Tobacco harm reduction; start with the most vulnerable – experts

Global tobacco harm reduction antagonists like the World Health Organization, (WHO), and the US Food and Drug Administration, (FDA), need to ‘humanise’ smokers instead of stigmatising them and blocking healthier nicotine alternatives to combustible tobacco. They need to be confronted to help society’s’ most vulnerable groups ‘or get the hell out of the way, so we can do what we need to do.”

This was said by activist and veteran social worker among drug users and mental health consultant, Professor Helen Redmond of the University of New York, at the fifth Scientific Summit on Tobacco Harm Reduction, Novel Products, Research and Policy held in Athens on September 21st and 22nd this year.

Speaking in a panel discussion on populations at risk and the learnings for high smoking prevalence countries, Redmond said the US Federal government and many public health organizations ‘with a great deal of money and power,’ were wedded to smoking abstinence and cessation – which made life far harder for poorer and more vulnerable groups in society and ended up victimising them.

“What the federal government did for the last three or four years is whip up a panic around vaping and this took all the oxygen out of the room in terms of a national strategy to deal with those with the highest smoking rates. The harm reduction community and human rights-based organisations, many of which I’ve been a member of many decades, are not on board with tobacco harm reduction. They believe in harm reduction for every other drug, but when it comes to nicotine and tobacco, they’re not pushing for alternative harm reduction products,” she said.

All of these were obstacles to working with vulnerable populations.

South African psychiatrist and mental health advisor to the Minister of Health, Professor Solly Rataemane, answering a question to the panel on smoking among pregnant women, said that in South Africa, foetal alcohol syndrome had been exposed as a major problem in poor rural towns (e.g. first uncovered in deeply impoverished De Aar in the Northern Cape, once a thriving railways hub) – and high smoking prevalence amongst women there went hand in hand with alcohol dependence.

“Many of the First World harm reduction products are too expensive – and in any case, there are no smoke-cessation clinics or tobacco harm reduction products at South African public health facilities,” he added.

Rataemane said South Africa’s 2021 Global Adult Tobacco Survey, (GATS), of 7 245 households showed that 12,7 million adult South Africans (29,4%) use tobacco and that 8,3% use smokeless tobacco. An estimated 42 100 of SA’s 61 million inhabitants died annually of smoking-related diseases, according to a Tobacco Atlas (University of Illinois, Chicago) global survey.

Marewa Glover, Director of the Centre of Research Excellence: Indigenous Sovereignty & Smoking in New Zealand said her country’s progressive 1990 Smoke-Free Environments Act embraced a harm reduction approach to smoking – with impressive results: Smoking prevalence had diminished from 27% in 1992 to 18.4% in 2011-12 and then to 10.9% in 2020-21, one of the lowest in the world. However, the Vaping Regulation, passed in 2020, signalled a shift from harm reduction to prohibition. Glover said this top-down prohibition was not person-centred, punitive, and lacked compassion.

“It will likely cause harm due to the injury/criminalisation associated with black market activity, worsened mental health, an increased marginalisation, and a shift to higher-risk substances.”

She said countries that want to reduce smoking-related harm would face the following challenges: a) a campaign of disinformation about relative risk of nicotine, b) loss of academic freedom, c) rise of “liberal paternalism,” and d) diminishment of human right to autonomy, dignity & right to consent, (e.g., to medical intervention.) She said countries should ‘beware’ of propaganda campaigns demanding prohibition and of policies for which there were no real-life scientific trials that recorded adverse effects and consequences. Long-term monitoring and evaluation was “vital.”

New York University’s Professor Redmond said ‘great advocacy work’ had been done by the International Network of Nicotine Consumer Organizations, the Smoke-Free Association, and the New Nicotine Alliance, who had a ‘real go’ at the FDA, protesting and disrupting it until it grudgingly got them on board, finally recognising the harm reduction value of e-cigarettes.

“You either confront these powers to get them to help vulnerable populations or we just have to get them the hell out of the way so we can do what we need to do,” she said.

Prof Peter Harper, a top UK oncologist and consultant to Philip Morris International, (PMI), said 22,3% of the world’s population still used tobacco (962 million smokers, 8% of whom suffer from lung cancer), with 36,7% of them males older than 15 and 7,8% females in the same age group. He said there had been very little reduction in global smoking prevalence over the past 50 years. However more recently technology had seen the advent of highly effective harm-reduction devices which could make a major impact on global health but was being resisted by dominant health bodies.

“That’s what we’re up against. You heard the presentation by my psychiatrist colleague in Athens saying that 68% of the patients in his clinic are smokers. We must stop looking at the population as a whole and start looking at different population groups” he asserted.

By Chris Bateman

Chris Bateman, a freelance healthcare journalist and former News Editor of the SA Medical Journal, was sponsored by PMI to attend the 5th Global Conference on Tobacco Harm Reduction, in Athens, Greece. He was not in any way influenced on what stories to write or whom to interview.