Should big tobacco be involved in harm reduction?

Smoking amongst people with mental health problems

I recently attended a fascinating talk on the topic of smoking cessation amongst people with mental health problems.The argument the presentation made was (as I understood it) that for many people with mental health problems, nicotine is actually a fairly helpful psychoactive substance – in that it can allow people to experience a reduction in anxiety, increase cognitive focus and help them structure their lives. The presenter also argued that e-cigarettes appear to be a low harm way of delivering nicotine and, as such, we should consider ways of encouraging uptake amongst this population. What did I think of  the ideas?

I can generally see the validity of these points – the ‘self-medication’ hypothesis which suggests that people with mental health problems can use nicotine to manage symptoms is not uncontroversial, but has accrued a reasonable amount of evidence – for instance amongst people with attentional problems, depression and schizophrenia ¹²³. In terms of e-cigarette being a low harm nicotine delivery system, again more research (in particular, long-term studies) needs to be done, but the preponderance of evidence supports this – to the extent of the Royal College of Physicans suggest the cigarettes are likely to be 95% safer than tobacco products⁴.

The presenter had done a lot of background interviews to support their case. One interesting thing that arose was that many of the interviewees they had spoken to clearly had access to NRT (usually a few boxes of patches in a cupboard!) but chose not to use it. Although this wasn’t formal ‘science’ or grounds for an evidence-based approach to treatment, this anecdotal report suggests that perhaps the cigarettes are a viable alternative these individuals – they made some effort to quit, but need something that meets their needs in a different way to patches or gum. So, I can also follow that encouraging these individuals to transition to e-cigarettes (which allow self-closing to far greater degree than do other forms of NRT) can be beneficial.

Could big tobacco compaines help be part of the solution?

What really got me thinking was a final point that was made. The presenter highlighted that tobacco companies have, in the past, offered discounted cigarettes and tobacco products to the US military and also to homeless shelters and outreach programs. They also went on to suggest that tobacco companies could perhaps be required, as a form of reparation, to do the same with e-cigarettes in regard to disadvantaged communities. This would, the argument goes, make them more accessible and reachable to people who could potentially experience reduced harm as a result. I think it is important to note the speaker clearly wasn’t an advocate of big tobacco companies. Their talk made quite clear the harms of the products of caused, and the legacy of mistruths and scientific shenanigans such companies have employed to argue, for instance, smoking is neither hazardous nor addictive. But this idea got me thinking – is getting tobacco companies involved in harm reduction something we should encourage, or something to be should be wary of?

Reparations or image saving?

My suspicion is the big tobacco companies will be more than keen to place their e-cigarette products in contexts such as shelters, clinics and outreach plans. In both the US and the UK, numbers of people using tobacco products has steadily been falling and, more importantly, so has uptake among younger people. Many people hope that we are experiencing the ‘endgame’ for tobacco products in the Western world. For the big tobacco companies, e-cigarettes represent a new product for a market who no longer wants the harmful old one. Supplying this would not only safeguard the future of their profits in these markets but also offers an opportunity to begin repairing a spoiled public image. And it is this latter aspect which I think concerns me. In countries such as the UK, the US and many other Western legislative systems, tobacco control policies (which reduce use and uptake) were only really enacted when it became very difficult for politicians to avoid doing so. In these countries it is very unlikely that such policies will be reversed such that tobacco can regain its status as a ubiquitously used substance. So, in the context of Western countries the net effect of e-cigarette’s being supplied by big tobacco companies in this way is probably positive. However, tobacco control is not the same the world over. I simply cannot see tobacco companies being as keen to supply discounted e-cigarettes in, for example, Africa or India. I also worry that if big tobacco companies rehabilitate their image in one market (for instance, the US) it may make it more difficult for pressure to be brought to bear on them in others. Thus, although may have a positive effect in some places, this may be at the expense of a more drawnout approach to the ‘tobacco endgame’ in the rest the world.

All in all,I’m really not sure what I think about this discounted e-cigarette issue though. Should big tobacco be part of the solution for people in disadvantaged communities? My feeling? To some extent, the jury is still out for me- it’s a complex, global, question, with no easy answer… But I’d always be aware that big corporations look to profits, and often do so before ethics (tobacco companies being no exception here!). So my instinct is to keep them out of it. Whether that is at all possible is, of course, another question….

It’d be great to get your thoughts on this – so why not leave a comment?

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