“People smoke for nicotine but they
die from the tar”
Mike Russell (1976)
Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. The aim of public health is to provide conditions in which people can be healthy and focus on entire populations. Harm reduction plays a very important role in public health.
The first harm reduction initiative happened with drugs of abuse like heroine back in the 1980s after noticing an epidemic of HIV that was severely affecting the UK population. Public Health professionals developed a harm reduction programme that consisted of working with those that were misusing heroine, so at least if they remained ‘users’ they had the opportunity to do so under ‘safer’ conditions. Initiatives included educating drug addicts on the dangers, and providing resources (needles, methadone treatment, or HIV testing). Interestingly, not everyone in public health considered these actions correct. Some believed that these actions would actively encourage more drug abuse amongst existing ‘users’, and may appeal to young people thereby creating new ‘users’. Sound familiar?
Tobacco harm reduction is not any different from drug harm reduction. The UK approach with the latter demonstrated its success when a survey in 2010 published that only 1% of UK injectors of drugs of misuse were HIV positive; these levels were significantly below levels in other western developed countries at that time that had not adopted a similar harm reduction policy. This approach showed that those that cannot quit their addiction clearly need another type of help if the existing options are not significantly effective.
At this very moment, an excellent alternative available for reducing tobacco consumption is Electronic Nicotine Delivery Systems (ENDS).
ENDS are seen as a harm reduction tool by very credible organisations, such as Public Health England (PHE) with their report stating that “e-cigarettes are at least 95% safer than regular cigarettes”, or the Royal College Of Physicians, who has recently said that ENDS can ‘’prevent almost all the harm from smoking’’ in their report “Nicotine without smoke: Tobacco harm reduction.”
A review of the Cochrane Library states that Nicotine Replacement Therapies (NRTs) increase the rate of quitting by 50 to 70%. Unfortunately, there is not enough quality data to make a similar statement with ENDS. However, ‘the smoking toolkit study’ by Fidler et al., a national study of smoking and smoking cessation in England that has been running since November 2006, has accumulated data from more than 200,000 respondents. Important findings from this ongoing study are that 37.5% of smokers that decided to quit in 2015 chose ENDS compared to 20.8% that chose NRTs, and that success rates in stopping smoking have increased since 2011. Coincidence? Probably not.
Despite all the data supporting ENDS as a harm reduction tool, there is still great opposition towards these innovative products. The arguments are very similar to those back in the 20th century: they are a gateway to smoking, appeal to young people, and potentially encourage them to progress towards smoking ‘traditional’ tobacco products, they can renormalize smoking, etc.
NRTs are not risk-free either, whilst lower down the scale of continuum of risk, they are not harmless and still present an element of harm, although of course they are a much safer alternative to tobacco. If regulators and healthcare professionals have accepted the use of NRTs focusing on the benefits instead of the inherent risks, why can’t they do the same with ENDS?