Last week, I was invited to speak at an informal seminar in Portugal under the banner ‘Portugal without smoke’ with a seminar title: Tobacco control and risk reduction: what are the options? The venue and attendees signalled, I thought, a very important step forward in acknowledging the link between tobacco and drug harm reduction.
The meeting was held in the headquarters of INFARMED, the Portuguese equivalent of the FDA; its President, Professor Maria do Céu Machado, was in the room sitting alongside Manuel Cardoso, Deputy Director of Portugal’s drug programme which is acknowledged by drug harm reductionists across the world as a beacon of light in the murky landscape of a prohibitionist-dominated global drug policy.
There is a strong synergy between HIV/AIDS, drug and tobacco harm reduction policies. Like the origins of HIV and drug harm reduction back in the 1980s, tobacco harm reduction through the use of safer nicotine products (SNP) began as a community-based, grass roots movement among smokers wanting to carry on consuming nicotine without all the attendant dangers of smoking. And as members of the gay community and drug users were and still are often marginalised and discriminated against, so smokers found themselves out in the street, huddled in corners as the new social pariahs offered no other option other than quit or die. Those campaigning on behalf of the health of the gay community and drug users focus on human rights and civil liberties, the right to universal health and the mechanisms and empowerment to have control over one’s health. So tobacco harm reduction should resonate with drug policymakers and practitioners not least because, while adult daily smoking rates have been falling in many western countries often below 20%, rates among those with drug and alcohol problems are north of 60%. And the health of those battling HIV can be deeply compromised if they carry on smoking.
But this is not an easy sell. The public discourse is driven by tropes of nicotine addiction and young people, possible long-term effects and the suspect motives of Big Tobacco. And while the vaping industry does take its public health responsibilities seriously, there isn’t a whole lot it can do about government regulations, so the general talk is more about consumers, products, market share and regulations. And this image of commercialisation can be a block to getting tobacco harm reduction accepted within drug harm reduction. After all, while advocates of drug harm reduction still stand accused of condoning drug use through needle exchange, opioid substitute therapy and drug consumption rooms, I don’t think Big Pharma, who manufacture methadone, buprenorphine and naloxone, get accused of a dastardly plan to ‘renormalise’ heroin use.
Even those who do support SNP as a Third Way to protect smokers’ lives, often equate tobacco harm reduction with wearing seat belts or crash helmets. Personally, I see harm reduction as more than just health and safety, but as a movement with political and social as well as public health aims. And this is what makes it so dangerous in the eyes of moral absolutists within both drug and tobacco control. In fact, even though interventions such as needle exchange and opiate substitute therapy are endorsed by the WHO, try getting the phrase ‘harm reduction’ into a UN drug policy document. It comes freighted with the idea that drug harm reduction is just a stalking horse for legalisation. With the spectre of Big Tobacco paranoia and fear and loathing of the A word (guess) hanging over it, tobacco harm reduction has an even harder fight.
But which country apart from Portugal would you most expect to be open to vaping? Maybe a country which has taken what some countries regard as a wholly irresponsible attitude to cannabis? Who allow cannabis smoking in certain establishments? Who argued that being more tolerant towards cannabis actually closed the gateway to otherwise totally illegal drugs? The Netherlands, of course. Wrong. Not only are the Dutch hosting the next WHO tobacco meeting in 2020, but their Minister of Health recently trotted over every tired non-evidenced based opposition to e-cigarettes while announcing a ban on e-cigarettes whether or not they contain nicotine. The aim is clearly to make the closest possible link between smoking and vaping. Hard luck then on over two million daily Dutch adult smokers, many of whom I’m sure would switch given encouragement, and hard luck for the 30,000 Dutch citizens who will no doubt continue to die every year from a smoking-related disease as yet again a government policy towards safer nicotine products just makes it easier for people to light up and further swell tobacco company coffers – or should that be coughers?
Back on more fertile ground, in the course of the meeting, Professor Machado spoke of her concern about lack of evidence and long term effects, but was receptive to the idea that because we don’t know everything, doesn’t mean we don’t know anything, and having spoken to other medical and academic attendees and two of the organisers of the recent international drug harm reduction conference in Porto, I came away feeling there is sufficient understanding of the synergies and a willingness to engage.
The only sour note struck was the last minute absence of an eminent UK tobacco researcher who was to elaborate on the latest SNP research. However, the Tobacco Taliban did its work and he was warned off at a very senior level from attending if he didn’t want his funding and career jeopardised because PMI had some relatively minor role in the event and had two representatives in the room. This is just an appalling and outrageous state of affairs which smacks of the crushing of free speech associated with totalitarian regimes. While academic institutions fret and worry about whether to demolish historic statutes or possible income from slavery 300 years ago, I would suggest there are more contemporary issues of freedoms to be addressed. Worth noting the presence of PMI personnel didn’t seem to bother the Portuguese officials. But then again if you adopt a grown-up non-moralistic approach to a serious public health policy issue like drugs - why would it bother you?
Be suspicious of any outfit that has ‘Truth’ in the title because you know from the get-go that herein lies…well, lies or at least information that is at least several generations of family distant from objectivity. I refer of course to the US anti-tobacco agency, the ‘Truth Initiative’ (TI) and its laughable attempts at anti-vaping propaganda. So here are some efforts at pointing out just how lame these anti-vaping efforts are. The use of puppets, by the way, suggests that those good people at the TI think most vapers are about five years old.
- Truth anti-smoking/vaping ads are AWFUL
- Anti-Vape ads are getting ridiculous...
- "This ad is so bad it is hilarious"
- TI get down with the heavy metal kids
Whoever dreams this stuff up and thinks it will have impact has either no idea whatsoever about what young people regard as credible, and/or inhabits some Disney-fied confection of white picket fences and mom’s apple pie. But ironically, these people have no more respect for the intelligence of young people than the tobacco companies who tried to associate smoking with an aspirational misogynistic lifestyle aimed at young men featuring fast cars and even faster women.
I might have mentioned this before, but the UK had its own bout of ‘The Minister Really Likes This’ moments with laugh out loud ads featuring Pablo the Dead Dog drug mule (should have been a mule really) and the Brain Warehouse where you could (or couldn’t) swap your cannabis-addled brain for a new one. Probably couldn’t – but I can’t be bothered to go on YouTube to find out. Come to think of it, I can’t remember where YouTube is. Near Oxford Circus? Should have gone to the Brain Warehouse.