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Refraction & Reflection, by Mo, CC BY-NC-SA

Why is Tobacco Harm Reduction so fraught, despite being a legitimate public health strategy supported by extensive scientific evidence?

As most of our readers know, a heated debate about the legitimacy of promoting tobacco harm reduction exists in our field. There are a lot of reasons for this, but one important reason is that public health wants nothing to do with anything that is seen as having industry links.

And it is true that unfortunately, the discourse of tobacco harm reduction introduces problematic optics. Given that harm reduction means reducing reliance on combustible tobacco products, which are among the most risky ways to consume nicotine, then embracing harm reduction means that it is impossible to unilaterally reject all nicotine and tobacco products produced by the tobacco industry. (Of course, expressing concerns about the safety of these products and advocating for their regulation is an important piece of the equation – we should never trust any industry, especially the tobacco industry, to produce products that are first and foremost designed to maximize protection for consumers.)

In recent years, the tobacco industry has wholeheartedly embraced a discourse of tobacco harm reduction, very intentionally co-opting the term for their own benefit. They likely reason that if people practice harm reduction rather than quitting all nicotine and tobacco products, they are simply able to line their own pockets. After all, combustible tobacco products aren’t the only products owned by tobacco companies; lower risk products are increasingly an important part of their portfolio.

But do these concerns about the optics of tobacco harm reduction mean that we should abandon not only what is a legitimate approach to public health practice, but also an approach that we know that people are already practicing? And troublingly, they are practicing it with little to no guidance from public health professionals.

Maybe it is time to rethink our own practice and reflect on why the tobacco control and prevention field in the United States is so hostile towards tobacco harm reduction. We might realize that it has little to do with what is in the best interests of the public.

I’ve just started reading Sandro Galea’s brilliant book Within Reason: A Liberal Public Health for an Illiberal Time – a book that so eloquently articulates the need for a self-reflective approach to the practice of public health. Dr. Galea isn’t trying to make friends with this book (a position we, at the Center for Critical Public Health, sometimes find ourselves in). Because “turning the gaze inwards” – which is an obligation of a critical public health that requires us “to look unflinchingly at [our] own practice” (Green & LeBonte, 2008; pg 7) – doesn’t always make you very many friends. But if we want to encourage and maintain the trust of the publics that we serve, don’t we have to think critically about our own practices and standpoints?

A relationship is broken if one side isn’t willing to self-reflect, adjust, and learn from the other. Public health proselytizes about the benefits of a community-informed approach to public health research and practice, and in some regards accomplishes this quite well. But it also feels that when the community perspective challenges the underlying assumptions, knowledge, and values of public health, heels seem more often likely to dig in rather than change direction. As Galea argues:

If we ignore the ways we are falling short because we do not wish to help our foes, we simply help them in a different way—by making ourselves weaker through our inability to speak freely, self-correct, and think for ourselves. This does no favors for the populations we serve.

Galea, 2023; pg 11

What excellent advice. Let me spell this out to be sure to make this analogy clearly.

If we in public health are so afraid to be perceived as failing to unilaterally reject anything that tobacco companies embrace, talk about, or produce, we help them in a different way – we make ourselves weaker by rejecting a scientifically valid approach to public health. People know that there are more and less risky nicotine and tobacco products, and some people who use combustible tobacco products want credible sources of information about these distinctions so that they can make informed choices about less risky nicotine use. But public health isn’t sufficiently responding. Instead, by failing to acknowledge and discuss the possibility of practicing tobacco harm reduction, we fail our most important constituents and possibly lose their trust too.

Tamar Antin

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