By the numbers, harm reduction is mostly about tobacco (including in India)

by Carl V Phillips

Harm Reduction International (HRI; formerly the International Harm Reduction Association, IHRA) just released a long report with the bold title, “The Global State of Harm Reduction, 2014”. Before you bother to look at it, though, I will point out that despite the broad title, it is only about heroin use and other injection drug use, and it is almost all about process (whether particular helpful government programs exist) rather than outcomes. Sadly, for this once broad-minded organization, which once also focused on harm reduction for much more common behaviors, they seem to have collapsed down to a narrow niche. They used to include in their purview sexual behavior, drug use more generally, and even let alcohol in the door. (They balked at including THR, however, because they were scared to challenge the powerful anti-tobacco lobby. That really says something, given that they are willing to challenge dictators who imprison people for advocating on behalf of injection drug users.)

Not that there is anything wrong with the narrow niche they have retreated to. The people in it are at particularly high risk, and are particularly badly treated. HRI should just stop speaking of it as if it were all of harm reduction, which it obviously is not. Even if we exclude from the term things like seat belts, and stick to the sense of “helping people who choose to engage in behaviors that there are attacked by governments and are otherwise the target of organized opprobrium campaigns” all of injection drug use is still a tiny niche. According to their numbers, they are talking about 10 to 20 million people worldwide. Compare that to over a billion smokers.

In fairness, injection drug users often lose many decades of potential life, as well as much of their potential productivity and ability to function in society. These losses are substantially due to HIV exposure and criminalization, and therefore could be dramatically reduced through harm reduction measures (providing clean needles, eliminating criminalization, offering lower-risk alternatives, etc.). This contrasts with smoking, where smokers lose only a few years of potential life, no productivity, and almost no ability to function. However, to the extent that smoking cause a loss of ability to function (apart from the health effects), it is entirely caused by the quasi-criminalization (punitive taxes that lower people’s wealth, place restrictions, etc.). And, of course, the health risks exist — more or less entirely — because people do not have access to satisfying low-risk alternatives, again thanks to organized campaigns by governments and others.

The situations are remarkably similar, they just differ in which number — the cost to the individual or the number of individuals suffering the costs — is bigger. When you multiply the losses by the population, smoking dwarfs injection drug use.

The HRI report emphasizes Asia, where problems from heroin are worst for various obvious reasons. Also in my inbox today was a call-for-papers from Harm Reduction Journal, for a special issue on harm reduction in Asia. The blurb about it is, unfortunately, restricted to HIV and injection drug use (again, not that those do not deserve attention, but they already get a lot of attention compared to tobacco-related harm reduction issues). However, I did inquire earlier about whether tobacco-related harm reduction articles would be welcome (I am an associate editor of the journal, so had advanced notice), and was told yes. [Update 05mar15: That yes became a no. They do not want my paper about tobacco harm reduction in Asia after all. Again, there is nothing wrong with a special issue specifically about IDU harm reduction in Asia — it should just not be called “harm reduction in Asia” without further qualification.]

There is a paper that I have mostly already written in various forms that I would like to submit. [Update, continued: I still want to write the paper, just not for that issue. And I have found a potential coauthor. But others are still welcome to jump in.] Mostly, but with one gap I cannot fill — and that is why I mention this here and where you come in, dear readers.

Oral dip products used by hundreds of millions of people in South Asia appear to be extremely harmful. If you believe the epidemiology that has been reported (which is pretty sketchy and biased, but is what we have), they cause life-threatening and debilitating diseases at a substantial fraction of the rate that smoking does, and which tend to occur much younger. The government response currently focuses on criminalization. If it were possible to substitute smokeless tobacco for these products — not a perfect substitute, since it is not as psychoactively potent, but similar enough to possibly work — the per capita reduction in harm would be similar to the reduction from substituting it for smoking. And, of course, it would allow people with very tough and sparse lives to continue to do a version of something they like.

There are two major barriers to this. India and other governments, driven by anti-tobacco crusaders at WHO, inaccurately designate the products that are used as “smokeless tobacco”. The products are primarily other substances, however, with tobacco sometimes included as a tertiary ingredient. The harms obviously do not come from the tobacco, since these products apparently cause a lot of harm, while smokeless tobacco does not. But it is hard to convince people to substitute smokeless tobacco for a product they are already being told is smokeless tobacco. WHO is basically sacrificing poor third-world users of these products in order to pursue their campaign of vilifying actual smokeless tobacco use in the West.

The other issue is whether it can be made affordable, and that is the one I simply do not know the answer to. The products currently used cost the equivalent of only a couple of cents per dose, which is about all that most of those who use them can afford. Using Western brand products, at a cost that is more than an order of magnitude greater, is out of the question for most of the target population. For this to work, there would need to be a domestic industry that could make product at prices that are locally affordable. India is a major tobacco leaf producer, so the raw ingredient is there, but I do not know if a local production process could be made cheap enough. Anyone out there have any idea, or know someone who does, either inside or outside of industry, and want to either be a coauthor or give me data?

Obviously this would just be a thought experiment about what could theoretically be done. But no one is likely to turn it into a political cause (or entrepreneurial business plan [Update, continued: My potential coauthor informed, very politely, that I was being rather ivory tower with this observation. He is already engaging in exactly that entrepreneurship. I should have had more faith in the market!]) without the thought experiment. And it matters. The number of people this novel form of THR could help is within an order of magnitude of the number of smokers who can benefit from THR.


7 responses to “By the numbers, harm reduction is mostly about tobacco (including in India)

  1. Ask Vietnam if they can do it. India is losing business to China, and China is losing business to Viet Nam.

  2. Carl what is in “Oral dip ” products?

    • Carl V Phillips

      The term generically refers to anything you use physically like smokeless tobacco. In this case, they usually have betel leaf and/or areca nut are the main ingredients, typically along with slaked lime (calcium hydroxide). It is quite plausible that any or all of these, in the quantities consumed, cause problems — there is (remarkably, embarrassingly) little understanding of what exactly the source of the problem is, at least nothing that is well known. Click the “gutka” keyword for other posts discussing it.

      • “anything you use physically like smokeless tobacco” Uh, do they include ‘sucking a pencil’ in that category? What sort of classification system is that, it sounds like the medieval bestiaries that placed dolphins and larger fish in the same group: they look vaguely similar and they all swim.

        Re betel nut/pepper leaf/lime mixtures, when I was younger I spent a bit of time in the Solomon Islands, chewing ‘betel’ was very common amongst the locals, it did seem to do visible damage to teeth and gums.

        • Carl V Phillips

          Actually it strikes me as a pretty perfect definition. Pencil does not fit because you do not tuck that clear into your mouth and hold or chew it for a while. Categorizations cross cut. There is a perfectly valid and sometimes useful category of “large animals that swim like a tuna or dolphin”; just because it is not the same as the genetically-most-similar category does not mean it is not useful. Of course, the problem comes if someone confuses the two, which is part of the error with regard to South Asian dip products.

          The conventional wisdom is that betel is measurably harmful. The epidemiology is weak and suspect, but it does seem to point to what you observed.

        • Carl I see your point on definitions.
          Re betel nut chewing I recently spent a month in Vietnam where betel nut is also fairly widely used, however there was little of the obvious signs of its use , that were every where in the Solomons.

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