A current thought on harm reduction

 Harm reduction was a term coined in response to diseases and maladies encountered by homosexual men and by intravenous drug users in the face of the tremendous onset of the AIDS epidemic in the late 80s.  Clean needles and condoms were seen as a way to offset the worst effects of a public health crisis until an actual cure or remedy for the diseases that were killing people was found. 

Since then the term ‘harm reduction’ has been bastardized by the tobacco industry as not a way to reduce harm until a remedy for tobacco related disease is found but a way to perpetuate tobacco industry profit under the guise of public health.  This is so very evident after we see that the same arguments for the ‘harm reduction’ of spit tobacco are the same used for the novelty of electronic nicotine delivery.  There is disease related to intravenous drug use and some sexual behaviors.  There is disease related to tobacco use.  One use of the term ‘harm reduction’ wants to find a remedy for disease.  The latter uses the term as a means of continuing tobacco industry profit.  The crux is that there may be a human inclination toward intoxication and certain sexual behaviors but that does not necessarily include nicotine.

Focusing public health efforts on safe sex and clean needles responds to modified and alternative behaviors as remedial. Focusing efforts on changing nicotine delivery responds to alternative nicotine delivery as the remedy.  The first is a public health strategy. The latter is a marketing strategy.  As the multinational tobacco corporations ease their way into electronic cigarettes we see more and more of the same arguments for ignoring actual data concerning dual use and disease.  Electronic nicotine provides no significant pubic health benefit.

One must look closely to see the tobacco industry’s subtle diversion of blame and rights with harm reduction. The original use of the term regarding drug use and sexual behavior wants to see individuals change their behavior.  The tobacco industry wants to see harm reduction confuse behavior with a choice of nicotine delivery. 

The tobacco industry is not concerned with rights, but profit.

Tobacco Leaves on a Dollar

Dr.s Simon Chapman and Ross MacKenzie’s 2010 paper, The Global Research Neglect of Unassisted Smoking Cessation: Causes and Consequences, and more recently Chapman’s op ed on the marketing and promotion of NRT and pharmacopeia for tobacco cessation may well be the key to the next paradigm for effective tobacco control.

Recently there has been much attention given the ostensible “inveterate smoker”, the smoker who does not quit. It has been felt that after we raise the cost of tobacco, create tobacco free space, and eliminate tobacco marketing there still are going to be people who will not or cannot quit. This alleged population has been much of the motivation for those referring to themselves as harm reduction advocates, encouraging the promotion of forms of nicotine delivery allegedly less harmful than smoking. Chapman and Mackenzie’s work here calls into question whether that population exists at all and the validity of research funded by those marketing NRT or pharmacopeia.

He make 3 structural points: Most research is done by those interested in interventions and because of that primarily are testing their own means. In a capitalist society there is the tendency for medical means to become commodities. And lastly that these interventions are based on the erroneous assumption that there are some individuals who have an impenetrable addiction that warrants the interventions.

Yet 3/4 of all ex-smokers quit with no assistance at all. Cold turkey quitters outnumber all cessation methods combined. Studies have shown that most successful nicotine addiction was overcome with no preparation at all, that certain environmental cues prompted cessation and abstinence.

Recent genetic discoveries have suggested that there are predispositions to nicotine addiction and has been a facet of the thesis of the inveterate addict. This should not be underestimated in evaluating the risks of ever starting to use nicotine. But Chapman and Mackenzie’s research sheds light on the need to shift our perspectives toward modifying the environment beyond increased pricing, tobacco free spaces, and marketing reform. What we have been calling cessation support perhaps should not take as strong an active, or pharmaceutically interventionist, role as it does a further reformation of the environment.

The theory that some people cannot quit without intervention becomes a self fulfilling prophecy when seen with the enormous amounts spent by pharmaceutical companies, and others, advertising cessation assistance and funding research to test their products. We know that youth are more likely to start smoking if they believe quitting will be easy. Are we not re-enforcing the myth that quitting is difficult with our capitalist emphasis on marketing cessation support?

The under publicized figures surrounding cold turkey cessation point to rogue capitalism as a major factor in challenging tobacco perhaps no less than that of the tobacco industry. Somewhere in the evolution of dealing with nicotine addiction the emphasis on changing people’s perspectives on tobacco use from a social issue to a medically treatable problem a step was missed. There is little doubt that if there weren’t a dollar to be made it would not have happened.

Dr. Chapman points out that for the developing world, the growth market for tobacco companies, NRT and pharmacopeia is not a viable economic or realistic option. His paper suggests that we are far from optimizing the environmental and behavioral cues that enhance cessation and should not be dissuaded by the drive to profit in our capitalist society.

This also helps clarify where the harm reductive E cigarette clamor is coming from. Right now E cigarettes can’t decide whether they are cessation devices or that fairy tale of a safe tobacco habit. Emphasizing the fact that most people overcome nicotine without NRT shows how unwarranted another nicotine delivery device is.

400 years ago European colonial efforts to export tobacco co-opted an entheogenic plant from aboriginal Americans. In short order the plantation economy spawned the genocide of native peoples and the importation of an enslaved African population. As the leading cause of death and disease today is the capitalism surrounding tobacco today significantly different? The profit certainly isn’t.

Industry collaboration

“We cannot continue allowing hatred and disdain towards tobacco companies to interfere with and trump efforts to achieve our fundamental goal of rapidly reducing the leading cause of disease, disability and death (i.e. cigarettes). Its daily cigarette smoking that is killing millions of people, not nicotine, tobacco, or tobacco companies.”

Bill Godshall, Pennsylvania

Mr. Godshall’s exemplary missive conveniently ignores the fact that daily cigarette smoking would not occur were it not for addictive nicotine. Nicotine is inherent to tobacco. Tobacco use would not be prevalent were it not for tobacco companies, and tobacco companies would not market nicotine were it not for the profit.

Our esteemed colleague, Dr. K. H. Ginzel has noted that harm reduction is analogous to Allied forces negotiating w Hitler on the beaches of Normandy for how many lives we can accommodate for the Nazis to remain in power. Collaboration, whether complicit or duplicate, is still culpable.

It most certainly is the tobacco companies that are killing people. Tobacco has not been a benign weed on the side of the road for 400 years. Without the predatory capitalist promotion of an addictive deadly product there would be no pandemic. To assume that tobacco companies are going to rectify this with new nicotine products is ludicrous.

We already have ‘harm reduction’ policies proven to reduce the harm of prevalent use: taxes, tobacco free space, and marketing reform. And criminal proceedings for corporate executives seems promising. The best we can hope for with Reynolds, or any tobacco company, in producing NRT products is a perpetuation of the misdirection that warranted a federal conviction in a U.S. court for fraud and racketeering. A corporations’ only obligation is to profit and the tobacco industry’s profit is incompatible with the public health.

One of the best gauges of the effectiveness of tobacco free advocacy is how the industry behaves. This dubious flirtation with NRT and the incredibly overhyped E cigarette should do little more than question the efficacy of either to actually reduce use. The tobacco industry has had decades to reduce the harm they cause and have responded with fraud, smuggling, endless litigation, manipulation of policies and politicians, and an ever increasing mortality rate in the developing world.

An alliance with the tobacco industry is just that. Don’t expect any applause.

Reducing harm or manipulating libertarians?

Harm reduction makes a primary goal an effort at reducing the harm of risk taking behaviors. Libertarians take risk taking behaviors as a primary right and harm reduction as a means of justification.

The tobacco industry has been quite successful in not only confusing this distinction but also recruiting advocates to perpetuate this misconception. Regrettably, this has worked to divide public health challenges to rogue capitalist goals.