In this last in our series of articles for harm reduction month, Rob Calder discusses vaping as harm reduction and the implications for the public health agenda. With just a small detour for a discussion of recovery from other research areas. And relatively few references to cakes.
I once ran a thought experiment with some psychology students. I told them to look at a nitrous oxide cannister and think of it as a drug, then to think of it as something to whip cream for a cake display and then remember that it could be a drug. As the mind drifts, so too does the legal status of the cannister. It becomes legal and illegal again. The status, the rights and wrongs are in the eye of the beholder.
A similar sleight of hand can apply to vaping. If you look at a vaping product and imagine young people being bought into nicotine addiction, then it is a terrible thing. If you then imagine people using vaping products to quit smoking, it becomes a good thing. If you let your mind drift from one outcome to the other, this small box of battery, coil and liquid turns from bad to good to bad and back to good. Never once changing its indifferent expression (which of course it doesn’t have).
“The drive towards population-wide measures can mean that those same measures are not quite right for many in that population”
So, is vaping a form of harm reduction? Is it something that encourages young people to start using nicotine? Is it a barrier to abstinence? Well, we can say with some certainty that it is a small, (indifferent) box of battery, coil and liquid.
There is growing evidence (including a Cochrane review) that vaping is effective at helping people quit smoking – I recently talked to Dr Mairtin McDermott and Dr Leonie Brose about this. When I worked on vaping reports for King’s College London, commissioned by Public Health England, we scrutinised data every year for changes in vaping among young people and have yet to find any evidence for the so-called youth vaping epidemic in England. Vaping as a barrier to abstinence? I might take a small detour.
A Recovery Agenda
Many current arguments about vaping remind me of the abstinence and harm reduction arguments that surrounded opioid treatment many years ago before the recovery agenda gathered pace. The Medications in Recovery report helped to re-orient attention away from methadone and abstinence as the dominant outcomes. It helped a sector to realise that everyone wanted people who use drugs to recover, to lead fulfilling lives, to develop relationships and careers. This change in approach helped the sector to move on from a polarised debate that showed no signs of going anywhere. Well, it reduced the frequency and harm of those debates anyway…
This kind of re-framing can help look at answerable questions. It is possible, for example, to reach an answer about how vaping can contribute towards improved health. It is also possible to understand some of the unintended consequences of vaping and how these might be reduced or managed. It is not possible to get a final answer on whether vaping, total abstinence or tobacco harm reduction are ‘good’ or ‘bad’. That is an argument that (like many addictive substances) is both attractive to join and difficult to leave. Perfect for Twitter, but not the best for making progress.
“Whilst the importance of quitting smoking is still very much agreed, there are now many different potentially desirable outcomes around nicotine and nicotine products”
Public health
On an individual level, different outcomes are easy to manage. You meet a young person who doesn’t smoke or vape; well, they should not use vaping products. You meet a smoker who has struggled to quit; another easy one – they should try using vaping products to quit smoking.
Problems come when you look at vaping from a public health perspective. There is a drive for there to be a single, correct approach. There is a need to know what the final verdict is. This can be a problem; such approaches can focus attention on finding a single, easy to communicate, final answer about what we should do as a population.
It is, of course, vital to gain an overview and to understand the wider context in which substances or interventions are used. The kind of overview that reports such as the PHE Vaping in England and NASEM reports do for vaping.
It’s this overview that public health approaches are supposed to engender, but the drive towards population-wide measures can mean that those same measures are not quite right for many in that population. It is important to avoid excluding people from health measures, particularly when it is often the most marginalised in society who are excluded.
To borrow, again, from another sector. Society has become used to different messages for different people in alcohol policy with relatively few headaches. Messaging that deters young people from drinking sit alongside national guidelines for levels of drinking that minimise the health risks.
Differing outcomes
For a long time, however, tobacco research and policy has agreed on a single desirable outcome: quitting smoking. Life was so much easier when everyone agreed on this! Vaping has not just disrupted smoking but has also disrupted a sector that used to agree (quite happily thankyouverymuch) that quitting smoking was the best outcome. Whilst the importance of quitting smoking is still very much agreed, there are now many different potentially desirable outcomes around nicotine and nicotine products. These can vary across people, circumstances, and countries. Ugh, what a mess.
So, next time you see a vaping product and find yourself trying to work out whether it is a good or bad thing, remind yourself that it’s also a small (expressionless) box of battery, coil and liquid. And maybe save yourself a headache by thinking of a cake display instead.
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