Should we apply harm reduction to nicotine addition?

Jan Hajek | August 14th, 2017

Cigarette smoking kills. We know this. The numbers are staggering; every day, more than a hundred Canadians die due to cigarette smoke.

As a province, we have banded together and have declared a public health emergency to address the catastrophic surge in opioid/fentanyl-related drug overdoses, and rightfully so. We have embraced safe injection sites, opioid substitution therapy, even providing injectable heroin to some people.

But, despite incontrovertible evidence that e-cigarettes and vaping (using similar technology to concert smoke machines) is much safer than smoking, it seems to me that we are doing very little to offer it as a harm reduction option to people with nicotine addiction.

Every day, at VGH, a few people smoke cigarettes on their breaks outside – next to signs that admonish them to not vape or smoke near the hospital.

Now, I recognize that cigarettes are not heroin, and vaping is not methadone – but, if we are serious about reducing harm from second-hand cigarette smoke, and, if we are serious about reducing the harm to our friends and coworkers, when they go outside for a smoke break, shouldn’t we encourage them to vape instead?

About the Author

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Jan Hajek
email iconjan.hajek@vch.ca  

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One comment on “Should we apply harm reduction to nicotine addition?

  • Dr. Milan Khara says:

    Jan, your post makes many good points and reflects the highly contentious debate that is occurring within the tobacco control and public health communities across the world: how should we deal with the emergence of e-cigarettes/vaping?

    Proponents of e-cigarettes make the same argument that you have: vaping is much safer than smoking and we should be offering these products to those who can’t or won’t quit smoking. In fact, the United Kingdom, the most pro-e-cigarette country in the world, have stated that e-cigarettes are “95% safer” than conventional cigarettes. That is a very difficult rationale to argue with. Yes, we would rather that he or she quits altogether but if that is not possible, an e-cigarette is highly likely to reduce risk.

    In my view, there are at least a few caveats though. First, the “95% safer” is an expert opinion only and is largely free of strong, long term safety evidence. There is every reason to believe that vapour poses less risk to the “vaper” and those who are secondarily exposed, but doubt about the degree of risk remains. Only more research, including long term safety studies will help.. The other concern is that in many who “switch” to e-cigarettes, what we actually see is “dual use”, and again there are challenges in quantifying risk.

    In Canada the market is not regulated; there are no standards in labelling, packaging and product design.

    Lastly, we should just keep an eye on what may be unintended consequences. Will e-cigarettes become the “gateway” to nicotine addiction and subsequent use of tobacco for a whole generation of young people? Current evidence on this is mixed. If these products become fully legalized, will we allow the tobacco industry to market them as they did cigarettes in the 60’s and beyond? Will that lead to a “renormalisation” of smoking/vaping behaviour?

    The benefits of other harm reduction measures (you mention methadone) have usually been well evaluated before we’ve embraced them. There is no corporate methadone lobby, but there is a big, powerful tobacco industry, with a history of appalling corporate misbehaviour with execs eyeing e-cigarettes as a massive cash cow. We must be carefully deal with them, , but we also have to think of the 6 million people who die prematurely every year due to tobacco and who may benefit from switching.

    So, for what it’s worth, this is a difficult and nuanced debate and answers are only just beginning to emerge. The likely next step is a federal regulatory framework allowing e-cigarettes to be made legally available and with some degree of standardisation. As this evolves, I think your perspective will become more mainstream and we may offer tobacco users this “harm reduction” option.

    Dr. Milan Khara MBChB, CCFP, Dip.ABAM
    Smoking Cessation Clinic, VGH

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