Why I’m Still Fiercely Optimistic About Tobacco Harm Reduction

Jul 05, 2023

Harm reduction is often misconceived as policies and practices introduced by governments and delivered by experts.

In fact, it is always driven by ordinary people who use drugs choosing to put harm reduction into practice. Yes, governments and experts can make it easier for them—or stand in their way. But ultimately, it’s individuals who take action to reduce harms they or people in their lives are facing.

It’s largely because of this that I remain optimistic about the future of tobacco harm reduction as the 10th annual Global Forum on Nicotine (GFN) approaches—despite the many challenges it’s faced and the many obstacles it has yet to overcome.

Tobacco harm reduction is based on a very simple proposition. If safer nicotine products are available, attractive, appropriate and affordable, most people who smoke will choose them. They will choose them over continuing to smoke cigarettes because most people are all too aware this is likely to lead to disease, disability or premature death.

Despite snus in Scandinavia and some smokeless products in the United States, both of which had a relatively low public profile, smoking had always been the poor relation in harm reduction. That was because of a lack of suitable alternatives.

Back in the 2000s, I thought we were on the cusp of an immediate breakthrough. I had overlooked the warning signs.

But the arrival of vapes from around 2007 brought growing realization that people could consume nicotine—including through inhalation, as many prefer—without the harmful effects of combustion. Since then, uptake has steadily risen in many countries.

Back in the 2000s, I felt the excitement about the prospect of a big transformation in how people use nicotine, propelled by by vaping. I thought we were on the cusp of an immediate breakthrough. With safer nicotine products, if we played it right, millions of premature deaths from smoking could rapidly be averted.

So in 2014, Paddy Costall and I organised the first GFN in Warsaw, Poland. The event was born of optimism. Rather than smoking and tobacco, it was the first ever conference to focus on nicotine and related scientific, policy, regulatory and consumer issues.

Reflecting on my comments at the time, I see that I was wildly over-optimistic about public health leaders throwing their weight behind an innovation which—unlike many public health interventions—could spread at no cost to governments. I had overlooked the warning signs.

Many medical and professional associations, health charities and foundations, governments, public health pundits and the World Health Organization (WHO) did not share my view. Many subsequently embarked on what amounts to a misinformation campaign, sowing fear and doubt about safer nicotine products—something which has not abated in 2023.

I’d worked on harm reduction and HIV prevention since the late 1980s. Making drug use and sex safer was both contentious and a struggle. But even that did not face the organized, well-funded opposition endured by proponents of making nicotine use safer.

The numbers paint a stark picture of global policy failures: One billion people smoked in 2000; one billion smoked in 2014; and one billion smoke in 2023.

This remains a huge frustration, especially when so many public health leaders who grasp harm reduction for other areas remain resolutely against it for tobacco.

Meanwhile, people who smoke continue to suffer ill health or premature death. Their numbers over time paint a stark picture of global policy failures: One billion people smoked in 2000; one billion smoked in 2014; and one billion smoke in 2023.

Over the last decade, it’s been surprising to see what a mess some countries can make of this issue. The US has a bizarre, cantankerous regulatory system with the perverse consequence that the vaping industry is being destroyed, while the cigarette industry isn’t. Australia—previously a leader on harm reduction—has made itself a case study in the impacts of prohibition for nicotine products. Politicians worldwide get agitated about vape flavors and exaggerated suppositions of dangers to young people—ignoring the implications for huge, often-marginalized populations of adults who smoke.

But the last decade has also witnessed stunning examples of how, in the right circumstances, people who smoke will rapidly switch to safer alternatives. The United Kingdom, Norway, Sweden, Japan and New Zealand all now see tobacco harm reduction driving down smoking rates. The UK continues to lead: Its new plan to give out one million vaping starter kits to people who smoke has echoes of needle and condom distribution during the HIV/AIDS crisis.

In the early 2010s there was optimism that the tobacco industry would be on a fast track to transformation, but—with some notable exceptions—this has not been achieved. The industry has severely neglected development of appropriate products for low- and middle-income countries, home to 80 percent of people who smoke. The advent of nicotine pouches may go some way to change this, but more action is needed from industry—and fast.

Something that’s missing from the international response to smoking is broad-based engagement. GFN was born on our belief that a wide variety of organizations could and should contribute to hastening tobacco harm reduction, and would appreciate an opportunity for open discussion.

Our vision of multi-stakeholder engagement came from our previous work on drugs and HIV prevention. This brought together people who use drugs, sex workers, public health proponents, educators, law enforcement and ministries of health and justice in an atmosphere of mutual respect.

We believed then—and still do—that progress on tobacco harm reduction requires getting everyone around the table. This means consumers—the people actually using safer nicotine products—as well as policymakers, regulators, scientists and manufacturers.

Consumers have always been central to GFN. They are the people who are doing harm reduction. Yet at many conferences, their perspectives and experiences hardly get a mention, let alone a place on the program. We saw the need to galvanize energy and enthusiasm among consumers, and provide a platform for them to connect and build networks. The last decade has seen gradual growth in consumer advocacy in this space, although it remains fragile and underfunded.

We still haven’t managed to engage the WHO, where harm reduction has been deliberately ignored.

Our vision also means getting industry—everyone from independent vape and snus manufacturers to the major tobacco companies now producing safer alternatives—talking to others and, more importantly, listening.

GFN, therefore, is the only large-scale conference in the smoking, tobacco and nicotine space which welcomes everybody with a stake in tobacco harm reduction. Unlike many other events, no one is banned from attending or speaking. This open-door policy does cause challenges: Some people working in tobacco control are barred from attending by their organizations, for example. But we firmly believe that respectful debate involving all stakeholders is the way forward.

We still haven’t managed to engage the WHO. The WHO Framework Convention on Tobacco Control (FCTC) includes harm reduction as one of three pillars of tobacco control, alongside supply and demand reduction. But harm reduction has been deliberately ignored. And the WHO is not in listening mode. Paranoia about engagement with consumers and manufacturers permeates the biannual meeting of the FCTC; unlike other UN bodies, the WHO is actively working against engaging people affected by global policies.

It’s not a matter of whether tobacco harm reduction will happen, but when.

But there is a pattern here. The WHO was behind the curve on harm reduction for other drugs at the early stages of the HIV response, banning staff from attending harm reduction conferences. Eventually, it was shamed into acceptance by other UN agencies. The WHO will eventually engage, far later than it should have, on tobacco harm reduction. It can’t ignore this forever.

GFN is a microcosm of what should be happening globally. It’s exciting and energizing to hear consumers talking to parliamentarians, talking to regulators, talking to manufacturers—important conversations that don’t take place elsewhere. As GFN returns to Warsaw next month for its 10th edition, we will do all we can to drive tobacco harm reduction forward.

And I remain optimistic. What’s behind this is consumers. Ordinary people, doing harm reduction. Regulators, parliamentarians, legislators might slow this down or speed it up. Yet it’s not a matter of whether tobacco harm reduction will happen, but when.

Photograph via pxfuel/Public Domain

The 10th Global Forum on Nicotine – Tobacco harm reduction: the next decade is taking place in Warsaw from June 21-24. Many sessions will be livestreamed, and online participation is free to all registered at the event website.

Filter is an official media partner of GFN23, which is organized by KAC Communications. KAC Communications’ sister company, Knowledge∙Action∙Change, has provided restricted grants and donations to The Influence Foundation, which operates Filter, for projects unrelated to the conference. The Influence Foundation has received grants from the Foundation for a Smoke-Free World, which has also supported KAC. Filter’s Editorial Independence Policy applies.