Tobacco harm reduction – a new opportunity or a step too far?

Citation

Klein, A. (2013), "Tobacco harm reduction – a new opportunity or a step too far?", Drugs and Alcohol Today, Vol. 13 No. 2. https://doi.org/10.1108/dat.2013.54413baa.001

Tobacco harm reduction – a new opportunity or a step too far?

Tobacco harm reduction – a new opportunity or a step too far?

Article Type: Editorial From: Drugs and Alcohol Today, Volume 13, Issue 2.

Harm reduction has been with us so long that it can even seem new and radical to kick against it. It was originally designed by enterprising practitioners who thought that conventional service provisions were not meeting the needs of problem drug users. A new approach, different methods, and a completely new attitude to drugs and drug users were needed to get people to engage with services. It required a new perspective on drugs and their role in society, and a shift in the overall objective of the service. Harm reduction aimed at behaviour modification, not cessation. It was this compromise with the reality of the client groups that enabled it to achieve great breakthroughs in public health and emerge as the dominant paradigm of drug policy in the past 30 years. Part of that shift was the renegotiation of values and attitudes towards drugs, the acceptance of the complex role these hitherto unknown and feared substances played in the lives of many. It meant removing the stigma attached to users and accepting them and their behaviour as part of a wider repertoire of “normality” in a diverse society.

Proponents in the early days had to take on established practices and entrenched opinions. Drug control proponents often have strong ideological positions which regard drug use as morally offensive, and the use of the law as fully justified. Getting people like the Health Minister Brian Mawhinney on board required skilful argument but most of all the demonstration of effectiveness. For that HR practitioners generated a lorryful of data. Not only did that help to make needle and syringe exchanges standard features of public health policy provision in many countries, but it also established the principle of evidence led policy.

This new evidence, and the needs of clients looking for help with complicated consumption habits, inspired a new set of treatment interventions. It also prompted calls for the review of the entire legislative framework on which drug policy is based. Not only did the criminal justice approach seem to fail the people who were most in need, but it was woefully unsuccessful in realising its objectives. It seemed that government and the myriad of agencies supported by the state were ill informed, and often ended up exacerbating the very problem they had been set up to solve. Change required enormous effort and was resisted at every step by a mixture vested interest, fear of the unknown and ideology.

Harm reductionists and drug policy reformers were small groups united by points of principle and a vision of better alternatives. They started out in small non-governmental organisations, on the fringes of the field, calling for reform and a closer look at the evidence. Working with allies in different public agencies they sought to mobilise civil society in order to move the state to rectify a position that was arrived at a century ago. The problem was not in making the case but in getting government to act on it. It was soon realised that even senior politicians lacked the clout or the political will to undertake something that required such a drastic change of course. A policy, once arrived at, had attracted so many parties with an interest in continuation that any call for change was resolutely resisted. But the campaign continues along clear fault-lines, with civil society campaigners calling for reform on the one side, and agencies of the state and government employees lined up on the other. Reformers call upon the government to withdraw: they want not more but less government. The state, for the past century, has not been the solution but at the root of the problem.

Interesting then the comparison with the “tobacco wars”, where a growing band of campaigners from the 1920s onwards called for the presence, not the absence, of the state. From the start, they were asking government to increase controls, to use its powers to constrain human behaviour and most importantly, to intervene in the markets. Their adversary was not government agencies with mixed agendas, but the private sector with a simple and transparent obsession – the pursuit of profit. Picking up momentum in the 1970s, the campaign has succeeded in restricting first the freedom of the tobacco industry, and then, of tobacco consumers.

Whereas in the drugs field reformers are calling on government to get out of the lives of users, tobacco control advocates are shouting just as loudly for government to get in. The justification is paternalistic: tobacco users are too impaired by their addiction to realise or represent their own best interest, and need advocates to do so. Not only does this depend on a dubious model of addiction, which is particularly inappropriate when applied to a substance like tobacco which has little intoxicating or mind altering effect. But it also disenfranchises tobacco users, depriving them of the right to speak for themselves.

The crucial step was emphasising the harm tobacco smoke inflicted on others via passive smoking. This shifted the debate skillfully from one of consumer choice and individual freedom to public health and protection. Once it had gained traction it was successfully used for driving smoking out of public spaces and into the periphery. The doctrine at work ran along the opposite trajectory from the drug reform movement by aiming to “denormalise” tobacco use. In the process, the campaign objectives moved forward. From reducing tobacco use as a means of promoting health, the campaigning objective became to reduce tobacco use per se.

And here lies the rub with regard to THR. Various alternative “nicotine delivery mechanisms” such as e-cigarettes or chewing tobacco appear highly effective in reducing tobacco-related mortality. But the control movement is opposed to them for fear of sustaining tobacco markets. The instincts behind this are questionable for two reasons. On the one hand it is an objection to Big Tobacco as an example of capitalist profiteering. It seems that many in the movement use the tobacco industry as a proxy for their fight against capitalism. While this may be a worthy undertaking, mixing up multiple objective in a single campaign risks losing sight of the erstwhile objective which in this case is surely the promotion of public health. The second reason has an even older ancestry, is the simple objection to tobacco use as a source of pleasure. It aims at the elimination of tobacco as a part of our material culture and therefore opposes the adaptation of “nicotine delivery” to minimise health hazards. When combined, the two positions can detach from the wider campaign altogether and disregard the pursuit of public health altogether. It is all the more alarming as the anti tobacco lobby has won over large section of the public health bureaucracy and entrenched itself as the new orthodoxy.

To us this is regrettable on multiple grounds. Policy should never be made on the basis of ideology, or in order to settle scores with an adversary. Second, the zealousness of the campaign and the mooted search for new targets suggests that the campaign against tobacco (then alcohol, pharmaceuticals, food industry) provides a cover for the policing of pleasure and does both public health and environmentalism a disservice. Third, the shift away from public health promotion loses sight of the value of tobacco as a source of relaxation and enjoyment. Perhaps the cigarette was an inappropriate a delivery mode when combined with advertising and mass production, but that should not rule out other forms of tobacco use.

Smoking, just like coffee and sugar, often used in combinations, were the first gifts of globalisation. They have come to mark our experience of modernity and facilitated the shift to an industrial economy. It would be a pity if we swap bland measures of efficiency for the refined pleasure of consumption.

Axel Klein