This morning I gave a speech at the 21st International Harm Reduction Conference in Liverpool. The topic I chose was 'Why do anti-smoking groups oppose tobacco harm reduction?' This is what I said...
For five centuries, opposition to tobacco has been founded on moral and religious objections to vice, as well as concerns over health. Under morality, we might include the claim that smoking was ungodly and sinful, that it was decadent and depraved, and that it was a habit suited only to ‘Red Indians’, Jews, blacks, Turks, Spaniards, or whichever racial group was out of favour at the time.
Under health, we could include virtually every disease in the medical textbook. Even confining ourselves to early modern Europe, we find references to deafness, blindness, hysteria, dyspepsia, impotence, infertility, paralysis and brain damage. The evidence underpinning these fears was, for the greater part of tobacco’s history, anecdotal at best, but even from the earliest days those who opposed tobacco did so on grounds that often had nothing to do with health.
From around 1700, rather by accident, the aristocracy of England and France engaged in a spontaneous experiment in tobacco harm reduction. Snuff came into fashion and smoking began to die out, amongst the upper classes at least. This should have pacified tobacco’s opponents for three reasons. Snuff did not fill the air with smoke, it did not carry the risk of starting a fire and it did not appear to be injurious to health. And yet it did not pacify them. Snuff was attacked as a vice - and an addictive vice at that - just as pipes had been. In the United States, similar moral objections were raised against chewing tobacco.
Today, the issue of health has become the dominant feature of the antitobacco movement, but the moral, and even puritanical, element is never far from the surface. In their efforts to ban smoking outdoors, Action on Smoking and Health (US) said such a ban was justified to prevent smokers from setting a bad example to others and listed smoking alongside swearing, drinking, gambling and the wearing of “scanty attire” as examples of unacceptable activities. Although smoking al fresco could not seriously be viewed as harmful to the health of others, it was still seen as sinful and offensive to the eye.
Similarly, Americans for Nonsmokers’ Rights - in a press release titled Electronic Cigarettes are NOT a safe alternative! - criticised the e-cigarette specifically because it mimics the act of smoking and because it contains nicotine. Only pharmaceutical nicotine products escape criticism, partly because they are marketed as a medicinal cure for a ‘disease’ and partly because they administer nicotine without providing pleasure. This has led to a somewhat inconsistent view of nicotine, described as being perfectly safe in pharmaceutical products but highly toxic in e-cigarettes, snus and other tobacco products. The EPA describes it as “acutely toxic (Category 1) by all routes of exposure (oral, dermal and inhalation)” while the MHRA says thats “nicotine, while addictive, is actually a very safe drug.”
Although the amount of nicotine delivered is comparable in all cases, the drug’s reputation as poison or medicine depends on how it is delivered and who is manufacturing it. Three industries are currently fighting for the nicotine market: the tobacco industry, the pharmaceutical industry and the e-cigarette industry. Each have a financial motive for denigrating alternative nicotine products. In the case of the pharmaceutical industry, this financial motive is shared by the various anti-smoking groups it directly and indirectly subsidizes.
This three-sided nicotine war is without historical precedent. Efforts to suppress alternative and/or safer tobacco products have traditionally been the preserve of the tobacco industry and the anti-smoking lobby. Initial opposition to cigarettes in the late 19th century came primarily from makers of chewing tobacco, pipe tobacco and cigars. It was from them that groups like the Anti-Cigarette League borrowed rumours of cigarettes being made in leper colonies and spiked with opium.
Attempts to bring a safer cigarette to market in the 1970s - in particular, by Liggett and Myers - were partly thwarted by rival tobacco companies closing ranks on those who, by introducing a safer alternative, would be implicating all existing brands as dangerous. In this, the tobacco companies found themselves on the same side as the anti-smoking movement, albeit for different reasons. By 1980, the consensus view amongst public health professionals was that any attempt to produce safer tobacco products would slow the quit rate.
Dr Gio Gori’s Less Hazardous Cigarette project, which was brought to a halt at the end of the '70s, was the last attempt to find a technological solution to a problem that many felt should be solved by behaviour modification. Thereafter, the doctrine of total abstinence took hold. The prevailing view was that the more dangerous tobacco was (or was perceived to be), the more people would quit. It consciously withheld safer alternatives from the individual in a bid to accelerate the quit-rate in the population. Reflecting on the new doctrine, Dr Gori said: “The new policy was - smokers shouldn’t be helped, smokers should be eliminated.”
At a time when governments were giving free syringes to heroin and free condoms to children, the ‘quit-or-die’ approach to tobacco raised ethical questions, and was only possible by an almost evangelical faith in the smokefree world to come. Total abstinence had previously been seen as a pipe-dream, but as the anti-smoking movement gathered pace in the 1970s, activists and governments came to believe it was possible within a generation. This was in-keeping with earlier reform movements, which invariably set their eyes on prohibition sooner or later. Just as the American temperance movement set out with a message of moderation and ended with complete prohibition, so the Anti-Cigarette League of the early 20th century went from a campaign that solely targeted ‘coffin nails’ to fighting cigars, pipes and chewing tobacco (which were the ‘less hazardous’ alternatives of its day). The Anti-Cigarette League’s absolutist slogan ‘A Smokeless America by 1925’ bears an uncanny resemblance to the Surgeon General’s equally ambitious of 1986: ‘A Smoke-Free America by 2000 AD’. Both serve as reminders that bringing
about total abstinence is easier said than done.
Four decades later, the ‘quit or die’ approach survives. Its political legacy can be seen in Britain’s ban on Skoal Bandits in the 1980s and Australia and Canada’s recent ban on e-cigarettes. It can be seen in Finland’s pledge to ban any safer tobacco product that might appear in the future. It can be seen in the ban on snus that is enforced in every EU country bar Sweden. Its impact on the health of populations, however, can only be seen by comparing Sweden’s significantly lower smoking rate and lung cancer rate to its EU neighbours.
In summary, modern anti-smoking activists oppose tobacco harm reduction because, like earlier reformers, they tend to be idealists. Even those who set out as pragmatists are liable to becoming more zealous once they become emerged in a worthy cause. Few activist groups of any hue avoid ‘mission creep’ for long. For the anti-smoking movement, the allure of prohibition - the only logical conclusion to its cause - could not be long resisted. To the anti-tobacco campaigner, the appearance of new tobacco products, even if demonstrably safer, innately feels like a step backwards. Their prohibition, on the other hand, feels perfectly natural and, since most alternative nicotine devices are niche products with relatively few users, they can be nipped in the bud with minimal resistance.
Tobacco harm reduction does not offer a Utopia, nor does it promise to rid the world of an addictive vice that some find intolerable. Nor, for that matter, does it hold the promise of destroying the tobacco industry; which is the stated goal of the most fervent activists, who have long convinced themselves that getting rid of the industry will get rid of the problem.
The oft-repeated mantra that 'if something is good for the tobacco industry it must be bad for public health' has come to be seen as a truism, and not without reason, but this logic can only be taken so far. Even the tobacco industry's fiercest critics must concede that no business benefits from killing its customers. When it comes to tobacco harm reduction, we might reflect that seeing the issue as good versus evil is more suited to lovers of comic books than to those looking for real-life solutions. If the tobacco industry - or any industry - can come up with less hazardous products, it should be seen as part of the solution, rather than part of the problem.
The future offered by harm reduction is not as tidy or pure as the vision offered by the idealists. Convinced that a tobacco-free world is within reach, a world of reduced harm seems pitifully unambitious. History provides many examples of anti-smoking crusades built on similar idealism collapsing under the weight of their own hubris, and no examples to the contrary. If they are aware of this inauspicious track record at all, today's crusaders would, I fear, reply with those famous last words: “This time it will be different.”