Public health is essentially concerned with prevention and when it comes to tackling global communicable diseases like smallpox, TB and other diseases, there are many public health success stories. However, preventing the development of non-communicable diseases like the fall-out from drinking, smoking and drug use is a much more challenging prospect. The early efforts at substance use prevention in the West were spearheaded by faith groups and moral reformers whose goal was total abstinence. But as we know, the subsequent legislative history in pursuit of those ambitions has been dogged by failure - Prohibition in the USA floundered, in recent years drug control policies have tended to balkanise across the world and as for a total ban on tobacco….dream on.
So with visions of abstinence shattered, the next level approach has been to deal with the adverse consequences to those in the orbit of the drinker, smoker or drug user. Aside from outright alcohol bans in Muslim countries (which apparently don’t necessarily apply to political and military elites) there are laws against public drinking ranging from alcohol free zones (certain city centres and public transport) through to dry US counties (including the county where Jack Daniels is produced). As for smoking, the only legislative weapon which has gained even a modicum of enforcement traction globally has been smoking bans in some indoor public places.
However, those most affected by the adverse consequences of smoking, drinking and drug use are the users themselves. Yet through the prism of preventative public health, they don’t seem to count for much because maybe subconsciously for many in public health, the stable door has been closed on these people - they have made some kind of ‘lifestyle choice’ so must suffer the consequences.
And if that sounds harsh, consider the rightly lauded pragmatic public health response in the UK to drug-related HIV/AIDS. Call me cynical, but I do wonder what the response would have been at a nation government level, if it could have been demonstrated that injecting drug users could not pass the virus beyond their own drug using community. And in the UK again, the term ‘problem drug users’ was coined, not as a reflection of the problems users experienced, but the problems they caused for wider society. Breaking the link between drugs and crime became a major political imperative which saw the drug treatment field well-funded while alcohol treatment services (whose clients were unlikely to be stealing to acquire alcohol) were the very poor cousin.
So what about smokers? Interviewed in 1987 on the direction of travel for anti-tobacco activists in the light of evidence about passive smoking, Stan Glanz said, that the emphasis of activism should be ‘framed on the rhetoric of the environment; toxic chemicals and public health rather than the rhetoric of saving smokers from themselves or the cigarette companies’ (emphasis added). In his Pulitzer prize-winning book Ashes to Ashes on the history of tobacco in America, Richard Kluger questioned this strategy of a singular focus on smoking as an environmental issue which he argued “was effectively trivialising the risk from direct smoking, which was thirty to forty times greater. It was an incendiary, effective and questionable tactic from those on the side of the angels”. And in their chapter for Ronald Bayer and Eric Feldman’s book Unfiltered: conflicts over tobacco policy and public health, Ted Marmor and Evan Lieberman noted, “the increased salience in contemporary control regimes of ‘denormalizing’ smoking. That has involved making smoking itself, sinful, stupid or both…There is considerable evidence…that at the beginning of the twenty-first century, the effort to turn tobacco smokers…into pariahs has become crucial elements in anti-tobacco movements”.
The book was published in 2004, well before e-cigarettes became widely available. Now we have clear evidence not only that e-cigarettes are significantly safer than cigarettes for smokers, but that they pose minimal risk to bystanders. In terms of the future of tobacco control, this should be as disruptive as it gets. However, there is so much political, professional, ideological and personal investment in promulgating an outdated narrative, that despite all the recent developments in tobacco harm reduction, the well-funded and highly influential NGOs are determined that international tobacco control should give no ground.
This is a particularly ludicrous policy position in regard to low and middle-income countries. Here is where most smokers live and die, both adults and young people and where due to population growth and increasing urbanisation, smoking rates are likely to increase. In regions like Africa and south east Asia, can it really be sane and sensible to argue against tobacco harm reduction on the grounds that e-cigarettes are a gateway for young people into smoking and that smoking generally risks being ‘re-normalised’?