by Carl V Phillips
The best thing I have read about harm reduction in a very long time is this post at The Influence by Shaun Shelly, “The Harm Reduction Movement Needs to Rediscover Its Soul”. The post, the publication, and the author all focus on illicit drug harm reduction, but almost everything in it applies to tobacco harm reduction also. Read it if you fancy yourself a supporter of harm reduction. As I have noted here previously (example), many — I would say a large majority — of those who fancy themselves THR advocates do not really support harm reduction.
I will highlight a few bits. Shelly’s thesis is:
Officially, harm reduction can be described as ‘‘policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption’’ (Harm Reduction International, 2011).
In my opinion, this definition does not capture the true spirit of the original harm reduction movement. Harm reduction is about meeting people where they are at, without judgement, and helping them find them achieve their drug use aims (including abstinence) in the way that causes the least harm to them, irrespective of the current legal and policy framework.
I am not sure I agree that HRI (which had not actually yet changed its name from IHRA in 2011) gets to “officially” define anything. I can say that I have a few serious differences with them (despite being a long-time member the editorial board of Harm Reduction Journal, which is the semi-official journal of HRI, and which endorses a definition of “harm reduction” that basically the same as HRI’s). But from the THR perspective, you do not even need to go on to Shelly’s next paragraph to see the disconnect with the soul of harm reduction.
Almost every time you see the phrase “harm reduction” used in the realm of tobacco today, it is referring exclusively to the substitution of lower-risk products or policies to encourage that substitution. Moreover, this inappropriate narrow usage narrows further still: It is almost exclusively about substituting for cigarettes (e.g., I can think of only a couple of us who have tried to get some traction for extending it to substituting low-risk smoke-free products for the high-risk smoke-free products that are popular in South Asia). Also, due to the odd twists of history, these days the term is almost always used to refer specifically to substituting e-cigarettes for cigarettes, rather than substituting some other low-risk alternative. (Note that I expect that will change soon, with heat-not-burn cigarettes getting a lot of attention.)
This is a remarkably close parallel to Shelly’s lament that illicit drug harm reduction has descended into just being about getting injection opioid users to reduce their risk of catching or transmitting HIV.
But notice that the IHRA/HRI definition — and that of anyone else who really believes in harm reduction — refers to also reducing the “economic” (read: financial) and social costs of drug use. In the case of tobacco use, as with many drugs, the great majority of the financial and social costs come not from the drug use itself, but from government actions. Smoking is expensive because of taxes and restrictions on the free flow of goods. More social harms from smoking are caused by government restrictions than by the act itself. Unlike with illicit drugs, few people are imprisoned or executed over tobacco (though not none), but unavoidable punitive taxes are not necessarily less harmful than rolling the dice on a small chance of getting arrested.
And yet, many people who fancy themselves supporters of tobacco harm reduction actively support most of those caused harms. They actively support punitive taxes on cigarettes, social opprobrium heaped on smokers, prohibitions against publicans being able to offer smoking sections, etc. Indeed, those individuals often celebrate or advocate for the caused harms because they create further incentives for the only aspect of harm reduction they actually support, switching products. It reminds me of the Orwellian themes of about half the anti-smoking propaganda I see these days: “Quit because it is so expensive and forces you to take breaks from hanging with your friends!” Um, yeah, and whose fault is that? It is the same as those messages of “if you smoke weed, you might lose your student financial aid and future employment prospects, so don’t go saying it is not bad for you!” Needless to say, you will never hear a peep of condemnation of this hypocritical “concern” for users’ well-being from the faux supporters of harm reduction.
The bottom line is simple: Anyone who supports punishing smokers does not actually believe in tobacco harm reduction. None of those “but for the greater good we need to…” protests changes this. Causing harm is not harm reduction.
I would also add a clarification to the last words of IHRA’s definition, and rephrase it as “without necessarily reducing the consumption of that drug”. The soul of harm reduction does not say “we support reducing the harm, so long as people stick to using only the specific drugs we approve”, as might be considered to be conceded by the original phrasing. There is little interest in helping those who smoke use their chosen drug with less harm (even setting aside the caused financial and social harms). Indeed, there is active opposition to it. Heat-not-burn cigarettes are, arguably, a method of smoking, in contrast with the use of e-cigarettes or smokeless tobacco, which are alternative drugs that can be substituted. There is a lot of hostility toward the introduction of heat-not-burn products from many e-cigarette cheerleaders and others who pretend to support harm reduction.
I have not even gotten to Shelly’s thesis paragraph, where he points out that HRI’s techy and bureaucratic definition does not capture the soul of harm reduction. Most of the supposed support for THR does not even qualify as supporting harm reduction under the techy definition.
Many grassroots supporters of tobacco product substitution live up to the additional consideration Shelly presents, of meeting smokers where they are. At the grassroots level, where a lot of e-cigarette advocacy lives, people are really very good about this. The vape shop operator or friend who has switched products is usually all about appreciating the current experience of the smoker standing before him. This seems to contrast with Shelly’s point,
People who use drugs have been ignored by those who loudly proclaim they are “leaving no one behind.” (Then again, is it possible to leave behind people who were never recognized as part of the group in the first place?)
On the other hand, the contrast may not be all that great. Much of that meeting of smokers where they are is focused on how to most effectively persuade them to stop doing what they are doing. It is not without judgement (their current choice is usually judged to be something that should be changed). It is only about helping them find them achieve their drug use aims if those aims include quitting their current drug, one way or another. And it certainly does not consider that the current legal and policy framework might be the problem and should be in play.
Moreover, I said that was the grassroots level. At the level of the self-appointed grandees who have come to dominate e-cigarette advocacy (particularly in the UK, which has, perhaps unfortunately, come to dominate e-cigarette advocacy), there is not even that. Yes, there is attention to where people are, with respect to their drug use. But that is not about meeting them there. It is more like the attention devoted to figuring out what motivates vermin that are eating the crops, to determine how best to manipulate them into not doing it. Shelly makes what will be a familiar reference in the context of the e-cigarette wars:
…opioid substitution therapy programs designed in a way that makes them more a form of social control than an aid to those accessing them.
Shelly also notes:
Disturbingly, however, people who use drugs are being marginalized even within the world of harm reduction advocacy.
How many openly dedicated users of high-risk tobacco products are included in any discussions of tobacco harm reduction? The discussions are mostly among those who despise smokers, those who switched from smoking but are humane enough to not despise smokers though they despise smoking (yes, they are people who use drugs, but not the same drug), and only a small handful of nonsmokers who rise above being motivated by despite. When representatives of smokers are offered a token seat in the discussions, they tend to be cigarette industry employees or Simon Clark from FOREST. None of them are smokers! I cannot claim any identity politics points here either: I am not a smoker, nor someone who quit smoking via product substitution.
Nevertheless, I have actively tried to build bridges to those who defend their choice to smoke and whose primary interest in tobacco harm reduction is eliminating the government-caused harms. Yes, they too are harm reductionists. They are key harm reductionists. Yet only the best-read of them even realize they are in the harm reduction space because of the aforementioned perversion of that term. Many smokers (mistakenly) think that harm reduction is their enemy because that term has been misappropriated by many who support harming them and merely want to “fix” their behavior by whatever means necessary. Smokers (correctly) think that they are marginalized in the discussion of tobacco harm reduction. They hate harm reduction. Some of them even take time out of their day to make clear they hate me, of all people.
Perhaps it is understandable:
I, too, am guilty of using this platform to sell compromise to policymakers. In pitching to them, I regularly use examples that show how HIV can spread from people who inject drugs into the wider community—drawing the conclusion that in order to protect the wider community, we need to protect drug users.
Not an exact parallel, but I am certainly guilty of trying to help THR “pass” in “respectable” quarters by pitching it as being the best response to the scourge of smoking. I think I probably leaned in this direction the least of any of my colleagues in the field. I would like to think anyone who was really paying attention to me would recognize my true commitment to harm reduction. But I understand that most judgments, especially these days, are made based on a few snippets, not an awareness of someone’s full corpus.
Finally, I particularly like Shelly’s observation,
The fact that US Drug Czar Michael Botticelli can receive a standing ovation at a harm reduction conference tells me that harm reduction has become mainstream and compromised.
There is a hint here that harm reduction has its natural home as an insurgency: mainstreaming results in it being compromised. At a gut level, I kind of feel like that is true, though theoretically it need not be. But the overt message is that someone whose role is mostly about judging, punishing, and preventing is no friend of harm reduction. “Pro-harm-reduction tobacco controller” is an oxymoron.
As I said, go read Shelly’s whole piece; there is more that should ring a bell. In particular, you will also notice those most responsible for destroying the real commitment to harm reduction are the UN/WHO and other powerful funders, a bunch of Western 1%-ers who pretend compassion while really thinking of most of the people in the world as, at best, serfs, and often merely as disease vectors. That also seems rather familiar.