Barcelona, Spain | 19/09/2018 Harm reduction: drugs and tobacco Gerry Stimson Emeritus Professor Imperial College London Harm reduction Harm reduction – based in public health and human rights • Many people do things that might harm themselves or others • We can help people to reduce risks of harms • A core public health strategy – as set out in the Ottawa Charter on Health Promotion – enabling people to make healthier choices and to lead healthier lives • International treaties on the right to health eg Risk Product Context/ Behaviour environment Driving Vehicle design, Road design Driver vehicles crash helmets training Harm reduction – Alcohol Commercial Design of bars, Drinking alcohol city zones, norms products, transport contexts, behaviours Drugs Cleaner drugs. Drug Drug using Pill testing consumption norms rooms, safe zones Pragmatic: • Safer, not absolutely safe Skiing Ski bindings, Piste design Ski lessons • There is no safe level of driving, helmets drug use, holidays… Drugs harm reduction ‘A drug free world’ But - Drugs supply and demand reduction strategies are not enough to reduce risks and harms • Harm reduction origins • Identification of HIV in injectors in 1986 • Europe, Australia and North America Opposition to drugs harm reduction late 1980s - the emergence of drugs harm reduction • Initially opposed by World Health Organization, UN Office on Drugs and Crime • ‘Harm reduction’ language not in international drugs treaties • 80 countries now have methadone, 90 needles and syringes • A public health success • But in some countries opposition continues HARM REDUCTION INTERVENTIONS IN CATALONIA FOR DRUG USERS • Opioid substitution therapy: methadone • Syringe exchange programmes • Prisons: syringes and methadone in all prisons and all wings • Outreach: street work, mobile units, peer involvement • Low threshold drop in centres for social and health care • Supervised consumption rooms • HIV, Hep C tests & counselling + HBV/HVA vaccinations • Access to HIV and hepatitis treatment • Health care workshops for drug users: safe injecting, safer sex, overdose prevention and response • Promotion and support of drug users and patient organisations • Heroin prescribing trial • Cannabis clubs Slide courtesy of Xavier Major Roca, Generalitat de Catalunya 7 In Catalonia 8000 on methadone 1m syringes p.a. 6 outreach buses 13 drug consumption rooms Slides courtesy of Xavier Major Roca, Generalitat de Catalunya Tobacco harm reduction The global smoking problem Half of all those who smoke Over six million people die 70% of deaths are in low will die prematurely from from a smoking-related and middle-income smoking-related diseases disease every year countries Global cost of smoking- WHO estimates that by the More people die from related diseases in terms of end of the century one smoking cigarettes than health care and lost billion people will have from malaria, HIV and TB productivity is estimated at suffered a smoking-related combined USD $1 trillion annually disease (WHO) Spain • 25.1% of the adult population smoke daily * • 10th highest in the EU 28 • 10 m daily smokers • 22.9% of male deaths are attributable to smoking ** • 53532 deaths a year attributable to smoking *** * 2017, WHO ** 2010, Tobacco Atlas Figure from: No Fire, No Smoke: The Global State of Tobacco *** Our World in Data Harm Reduction 2018 (2018). London: Knowledge-Action- Change Tobacco control Ambition and strategy But Just as with drugs • A world without tobacco • Supply and demand reduction • Strategies to reduce demand are not enough to reduce risks and supply and harms • Foresees an ‘endgame’ where tobacco use and tobacco companies cease to exist • Stigma as a public health tool Nicotine is the Smokers risk second most disease and popular drug premature death Most smokers say Many have tried they want to stop to stop The tobacco smoking harm reduction Many are unable Smoking tobacco proposition: or unwilling to is the most give up nicotine – harmful way of they like it delivering nicotine Providing safer ways to deliver nicotine enables people to continue using it but to avoid the health risks of smoking The problem - combustion Mike Russell “Smokers cannot easily stop smoking because they are addicted to nicotine…. People smoke for nicotine but they die from the tar” 1976 BMJ 1: 1430- 1433 Figure from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action- Change Safer Nicotine Products (SNP) deliver nicotine with a significant reduction in risk compared with combusted tobacco products. There is ‘No Fire, No Smoke’ E-cigarettes, heat-not-burn, snus Current smoking (blue) and vaping (red): EU 28 Spain = 1% adult population currently vape Ratio of vaping/smoking • 0.29 UK • 0.04 Spain Figures from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action- Change Tobacco harm reduction in action – four case studies Norway – due to snus, smoking is fast disappearing. Only 1% of young Norwegian women smoke, but 14% use snus Figures from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action-Change Sweden – due to snus, lowest rate of smoking and lowest rate of tobacco- related deaths in Europe Figures from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action-Change Update 2018 = Update 2018 = 3,200,000m 6.2% UK – rapid rise in e-cigarette use and decline in smoking Figures from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action-Change UK smokers use e- cigarettes to quit smoking Japan – heat-not-burn pushing out cigarettes, 27% decline in cigarettes sold in two years Figures from: No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action-Change My assessment of tobacco harm reduction • Safer nicotine products can replace smoking • This can happen quickly • Indicates an appetite, among smokers, for safer, attractive and suitable alternatives to cigarettes • These trends have happened mainly without public health endorsement or government support • An end to smoking may be achievable but not an end to nicotine use • ‘Smoking cessation’ repositioned from medical ‘treatment’ to pleasurable experience • From stigma and guilt to guilt-free enjoyment of nicotine • Self-help approach to switching from smoking Consumer advocacy organizations Opposition to tobacco harm reduction Public Health and Tobacco Control caught off- guard and left behind Predominantly a ‘threat’ narrative No public health from PH and Tobacco Control thought workforce vision leaders. E-cigarettes - of tobacco harm reduction • Undermine anti-smoking policy potential • Encourage young people to smoke/become nicotine addicts • Prolong smoking, delay quitting • Normalise smoking • No evidence for effectiveness • A tobacco company plot • Abstinence the best option • Instead seek professional help, use ‘proven’ therapies Similarity in ‘threat’ + ‘fear’ narratives Narrative HIV and drugs HR - Smoking and Needles and E-cigarettes syringes Undermines Undermines anti- Undermines anti- drugs policy smoking policy Gateway Encourages (young) Encourages young people to inject, use people to smoke drugs Prolongs/ Prolongs addiction Prolongs smoking increases and delays and delays quitting recovery Normalises Normalises Normalises smoking injecting, drug use Abstinence Abstinence is the Abstinence is the ambition best option best option Tobacco harm reduction, international treaties and human rights • Framework Convention on Tobacco Control 2005:Art 1d: “A range of supply, demand and harm reduction strategies that aim to improve the health of a population by Human rights, eliminating or reducing their consumption of tobacco the right to products and exposure to tobacco smoke”. • European Social Charter 1965: “Everyone has the right to health, benefit from any measures enabling them to enjoy the smoking and highest possible standard of health attainable”. Art 11 requires states to take measures to prevent disease and SNP to encourage individual responsibility in matters of health. • The EU Charter on Fundamental Rights 2000. Art 35 - a high level of human health protection shall be ensured in the definition and implementation of all the Union's policies and activities. Safer nicotine products and a new landscape of smoking cessation A success for the health of the public without help from Public Health Drivers – not Public Health but: Technology Consumers Private sector Funding – unlike most public health interventions this is zero cost to tax-payer Two problems, two public health responses Compared with HIV and drugs harm reduction, and most public health interventions, tobacco harm reduction is cheap and easy. Smokers, of their own accord are taking responsibility for their health. BUT The Spanish (and other countries!) paradox: • Supportive of harm reduction and drug law reform • Hostile to tobacco harm reduction and tobacco law reform Publication 2 Oct 2018 No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 (2018). London: Knowledge-Action-Change • END Innovation Market feedback – Intervention design good products emerges, mainly thrive unplanned Success measured Consumers by uptake (sales), promote product – switching; vaper to smoker observational not peer education RCT Strategies for health A public promotion health vision Advocate: Enable: … individuals must become empowered to control the determinants The