By M.D. Delon Human, Consultation Event Nicotine Panel Chair; President & CEO, Health Diplomats; Adviser to the UN Secretary-General; Secretary-General of the Africa Medical Association; Former Secretary-General of the World Medical Association; Author: Wise Nicotine

One of the public health triumphs of the last century has been the prevention of the spread of the human immunodeficiency virus (HIV). UNAIDS reported a decline of 33% in the number of new infections from 2001 to 2012. Part of this success can be ascribed to the decrease in transmission of HIV among intravenous drug-users. Here harm reduction methods, such as education and encouraging countries to implement needle exchange programmes, have been successful in preventing disease and premature deaths. UNAIDS still recommends that countries provide a minimum of 200 sterile syringes per year for each person who injects drugs as a harm reduction measure.

The term “harm reduction” may have started with HIV, but is in fact an age-old practice. We know that the use of alcohol, tobacco and other psychoactive substances goes back many thousands of years. In most cultural settings, norms, social codes or rituals regulating consumption and associated behaviour were present. Over time these harm reduction practices have grown into a philosophy and science within public health, offering a progressive alternative to the prohibition of certain potentially dangerous lifestyle choices. Recognising that certain people always have and always will engage in behaviours which carry risks, the aim of harm reduction is to mitigate the potential dangers and health risks associated with this, without achieving total abstinence.

In modern terms harm reduction manifests as policies, programmes and interventions aimed at reducing the health, social and economic harms associated with not only illegal drugs, but also the safer use of automobiles (e.g. seat belts, helmets), alcohol (responsible drinking), tobacco (non-combustible nicotine products), infection control (hand washing) and safe sex (condoms). Despite the fact that harm reduction does prevent disease, disability and premature deaths, it is not universally accepted or practiced within the public health community. Within tobacco control, for example, some would argue that tobacco harm reduction is not possible and that abstinence and a tobacco-free world should be the paramount goal. Some drug addiction experts share the same vision of a “quit or die”, drug-free world.

This abstinence-only approach often leads to a stigmatisation and dehumanisation of consumers and demonisation of the substances concerned. This article calls for a re-humanisation of the issue and a greater involvement of science in the development and expansion of harm reduction. It also reflects on some of the current opportunities where harm reduction might lead to the prevention of millions of premature deaths and disease, such as the e-cigarette revolution.

What substances cause the most harm?

Where can harm reduction science, policy and practice lead to the most gains? Consider that out of the approximately seven billion people on earth, there are:

  • 1,3 billion consumers of tobacco products, of which cigarettes account for around 92% of the value of the global tobacco market. The World Health Organisation states that tobacco kills up to half of its users.
  • 13-15 million intravenous drug users at risk of exposure to blood-borne infections. Up to 10% of HIV infections are linked to drug injection. Infections might also be contracted through contaminated drugs (e.g. anthrax in heroin) or secondary infections of injection sites.
  • 2,5 Million deaths per year due to hazardous or harmful use of alcohol. This is currently the world’s third largest risk factor for disease burden.

From these figures it is clear that tobacco harm reduction (THR) has the greatest potential to prevent disease and save lives. Paradoxically, nicotine used in nicotine replacement therapy and other THR products is regulated much more strictly in comparison with combustible cigarettes, the individual components of which are currently not regulated at all. Surely a more pragmatic and risk-differentiated regulatory system should be established to help guide consumers towards decreased risk in their choice of products!

Ethics and the imperative to engage health professionals and consumers

The relative disregard of consumers and the ethical elements of harm reduction merit closer inspection. Fortunately, the growth of HIV/AIDS consumer activism has highlighted the need for the involvement of consumers and patients in the debate. Their battle cry of “NOTHING ABOUT US WITHOUT US” proved to be a powerful galvanising force in assuring accessible and affordable anti-retroviral treatment for HIV/AIDS. It also paved the way for the development and empowerment of other consumer movements, such as seen with the burgeoning E-cigarette consumer movements worldwide.

Tobacco harm reduction

Although nicotine is the major addictive substance in tobacco products, it is also unfairly given the major blame for the disease and death caused by tobacco products. In terms of toxicity, it is the smoke that kills, not the nicotine. Tobacco harm reduction is taken to mean encouraging and enabling smokers to reduce their risk of tobacco-related illness and death by switching to less hazardous tobacco products. This switch could be short-term or long-term, partial or full, with the understanding that every time an alternative tobacco product is used in place of a cigarette, risk of tobacco-related illness and death is reduced.

Health professionals can and should play a central role in strengthening the scientific evidence base related to drug, alcohol and tobacco harm reduction. There are surprisingly few health professionals in the world: approximately ten million physicians, 14 million nurses and about a million apiece of pharmacists and dentists. Ethics is a common thread in their work and its imperatives ought to be applied to these areas of addiction. Drug, alcohol and tobacco control is a natural product of a population-based, public health mind set. Harm reduction on the other hand, seems to be a natural outflow of health care provision to the individual. It should therefore be much easier for primary care health professionals to evaluate any potential role of a principled and pragmatic harm reduction approach in management of substance abuse.

Physicians in particular can play a meaningful role in this debate. The patient-physician relationship remains the core of their work. This unique relationship, facilitates an exchange of scientific knowledge and care within a framework of ethics and trust. It also places the individual patient, as opposed to all of society, at the centre of the question – what is in the best interest of the patient in front of me?

An understanding of the values of the medical profession is also applicable to how consumers of drugs, alcohol and tobacco should be approached:

  • Autonomy: Recognition of the consumer or patient’s right to self-determination, i.e. the right to refuse or choose their treatment;
  • Beneficence: Acting in a manner that promotes the wellbeing of others. In the medical context, this means taking actions that serve the best interests of patients;
  • Non-malfeasance: “First, do no harm”;
  • Justice: This concerns the distribution of scarce health resources, and decisions about who receives scarce treatments (fairness and equality);
  • Dignity: The patient and the treating physician have the right to dignity; &
  • Truthfulness and honesty: Informed consent.

Public vs. Individual Health

At times there is a perception of conflict between ‘public health’ and ‘individual health’. This is unfortunate since society is made up of individuals and in a perfect world the best interests of the patient would also be those of society at large. In harm reduction a divide is clearly visible; for example, Swedish citizens are allowed (and even recommended) to use snus as a cessation or substitute product for combustible tobacco, whilst in other EU countries this is not possible because snus is banned.

Perhaps more weight should be given to the right of individuals to health. Member states that are parties to the International Covenant on Economic, Social and Cultural Rights (ICESCR), specifically article 12, have recognised the right of every person to enjoy the “highest attainable standard of physical and mental health”. This is also one of the mission statements of the World Health Organisation. In applying this principle to harm reduction, Kozlowski offers this wise guidance: “Public health concerns should trump individual rights only when there is clear and convincing evidence of harm to society. Lacking that evidence, individual rights should prevail”.

Non-combustible nicotine: The next big breakthrough in public health?

A striking oversight in tobacco control over the last decades has been the failure to address the product (combustible cigarettes) itself. Tobacco control measures have mostly focused on where, to whom and at what price cigarettes should or should not be sold; and on labelling and the disclosure of toxic ingredients. However, it has long been recognised that “smokers smoke for the nicotine but die of the smoke” and thus modification of the nicotine delivery system has been long overdue. Nobody questions harm reducing modifications to automobiles, but somehow the same sentiment does not apply to nicotine: e-cigarettes, for example, have not been universally welcomed as a possible tool in tobacco harm reduction.

Nonetheless, the current e-cigarette revolution, particularly how widely the product has been embraced by consumers, highlights its potential for harm reduction. The reasons why consumers are attracted to e-cigarettes include:

  • Health: Perceived as less toxic than tobacco products;
  • Cessation: To aid in quit smoking or to avoid relapsing;
  • Cravings: To deal with cravings or other tobacco withdrawal symptoms;
  • Cost: Cheaper than cigarettes;
  • Enjoyment;
  • No second hand smoke; &
  • Cutting down: To reduce combustible tobacco intake.

Although originally invented in 1963, e-cigarettes were only commercialised in 2004, when they were sold in China. They first became available in Europe and the USA in 2006. Since then, e-cigarette sales have doubled or tripled every year. In 2012 the global market amounted to around $2 billion and given the rate of growth, it will probably be larger in 2014 than the market for nicotine replacement therapies (gum, patches etc.) A leading Wall Street tobacco stock analyst forecasts that e-cigarettes are well on their way to outselling conventional cigarettes if proportionate regulation is put in place to allow e-cigarettes to compete with combustible tobacco.

Significant health gains are to be expected if this type of growth is realised. During 2013, in the United Kingdom alone, there were approximately ten million cigarette smokers and one million “vapours” of e-cigarettes. A leading UK scientist of the Royal College of Physicians Tobacco Advisory Group said that: “if all smokers in Britain stopped smoking cigarettes and started smoking e-cigarettes, we would save 5 million premature deaths in people who are alive today”.

Arguments against harm reduction and products

Despite the possible gains to be made from harm reduction, there remains a substantial resistance to such measures, including:

  • These practices merely substitute one form of addictive drug with another, perpetuating the use of an addictive substance in society;
  • The “gateway effect” is a very sensitive issue relating to children. For example, were children to use low risk nicotine, might this not lead them on to smoking cigarettes? This remains one of the most valid and troublesome concerns for the public health community;
  • Decrease in cessation: Harm reduction decreases the effectiveness of the central message of tobacco control, that all nicotine or tobacco product use is potentially dangerous and undesirable;
  • Increased relapse rates for consumers who have quit;
  • Normalisation of drug and tobacco use;
  • Promoting harm reduction could create a perception that the tobacco industry can play a con-structive role in society, while at the same time continuing to sell highly hazardous cigarettes; &
  • Public health advocates should not promote anything which is not entirely healthy.

How can science be a lifesaver in drug, tobacco and alcohol-related harm in the future?

In these areas the debate has too often resembled an ideological war rather than a systematic process of developing thoughtful, evidence-based policy. Health Diplomats and groups like SciCom are more than ever calling for a review process. All consultation event delegates agree that science can make a difference. The current debate and development of regulations on e-cigarettes, for example, could be greatly aided by research and scientific validation in the following areas:

  • Establishing clear product safety and quality standards to ensure the safety and quality of ingredients in non-combustible nicotine products;
  • Differentiation of risk between the different classes of nicotine-containing products, from combustible cigarettes through e-cigarettes to NRT;
  • Rectifying the incorrect assertion of ‘equivalence’ between smoking and e-cigarette use;
  • Rectifying misconceptions about the toxicity of nicotine. Most health professionals still believe nicotine to be a carcinogen, which is not in line with the evidence;
  • Expanding behavioural science studies for a better understanding of nicotine using behaviour, including how self-dosing is managed by consumers;
  • Developing health economic studies to better understand the economic impact of harm reduction approaches and products;
  • Developing appropriate approaches to risk management through marketing, pricing and tax mechanisms; &
  • Testing and clarifying assertions regarding ‘gateway effects’ so as not to exaggerate risks and lose the opportunity to use risk-reduced products to prevent disease and save lives;

In summary, harm reduction science shows much promise. It could form the basis for risk-differentiated regulatory frameworks, the pragmatic use of risk-reduced products and lead to a more dignified approach to the consumers of drugs, alcohol and tobacco. For them, it could ultimately be the difference between life and death.

“We need a better regulated market based on sound science to prevent the promotion of smoking or e-cigarette use to non smokers and our youth. The innovation of companies towards new nicotine delivery systems is a fast growing, high-stakes phenomenon presenting both risks and undoubted opportunities for public health worldwide. We urgently need more research into nicotine addiction while encouraging other countries to take a pragmatic approach like the UK solely aimed at saving lives.” Martin Dockrell, Director of Research & Policy, Action on Smoking & Health (ASH), London.