Part 3 will look in detail at the utterly disgraceful position put forward by the World Health Organization (WHO).