I recently wrote a blog for the website of the Wellcome Institute called Guerrilla Public Health. It was a brief overview of the history of harm reduction in the UK and centred on the fact that the early days of harm reduction were really driven from the bottom up, by drug users themselves concerned about their health and supported by other enlightened health professionals. It was the introduction of needle exchange schemes and a far more flexible approach to opiate substitute therapy that kept incidence of HIV among UK drug users down to some of the lowest levels in Europe. From small and isolated beginnings, the drug harm reduction movement now has global reach.


Similarly, the genesis of vaping was a consumer-led phenomenon driven by the concerns of smokers wishing to protect their health without necessarily giving up nicotine, backed by a nascent grassroots industry and enlightened public health experts.  Inevitably as the market grew and the commercial potential became apparent, the tobacco industry became increasingly involved both buying up small companies and producing their own products. On the surface, it looked as if the industry would take over with all their marketing and promotional capacity to drive forward the sale of safer nicotine products. However, it turned out that for all its marketing muscle, the tobacco industry (with some exceptions like heat not burn products in Japan) is essentially disbarred from any kind of promotional or marketing activity. The situation is so ridiculous I understand the industry is not even allowed to promote the new products within a packet of cigarettes to existing smokers. So there can be no equivalent of a patient information leaflets you find in medicines bought over the counter.  And it doesn’t look as if this situation is going to change any time soon. Left to its own devices (if you’ll pardon the pun), the tobacco companies will continue to struggle to find any sort of viable workaround against these legislative barriers.

So rather than being side-lined by big business, the role of the vaping community in being the boots of the ground of public health improvement is more crucial than ever. People want to know what other people think – look at the success of Tripadvisor and that hardly counts as a ‘trusted source’. Yet people make decisions based on what they read there – similarly with customer reviews on Amazon. A critical mass of criticism (or praise) makes an impact. Therefore, a genuinely trusted source is even more powerful, a critical element in trying to push on with the growth of safer nicotine products given the depressing evidence showing people are increasingly more distrustful of the new products.

There are various papers out there on the issue of perceptions of relative risk including this important one from Saul Shiffman and colleagues due to be a poster presentation at the Society for Research on Nicotine and Tobacco

“Tobacco and nicotine products vary in risk, with combustible cigarettes being the most harmful types. Smokers can benefit from switching to less harmful alternatives, which requires knowledge of relative product risk. However, publicly shared information often emphasizes absolute risks, rather than relative risks. To understand smokers’ perceptions of product risk, we assessed perceptions of various non-combustible products, relative to cigarette smoking, among 31,269 US adult smokers in a series of cross-sectional online surveys between 2009 and 2017.”

“Smokers aware of a product rated that product’s risk relative to cigarettes on a 7-point scale, from "a lot more risky," through "same as cigarettes," to "a lot less risky."  Products included snus, other smokeless tobacco, and tobacco-heating products; vapor products – cigalikes, tanks, and other vapor products – were added in 2015.  Logistic regression was used to analyze linear trends among the proportion of smokers who considered each product to be at least as risky as smoking (i.e., having either the same risk as smoking, or more risk). Analyses also compared risk perceptions of different vapor products.”

“Generally, smokers' perceptions that non-combustible products are at least as risky as cigarettes increased significantly over time. This was true for tobacco-heating products (61% to 66%), cigalikes (39% to 44%), and tanks (43% to 48%); there was no change for other vapor products (45% to 47%) or snus (73% to 73%).  Perceived relative risk of other smokeless tobacco declined significantly over time (83% to 80%). Among vapor products, tanks were the most likely – and cigalikes the least likely – to be rated at least as risky as cigarettes”

“Majorities, or near majorities, of smokers perceived each of the non-combustible products to be at least as risky as cigarettes. Except for smokeless tobacco, which large majorities deemed at least as risky as smoking, this misperception increased over time. Smokers' misunderstanding of the risks of non-combustible tobacco products may be abetted by messages that fail to put information in a relative-risk context, likely impeding harm reduction among smokers”.

So bearing in mind most of the anti-vaping information is coming from government agencies, how much are they actually trusted?  A survey of 5000 people conducted by the University of Georgia suggest that trust levels of agencies like the FDA or CDC as effective communicators of risks about SNP are only modest. The authors matched perceptions of risk concerning SNP against a variety of socio-economic factors including current and former smokers, income grouping and race.  But their main focus of attention was how those with differing worldviews took on board risk communications from a variety of sources; government agencies, industry and the media. The suggestion is, perhaps not surprisingly,  that more independently minded people were more likely to trust information from non-government sources such as the tobacco industry and vaping community.


And finally on the importance of the community of users in the whole discourse is this comment piece in Addiction which speaks to the need for users to be more involved in research to bring more real world experiences to the table which includes the unpalatible truth for some that it isn’t just about quitting.


So without getting too Churchillian about it, in default of significant legislative change allowing advertising , guerrilla public health maybe the key plank in the grand strategy of promoting tobacco harm reduction.

All the best for 2018!