Are we ready to “roll up our sleeves and work together”?
Part 1
Vaping as a form of Tobacco Harm Reduction (THR) has been embraced by some and doubted by others. When vapor products were first introduced to the market around 2004, they weren’t produced by the tobacco industry. The tobacco industry entering the market added fuel to the fire of the doubters. An intense battle between opposing sides has grown.
While the focus has shifted from smoking to nicotine it feels like we’ve forgotten the words of former Surgeon General C. Everett Koop when he reminded us “Don't Forget the Smokers”. In 2015 the worldwide death toll from smoking was 1 person every 6 seconds. By 2019 that rate accelerated to 1 person every 4 seconds. How do we get back on track and focus on the 8000000 deaths caused each year by smoking?
Long before vaping became popular, the topic of THR was being discussed. Even then, there wasn’t a consensus on the meaning of terms used by both sides or the value of tobacco harm reduction. The 2002 paper “Tobacco harm reduction: conceptual structure and nomenclature for analysis and research” discusses this issue and said “Decisions made about THR are likely to shape tobacco control policy for decades to come, with potentially profound implications for public health. Clarity in analysis and debate is essential if we are to make the right decisions on these weighty questions.”
Words and their meanings matter. Perhaps before we can take steps to end the nicotine war we need to change how we talk about people who smoke (PWS). With substance abuse disorders (SUD) we no longer use stigmatizing words like “addict” and “junkie”, but when it comes to tobacco use disorder (TUD), or any consumer use of nicotine, we call PWS “smokers”, a term with stigmatizing connotations. We also need to take a look at the use and definition of words like “epidemic”, “addiction”, “dependence”, and “harm reduction”.
While I believe all of us want to reduce the death and disease caused by smoking, we don’t have a consensus on THR as a pathway to get there. Even amongst those of us who think that THR is a viable option, we’ll have to find a way to agree on what THR means and what it would look like. One definition of THR was given as: “Tobacco harm reduction has been defined as minimizing harms and decreasing total mortality and morbidity, without completely eliminating tobacco and nicotine use”
Last year the Truth Initiative took the bold step to release what they envision tobacco harm reduction should look like. I’m excited to see harm reduction becoming a part of the conversation about smoking by one of our largest anti-tobacco NGOs! Their paper acknowledges the division amongst those discussing nicotine. They said “There is a contentious and ongoing debate regarding what role the concept of “harm reduction” should play for smokers who have rejected FDA approved cessation methods, who find those alternatives unattractive, or simply wish to continue using nicotine”. The paper goes on to offer suggestions of what they see the future THR market would look like and how it would be regulated.
What frustrates me about the Truth Initiative statement was their suggestions for regulating THR products make it easier for consumers to continue to smoke than to use THR products. I think that is often an unintended consequence when we lose our balance in the discussion of youth uptake vs helping adults quit smoking. Another area of frustration goes back to agreeing on terminology and what those terms mean. I felt that some of the language used in that paper was negative, stigmatizing, and lacking in compassion. I think their statement provides an example of how hard it is to change the way society views PWS.
The big challenge is going to be agreeing on our goals and what trade-offs we’re willing to accept to achieve those goals. In 2016 Clive Bates wrote the article “ Who or what is the World Health Organization at war with?” Mr. Bates discusses goals and trade-offs under the 3rd bullet point “The wrong war: the confusion of tobacco policy aims”. My favorite in his list of potential goals is to “reduce disease and premature death”. I believe that’s a goal everyone can agree on.
As the THR debate heated up, the authors of “Electronic cigarettes: achieving a balanced perspective” said, “we hope that continued discussion about the promise and perils of e-cigarettes is based on a balanced view of the available science, rather than an ideology that opposes harm reduction without consideration of both sides of the issue, including potential public health benefits.” I believe that ideology and choosing sides between youth use of nicotine and adults who smoke has proven to be an issue that continues to harm people instead of helping them. If we fail to start working together, this problem will persist.
Society’s ability to set goals becomes harder to achieve because nicotine use is conflated with smoking. At the Global Forum on Nicotine in 2018, Joe Gitchell discussed the issue surrounding nicotine. Mr. Gitchell points out that much of the discussion over goals and trade-offs relies on “deeply held values and feelings' ' that “dominate much of our thinking”. When the issue was based solely on smoking we didn’t need to look as hard at trade-offs. Now that nicotine (and the tobacco industry’s involvement in THR) has been thrown into the debate, we do. He encourages all of us to “roll up our sleeves and work together”.
Are we making progress in that Call to Action (CTA) to work together? Yes, I believe progress is being made, although not as quickly as it needs to. In 2021 Clifford Douglas, JD, an expert in the field of tobacco control (TC) grabbed the “work together” banner and issued his own CTA. He invites all sides of the nicotine debate to “act with integrity and end the internecine warfare over e-cigarettes”. Mr. Douglas points out that the continued rate of smoking in certain marginalized populations has become a social justice issue. His commentary described things that both sides are getting right and pointed out the weaknesses in our efforts that contribute to the endless war over nicotine. He ends with this thought for everyone to ponder: “People who smoke should not have to die because they do not know they have less harmful sources of nicotine.”
Shortly after the commentary by Cliff Douglas, 15 past presidents of the Society for Research on Nicotine & Tobacco released a paper in the AJPH. They point out that the “use of nicotine-containing electronic- or e-cigarettes has divided the tobacco control community along a spectrum from fervent opponents to enthusiastic supporters”. They have added their voices with a CTA “to encourage more balanced consideration of vaping within public health and in the media and policy circles”.
In 2022 the AJPH published a paper by 13 experts in the tobacco control field. Their CTA challenged “the public health and scientific community to move away from characterizing scientists as “opponents” or “supporters” of e-cigarettes”. They pointed out that “the “opponents/supporters” terminology highlights division rather than the many areas in which there is agreement”. Some view this paper as an olive branch showing where the 2 sides of the debate are finally reaching common ground.
Is it possible for a group of people to get together and discuss the future of nicotine? Of course, it is! Somebody needs to get the ball rolling. Policy recommendations are made all the time. We need to look at long-term goals. Talking about a comprehensive long-term nicotine policy has been going on for years. Back in 2009, there was a Strategic Dialogue on Tobacco Harm Reduction Group. I found the list of funders and participants interesting. I would guess some of those conversations were challenging, and yet the group was able to come to a consensus on several points and made recommendations for the path forward.
No conversation on how we change the conversation from a nicotine war to working together to end the potential morbidity of some forms of nicotine use is complete without looking at the challenges and divisions faced by those who research, make policy recommendations, and teach our future scientists. The 2020 authors of “Polarization Within the Field of Tobacco and Nicotine Science and its Potential Impact on Trainees” put out a call to action to the scientific community. They said “Divisive, dominant perspectives on e-cigarettes move the field of nicotine and tobacco science away from scientifically rigorous discourse on this important public health topic, which involves millions of lives at stake. If norms do not change, the polarized climate may pressure trainees to choose or inherit an allegiance towards an uncompromising, one-sided stance. That allegiance can then restrict career development, undermine the credibility of research, and hinder public health progress. There is an urgent need to act to avoid negatively affecting the next generation of nicotine and tobacco research scientists…we are calling for reflection among everyone in the field and particularly among those with influence and power.”
The final elephant in the room is the power and influence of those financing portions of the nicotine war. Why would anyone invest so much money in a cause and refuse an invite to discuss the issue they’re so passionate about? They could lead by example if they’d agree to participate in an opportunity to change the conversation and work with others to save more lives.
As we try to move past our emotional war over nicotine and discover ways to change the conversation, I suggest we remember the words of Jonathan Haidt: “Morality binds and blinds. It binds us into ideological teams that fight each other as though the fate of the world depended on our side winning each battle. It blinds us to the fact that each team is composed of good people who have something important to say.”
Are we ready to roll up our sleeves, get to work, and figure out How to Think—Not Feel—about Tobacco Harm Reduction? How many more lives could we save if we stopped fighting a war, changed the conversation to a solutions-orientated one, and included everyone with an interest in or a concern about nicotine?
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Thank you to all who have been urging everyone from consumers, regulators, media, public health, and scientists to “change the conversation”. There were too many of you to list in this commentary.
To learn more about ending the nicotine war and changing the conversation to a solutions-orientated one, please check out the links on this Safer Nicotine Wiki page.
Thank you Joe Gitchell for helping me with edits!
