There’s no excuse for ignoring tobacco harm reduction, hears DDN.
There’s tension between tobacco harm reduction (THR) and ‘traditional’ harm reduction, said Tony Duffin, introducing a dialogue hosted by Knowledge Action Change. ‘But harm reduction is about active intervention and not standing about waiting for something to happen.’ So what’s going on, and what should we be doing?
Firstly, we had to understand the pressing need, said Professor Gerry Stimson. Twenty per cent of the world’s population now smoked and it killed more than malaria, AIDS, TB and illicit drugs combined. Cigarettes were a convenient but very dirty delivery system; furthermore they were highly reinforcing, providing a big spike in nicotine that quickly made smokers want another.
THR had mainly been about making it difficult to smoke and was also one of the only public health areas to use stigma – the deliberate stigmatisation of smokers. Harm reduction had lagged behind as nicotine replacement therapy was ‘boring’ – there was no hit. Then e-cigarettes came along in the 2000s and were a consumer-led intervention that changed all that, said Prof Stimson. But a lot of misinformation – and silence from key organisations that could have furthered the dialogue – had stalled progress.
The fact remained that most drug users smoked and smoking-related deaths were the biggest health risk they face, he said. So it made no sense that smoking was still ignored by many services.
‘Tobacco harm reduction is even more contentious than drug harm reduction,’ said Dr Garrett McGovern of Priority Medical Clinic in Ireland. ‘The field hasn’t embraced it at all and there’s a disinterest in getting involved.’ Vaping was revolutionary but was ‘often thrown under the bus’ along with smoking. ‘It’s hard to believe that tobacco harm reduction is so controversial,’ he said. ‘It should be an easy sell.’
Wider smoking harms
The risks of smoking were not limited to cigarettes, emphasised Dee Cunniffe, lead of the SWERVE harm reduction hub in London. Safer inhalation and pipe provision could make a significant difference to the health of people using crack – many homemade pipes used steel wool that resulted in people ingesting metal. Yet it was currently illegal to give out pipes and gauze.
‘People think smoking is safer than injecting, but with new synthetic drugs that’s not always the case,’ she added. ‘It’s just as risky as injecting.’ She called for more harm reduction hubs – places like SWERVE, which was unusual as it wasn’t part of the drug and alcohol service. ‘It works better as people don’t fear their prescription will be changed,’ she said.
Mobile Outreach
Dr Al Story, professor of inclusion health at University College London, is involved in running a pioneering ‘electric tricycle clinic’ outreach service that’s equipped for scanning, testing and treatment. The initiative is part of Find & Treat, in partnership with Central and North West London NHS Foundation Trust, whose focus is on early detection and treatment of tuberculosis. London was ‘the TB capital of Western Europe’, he said.
‘We talk about harm reduction but not harm diversion,’ he said. Seeing inside people’s lungs on a day-to-day basis showed the damage inhaling could cause, and there were significant risks of TB from smoking crack – ‘It hits your airway like a volcano exploding, but it completely numbs your lung. It anaesthetises you, so you carry on. It’s a superhighway to becoming a respiratory cripple.’
His colleague at UCL, Robert West, had carried out a ‘willingness to quit’ survey. Pre-radiology the results were the same as for the general population, but post-radiology the scale of willingness ‘went through the roof’ as people were conscious of the harms. ‘We don’t use any of these opportunities in the NHS,’ he said, and so remained very poor at promoting any kind of harm reduction.
Misconceptions
Martin Cullip of the Taxpayers’ Protection Alliance underlined a fundamental problem – that people routinely believed that nicotine caused the harm rather than the combustion. ‘It’s a simple concept, but consumers need to have accurate information – 63 per cent of people who smoke think vapes are at least as harmful as cigarettes.’
The Tobacco and Vapes Bill was a ‘despicable policy’ in terms of its vape regulations, and would cause harm, he said. ‘Access, affordability and choice are what you need, and it limits those.’ We were turning a blind eye to the evidence on every level, he said – in Sweden people used snus as an alternative to smoking and the country had one of the lowest cancer rates in Europe. ‘But its sale is banned here, and that’s crazy.’
‘We now have a hysteria around e-cigarettes and youth,’ added Garrett McGovern. ‘It’s far from an epidemic – it’s rights of passage stuff. You don’t see kids smoking in the media, just vaping – but that’s far better than smoking.’
Challenging environments
Mick Stoney, governor of HMP Barlinnie, described the challenges of introducing harm reduction to the prison estate. Prison not only took away freedom, it also took away freedom to make choice, so with any health intervention (such as hepatitis C testing and treatment) it was hard to gain trust. In 2018 smoking was banned from prisons – for reasons of prison officers inhaling second-hand smoke – and vapes were introduced, which turned out to be a successful transition.
People often left prison in much better health than when they went in, he said, but if there were no plans in place when they came out the improvement was doomed to failure. We had to take into consideration that the vast majority of people in prison had experienced a range of adverse childhood experiences (ACES) and needed support at all levels.
For Adriana Curado of the harm reduction network GAT in Portugal, harm reduction was ‘a way of thinking, dignity and social justice… but if it is inclusive, it must include tobacco.’ Dialogue was ‘prohibitionist, driven by fear’ and the other barrier was cost – safer nicotine options were more expensive than cigarettes. But people needed choices about their own health. Two nicotine harm reduction projects in Portugal offered access to free products and a space without pressure or moral messaging. The conversion rates were good, she said: ‘People were tired of smoking and aware of the harms.’
Reducing Harm
‘To help people reduce harm we need to have an honest conversation – the most vulnerable people aren’t engaging,’ said Alex Boyt. Misplaced focus in our drug strategy had seen deaths rising every year, and services weren’t attractive to people who needed harm reduction the most. Services had never cared about tobacco harm reduction – ‘I smoked for 30 years and no service addressed that.’
‘It’s appalling what services don’t do – including ours – around smoking,’ said Paul Townsley, CEO of Waythrough. ‘It’s a whole area that’s not seen as relevant to treatment services. We can improve massively.’
We needed to go back to the evidence base – what works for people, he said. Despite being much better resourced than we were 20 or 30 years ago, we were also now working in a ‘policy vacuum’ – ‘the government is not interested in the people we’re working with’. We had to have more buy-in from politicians and local areas on every level, he added. And for tobacco harm reduction? ‘It’s about looking forward, notwithstanding the challenges we’re up against,’ he said. DDN