Among more than 100,000 people who used heroin in England, smoking accounted for 24% of premature deaths, nearly matching illegal drugs at 28%. Yet smoking remains routinely overlooked within drug treatment and harm reduction services.
Shot on location at GFN 2026 in Warsaw, Poland, David MacKintosh of the Global State of Tobacco Harm Reduction explains how integrating safer nicotine could deliver a low-cost, high-impact intervention that helps people live longer and healthier lives.
Featuring:
David Mackintosh
Director, Knowledge Action Change
Fmr. Chair of Trustees, Drug and Alcohol Services London kachange.eu
Transcription:
Smoking among people facing problems with drug use
Interview transcript · Global Forum on Nicotine (GSTHR briefing paper)
David MacKintosh (Knowledge•Action•Change / Global State of Tobacco Harm Reduction) in conversation with Brent Stafford (RegWatch)
Brent Stafford 0:00:05
David, what prompted you and GSTHR to look into this intersection between smoking and drug use?
David MacKintosh 0:00:15
It's an interesting question. Actually, in some ways it's a surprise it's taken us quite as long to get round to it as we have because most of the people who work on the project have a background in drugs and drugs policy and drugs harm reduction. So it's been something that we've been thinking of doing for a while.
It actually took us quite a while to get to the finished product. It took us a year from starting, from conception to delivery. But it was something that we've been meaning to do, and I think we're all very pleased, actually, with how it's turned out, both in terms of the process and the end product.
Brent Stafford 0:00:53
What is the global state of tobacco harm reduction?
David MacKintosh 0:00:57
Right, so this is a programme that's funded through Global Action to End Smoking, and it's the briefing papers, of which this is one, that's part of that.
Other parts of the GSTHR programme include the website which gives a global overview of the regulatory situation and what we have in terms of data on every country in the world and it also runs a series of events to promote the potential of tobacco harm reduction.
Brent Stafford 0:01:29
So what were you hoping to learn?
David MacKintosh 0:01:32
From this particular thing, well, I guess it was to engage with people who are actually working in drug services. A lot of that was done in the UK, but we had some input from other countries, including in Central Asia. We're very conscious that, you know, this is a global problem.
It's interesting actually to see how the sort of proportion of smokers and people in drug services is often replicated in many, many different regions. So what we really wanted to do is see what's happening, which sadly, unfortunately, is not a huge amount.
but we wanted to see what we could do to help encourage more drug services, more harm reduction services, to think about how they can consider smoking within the people who use their services.
Brent Stafford 0:02:24
Now, historically, has there not been some reticence amongst drug harm reduction folks?
David MacKintosh 0:02:31
There has, and I think in drug services generally, and I can go back to when I was involved as a trustee of drug services, smoking wasn't necessarily seen as one of the things that we did. Often there was far more apparent immediate problems and kick the smoking can down the road.
I can remember my moment of thinking, actually, I think we could do this, and it kind of worked in the service that I was involved with. But it's still true to say that a lot of services, they're focused on the here and now. They're focused on dealing with the client who's turned up, the person in front of them who's got a drug problem.
They're funded often just to deal with that problem. So, you know, very conscious that in some ways asking them to, but what about the smoking? It's another burden.
In a lot of cases, it's an unfinanced and under-resourced additional bit of work, but one of the things we hope this encourages is people to think that actually some of this isn't resource-intensive, it's not going to require a lot of money, and hopefully in some places it encourages agencies to go out there and find where there may be support for them to do things that might need a bit of money to help.
Brent Stafford 0:03:52
Tobacco harm reduction as a movement could benefit if the drugs harms people were out there banging on the doors of government looking for funding to add these services to what they're already doing.
David MacKintosh 0:04:04
I think it could help and I guess one of the things that's become very evident during the process to produce the briefing paper and the implementation document is that actually harm reduction is harm reduction. And, you know, this fits very well. Tobacco harm reduction does fit within the broader harm reduction agenda. You know, it's the same principles.
You know, it's very person-centred. You know, you do it with people, not to people. So it can fit in quite well like that. But as I've just said, you know, we're very conscious that a lot of services are under a lot of pressure and it is, you know, do we really want to be thinking about another problem? But yeah, point you make, the potential is massive.
Brent Stafford 0:04:53
Often it is that immediacy issue when it comes to some of the reticence because somebody's got a hard drug problem and they're on the street usually, their life is in danger now, whereas tobacco can take 20, 30 years to kill you.
David MacKintosh 0:05:11
I think that's really one of the big problems. Someone presents, you're dealing with the person in front of you. Their lifestyle is probably quite chaotic. They're possibly looking to go to court or they're known to the police. There could be immediate issues with family. There could be some very acute health issues that you're dealing with.
So it is difficult to say, yeah, but what about they're doing something that might not kill them for two decades? I think when you can get to the position, and one of the things that we evidence here, and there is good evidence from lots of pieces of research, that when you look at the long-term outcomes, that's where you get the real payoff.
We know that drug services are really good at keeping people alive. Just being in contact with a drug service, a harm reduction service, increases your likelihood of living. But if you look down the track, you know, people who are known to services, you know, unfortunately, many of these people do die prematurely.
And about a quarter of those premature deaths are smoking related, right? It's almost the same level as the number who will still be at risk from dying because of drugs.
Brent Stafford 0:06:25
Now, that's what's extraordinary. I think from this research, and correct me if I'm wrong, but the numbers were 24% due to smoking-related illnesses and 28% due to drug-related deaths.
David MacKintosh 0:06:42
So, wow, that's not far apart. No, not at all. And in certain services with certain cohorts, if you're looking at the people who have had the most severe problems, It's very evident. We're talking about people who are dying prematurely in their 40s and their 50s, often of smoking-related causes. So there is a lot there, there is a huge potential there.
I guess if I was trying to do the sales pitch, generally, not just to the hard-pressed drug worker or drug service, this is about getting the maximum return on investment. We know drug services offer a great return on investment in terms of the money spent, the outcomes, keeping people alive, helping people live longer, healthier, better lives.
If we can add smoking and reducing smoking into that mix, we really improve that outcome even more.
Brent Stafford 0:07:43
Tell us about the research, you know, was it 100,000 heroin users in the UK?
David MacKintosh 0:07:49
Yeah, so that's from the English data about people who are entering drug treatment. So we have very good evidence about rates of smoking amongst people when they come into services. It also tells us about how many of those people get support around smoking, which is not anything like as many as I'm sure any of us would like.
But we also have other research that shows many of these people are motivated to give up. If you say, would you like to give up smoking? A lot of them would go, yeah, I really would, but it's difficult. We need to encourage people to have that conversation, you know, to offer the brief advice, just to start that conversation going.
And for a lot of those people, you know, you will be able to start doing things with them. And tobacco harm reduction is, you know, it's another tool in your kit. Because, you know, we're not necessarily saying you've got to give up nicotine. If you want to, you can, great, brilliant.
But if you're really worried about that, there are these alternatives which, you know, work for a lot of people. We've got very good evidence around that the most successful tools for smoking cessation are vapes and some of the other reduced-risk products. Bringing that into this space, huge, huge potential for people.
Brent Stafford 0:09:11
Just how big of a problem is smoking amongst this population? And is it higher?
David MacKintosh 0:09:16
Obviously — yeah, it's much higher. I mean, in general, if you were talking about people in contact with drug services — and this is interesting, this is one of the things that's replicated around the world — you get typically smoking rates that are two to four times higher than national averages.
If you look at people in particular groups within that, and opiate users are the ones that we've got the good firm evidence in England on, you'll see smoking rates at 75%, 85%, 90%. In reality, there are some services where everyone using that service smokes.
You know, and if I go back to the drug service that I was involved with in East London, when I was going in there for the trustee meetings, you would see many of our clients sat on the wall outside and they'd all have a cigarette. And it was just the fact that we kind of accepted it. And I think there's a problem there because it's normal.
It's normal within the group. Smoking is the norm. And as a drug service, as a drug worker, everyone smokes. We see it every day. That kind of — you can overlook it. And as we touched on anyway, at the moment there's things that could kill them today, tomorrow, next week. They could be back in prison.
I'm working on trying to avoid all that, so to say, “Yeah, but what's their lung health going to be like in 15, 20 years?” can seem a big ask. But it can be done.
And One of the things that I know, and this is into the realms of the anecdotal, not evidential here, I know some of the people who were in contact with drug services who were helped to give up smoking, and the impact it had on them was visible. They were really proud that they'd achieved this. I've given up the fags.
You know, and, you know, there's bits in them. My kids say I smell much better when I come around. They say the flat, my apartment, smells much better. Real pride. And, you know, and you could see, you know, this was a big win for people. And, you know, again, this changes from country to country.
But in the UK, you know, if you can move someone from smoking and a lot of these people smoke quite heavily to, say, vaping, you're putting money back in their pocket at the same time. So, you know, That's real. Those are wins now.
Brent Stafford 0:11:48
Money back in the pocket, improving their health, and as importantly, improving their own sense of self-worth. Absolutely, yeah. So how could public health not get behind and support that?
David MacKintosh 0:12:02
Well, I think to be fair, some people do. And we've seen in the process that's led to this, we've had some very positive engagement from agencies delivering these services and others. I think lots of people are still very wary around tobacco harm reduction because, you know, tainted by the big, evil tobacco companies.
It's very difficult to move on from that.
We are cursed by the history of the tobacco companies' behaviours decades ago, but it's still influences attitudes and behaviours now, and this whole idea that all these reduced-risk products are, you know, but they're all invented by, it's just a big tobacco conspiracy, is, you know, many people, even if they know that's not quite true, why do they want to get involved in a subject where they might get a lot of flack from people.
Like, oh, you shouldn't be involved with that. It's a very simple position to be in. We don't want to have anything to do with this and people should just give up. But there is a conflict there. I mean, I have colleagues, friends who would have, No problem at all championing drug harm reduction.
They would be very happy to stand up and say needle exchanges are a vital part of any sensible public health approach. Of course we should provide methadone and other opiate substitutes. Great benefit to individuals and communities. And then they would feel very uncomfortable saying, and vapes are a valuable public health tool.
A lot of people would feel uncomfortable doing that. And it is partly because, you know, it isn't coming from the medical health establishment.
Brent Stafford 0:13:52
It's interesting because, you know, for those in the medical health establishment and public health that have come around to drugs harm reduction in the last, say, 20 years, and many have, I mean, you know, many governments in Canada, for instance, very supportive of all of those efforts.
And they often talk about how that we must respect the autonomy and dignity of the drug user because you know, that's the way to support them. Yet they don't accept the autonomy or dignity of a smoker who's trying to save their own life using safer nicotine.
David MacKintosh 0:14:29
I think the smokers do seem to be one of the last groups which can be treated in a way that we, you know, just wouldn't accept with any other group. I can't think of an equivalent now, but you are right. And you can see this in the failure to engage with smokers or even representatives of groups that use safer tobacco products. It's remarkable to me.
Because you are talking about the same people. You could be talking, when I am talking about David and his opiate or his crack cocaine problem, I will be conscious of my language. I will not want to be stigmatising. I will want to hear. I would really appreciate his involvement when I'm considering my service design.
you're not going to see a lot of that around smoking services or tobacco harm reduction yet. But I think, you know, we need smokers and, you know, this is a reminder, do not live in isolation. You know, many of them will have other health challenges or have other issues going on.
And, you know, we need to apply what we know works in other areas to this area as well.
Brent Stafford 0:15:52
All of this over nicotine, that's a shocking position to be in, considering of course, in your experience, dealing with people who are addicted to much more unhealthy drugs.
David MacKintosh 0:16:05
I think nicotine, it does have its own sort of, it triggers its own responses amongst professionals. I think when we look at smoking, you know, I think one of the things that actually that while people can say, you know, true, you know, 50 plus percent of people who smoke regularly are going to die prematurely because of their smoking.
So actually, you know, it's how you consume your nicotine dictates the danger. And that's really high. I mean, you know, 50% of heroin users do not die from heroin. You know, so at that level, smoking nicotine is, you know, And yet we haven't really deployed the full range, the full arsenal of public health responses.
We seem to have got stuck somewhere around banning stuff and taxing it. And moving into things that engage more effectively with the people who are using the substance is really quite woefully underdeveloped when it comes to nicotine.
Brent Stafford 0:17:09
So when I look at the downtown Eastside in Vancouver, right in my hometown, that doesn't seem to get smaller. The problem keeps growing. And so I often wonder, you know, where are those new younger people coming in?
And how come public health isn't, you know, got their hair on fire over the youth that are vulnerable to moving into crack, fentanyl, heroin, and all of the other drugs that are on the downtown east side of Vancouver, they don't seem worried about another generation of young people becoming addicted to hard drugs.
David MacKintosh 0:17:48
I don't know enough about the Canadian situation to really comment. I mean, you do have a bigger problem in North America with the fentanyls and such than we do so far in the UK. But I think there is a danger that people end up accepting a level of problem And it's because it becomes a norm.
We've been speaking about, you know, the norm is, you know, this happens and it can get this happens in this locality. I think there are real challenges there because people do just accept it. And, you know, that's something I can see in perhaps all being guilty of professionally. That area has that problem. And, you know, maybe try to keep a lid on it.
But realistically, what can we do? So I think sometimes, There may be a lack of ambition. I do think around smoking, actually, in terms of practical terms, there's often a real lack of ambition. People are very good with the abstract ideas, we will end smoking and we'll set some notional target. What are you doing to effectively stop smoking in the 2020s?
Not talking about what it will be in 2045 or 2050. What are you going to do this year, next year, the next decade?
Brent Stafford 0:19:11
Now is the time that we advance the conversation to not just be about those that are smoking and getting them to switch — although that, obviously, is clearly the focus — but as every day and year goes by, millions more people have switched from smoking to using safer nicotine products, vaping, pouches, and so forth, it seems that they become forgotten.
Restrictions, flavour bans, all these things, they don't have the same impact on a smoker who's still smoking. They have a disastrous impact on those who have already switched.
David MacKintosh 0:19:49
Yes. Harm reduction often lacks champions, generally. I mean, there have been the odd occasional politician who's championed harm reduction, but in general, not.
What I think we're seeing here now is a strange reluctance politically in the UK, and it would be shared across the parties, actually, to say, actually, haven't we achieved a big win on the smoking? No one's taking any credit for the role that safer products have played in reducing the number of smokers.
I also think it's a great shame that not more effort's been put into monitoring people who have switched in terms of having more data. There's some about What does their health look like? So instead of having good data, we have repeat scare stories that nearly always get debunked about, you know, my lungs collapsed or whatever.
It wasn't because of vaping, was it? We see that. So there is a reluctance, a shame there. And it's a great loss in terms of people saying, this has worked. We should have a few people up on the rooftop saying, actually, some of this has gone really well. And that would have a wonderful effect to encourage other people to take it on.
I mean, you know, we have some quiet sort of tobacco harm reduction champions. We have some quiet harm reduction champions politically. I've worked with some. You don't tend to get many people who go, you know, those needle exchanges were great. Why is it that the countries that introduced needle exchange in the 80s and 90s, they have the lowest HIV rates?
It's not magic. It's not a coincidence. But people are still often reluctant at a political level to lay claim to some of that. And the UK... Almost accidentally finds itself, in some ways, one of the leaders in tobacco harm reduction. But you don't get many people going, “Oh, we did well, there was an inspired policy decision.”
Brent Stafford 0:22:11
You know, when you look at the Global Forum on Nicotine, how does it help play a role in this effort?
David MacKintosh 0:22:18
I, I think GFN still plays a unique role, really, in bringing people together to kick around some of the ideas. And, you know, they've asked some sort of more public-health, more academic-focused meetings, but this is one.
And one of the unique things about GFN has always been there's a lot of people here who are consumers of these products, who are often — a lot of professionals — they would say, when they're vapers, you could look at them: these are people who have successfully quit smoking. You know, there's a lack of championing of these.
An analogy with the drugs world, you know, not always well, but we've often, you know, recognised the value of having people who've come through a programme successfully, championing that to others, to their peers or former peers. You know, look, you can turn your life around, you can live a healthier life. We've kind of ignored a lot of that.
We've had pockets of individuals who have done it around vaping and similar, but you know, again, we should be, you know, these people should be put in a position that say, this is what works for me. And you know, we are seeing, not just in the UK, lots of countries, you're seeing dramatic drops in smoking. and an increased use of safer products.
And some people will wring their hands and think that's a disaster. And you kind of think, but actually it's a real public health gain.