Face facts: some smokers will never quit. So how do we help them?

The Spinoff
31 May, 2018

Today on World Smokefree Day, it is time to listen to the needs and preferences of smokers.

Yes, that will sound counterintuitive – perhaps even abhorrent – to some. Tobacco control policy, after all, has not been particularly kind to smokers.

Smokers have been made poorer through rising excise, they have been stigmatised through publicly funded ‘denormalisation’ campaigns, and they have literally been sent out into the cold due to designated smoke-free zones.

Yet despite concerted efforts by policymakers, some smokers continue to smoke.

Our current set of policies have been largely successful in preventing smoking uptake, particularly amongst youth. An ASH survey shows that only 2.2% of year 10 students smoking daily in 2016, compared with 15.2% in 1999. Tobacco policy has faltered, however, in encouraging current smokers to quit.

Political parties, policymakers and advocacy groups need to consider a more compassionate approach to tobacco policy. An approach focussed on tobacco harm reduction, rather than abstinence and prohibition. And luckily, there has never been a better time to do it.

Understanding why people smoke is key to helping them quit
When it comes to tobacco harm reduction, the aim is not to ignore or deny the very real harm that smoking causes. Rather, harm reduction recognises that harm elimination in the form of abstinence-only policies will not improve the welfare of those individuals who cannot or do not want to quit.

Tobacco harm reduction, like drug harm reduction, also recognises that there are unintended adverse consequences involved with prohibition.

There are many reasons why people continue to smoke, despite the harmful financial and health consequences. A report published in conjunction with the Ministry of Health looks at why young Māori women smoke, and the barriers to quitting.

The report warned against compounding the great sense of shame and stigma associated with trying and failing to quit. It also noted that “forcing smoking cessation to the fore” can be counterproductive and alienating.

Rather than enforcing abstinence on people who might be facing other struggles in their lives – and let’s not forget that smoking is largely concentrated among the poorest – a more compassionate option would be to make less harmful alternatives to smoking available.

That doesn’t mean abandoning public health goals, but realising that public health policy must consider the needs and aspirations of the people it purports to help.

A less harmful way of delivering nicotine
One of the greatest scientific developments in tobacco harm reduction was the observation that while people smoke for the nicotine, it is the smoke or combustion that causes the most harm. The development of the e-cigarette was borne out of consumer demand for a less harmful means of delivering nicotine to the system. Though Nicotine Replacement Therapies like gum and patches are available, they are poor substitutes for the sensory characteristics that some smokers prefer, and do not deliver the level of nicotine intake that smokers are accustomed to.

Vaping (the use of e-cigarettes) is a great example of smokers choosing to quit smoking on their own terms, using methods that work for them. The friendly vape store assistant is contributing to public health as much as any doctor offering advice on smoking cessation.

But e-cigarettes are just the beginning. Many New Zealanders will now be used to the sight of vapers, and e-cigarettes have successfully helped many Kiwis quit smoking. However, they will not work for everyone. There are now a range of nicotine delivery products available including snus and heat-not-burn to help people cut down or quit smoking.

Access to these products can not only reduce the harms from smoking, but might even make the process of quitting smoking an enjoyable one. After all, for once smokers are not being told to give something up (nicotine use), but are simply switching to a less harmful alternative.

A tobacco and nicotine hit without the smoke
Over ten years ago, the Ministry of Health concluded that snus (small pouches of reformulated tobacco that are placed under the gum) carries a considerably lower risk of harm than smoked tobacco. Yet New Zealand continues to ban the sale of the product, despite reputable international bodies confirming the role snus could play in tobacco harm reduction.

Meanwhile in Sweden, where snus is legal, the smoking rate sits at a low 7%. The interesting thing is that the Swedes are not giving up nicotine. The rates of snus use have overtaken the smoking rate as the Swedes switch in large numbers to a less harmful alternative. Similar trends have been observed in Norway, where the gap is closing between smoking rates and snus use.

In these countries, a smoke-free future does not seem like a lofty aspiration but a natural progression.

Newer products, like heat-not-burn, are being developed too. Heat-not-burn products are inhaled like e-cigarettes, but contain reformulated tobacco rather than nicotine e-liquids. Tobacco is heated to a temperature that releases nicotine and flavour, without reaching the point of combustion. The products could very well appeal to those who do not prefer e-cigarettes.

Public Health England and the UK Committee on Toxicity have found that these products are less harmful than conventional cigarettes. And while most public health experts would point out that a level of risk remains, remember that at this point, we need to be thinking about what to offer smokers who otherwise cannot or do not want to quit.

The sale of vaping and heat-not-burn products is now legal – but this is just the first step
Earlier this month, there was a watershed moment in New Zealand’s tobacco harm reduction history. The Ministry of Health announced that the sale and distribution of vaping and heat-not-burn products is legal. Before this, domestic retailers were operating in a regulatory grey area.

The Ministry are currently considering how best to apply risk-proportionate regulation across these products.

But smokers might not want to breathe a sigh of relief just yet.

“Risk proportionate” could very well mean regulating these products to the point of obscurity. Tobacco-style regulations like excise and standardised packaging currently apply to all tobacco-containing products, despite the fact that these less harmful products do not pose the same level of risk as smoked tobacco, and might even improve health outcomes.

Applying such regulations sends the harmful and counterproductive message that these products are just as harmful as smoked tobacco, so people might as well smoke. Imagine looking at a pair of dirty lungs or a diseased foot every time you use a product that is reducing your exposure to harm. Or imagine being told that politicians don’t want to “normalise vaping” as socially acceptable even though you only switched to vaping because of the crippling social stigma associated with smoking.

It is also disappointing that the Ministry has excluded snus from its announcement, despite the fact snus is an older product than e-cigarettes and heat-not-burn and therefore has a longer-term body of evidence behind it.

Risks matter in public health policy, but benefits matter too. Smokers should be made aware both of the risks of these alternative nicotine delivery products, as well as the potential benefits to their health and enjoyment.

In reality, these alternative nicotine delivery products should be celebrated as achieving one of the goals of New Zealand’s cornerstone tobacco policy. One of the purposes of the Smoke-free Environments Act 1990 is to reduce the harmful constituents of tobacco products and smoke.

Why not just take cigarettes off the shelves?
Of course, it is hard to talk about New Zealand’s smoke-free future without addressing the big butt in the room: cigarettes. There are many in public health who would like to see cigarettes banned from the shelves altogether.

I want to address this point by first acknowledging that broadly, most people in the tobacco control/tobacco harm reduction space want the same thing: to discourage youth uptake of smoking and to reduce the harms experienced from smoking.

We only disagree on how to achieve that.

But we only need to look at the adverse consequences of our drug policies to realise that prohibition does not work, and disproportionately hurts those who are already disadvantaged. In a perfect world, policymakers might be able to ban cigarette sales. But in that perfect world we must also assume there will be no black market, and no unhappy and resentful smokers who did not want to quit.

A tobacco harm reduction approach considers the world as it is, and people as they are, not the way we fantasise they could be.

The ability for smokers to make positive improvements to their health and livelihoods is surely a worthwhile public health goal, even if further improvements are always possible.

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