Smoking remains one of the world's biggest preventable killers, yet people who smoke are often denied the same harm reduction principles that have transformed responses to other public health challenges.
If reducing harm works for other risky behaviours, why is it still so controversial when it comes to smoking? The growing evidence suggests that how nicotine is consumed—not nicotine itself—plays the biggest role in determining health risks. Treating adults who smoke with dignity, respecting informed choices, and making lower-risk alternatives available could save millions of lives.
Public health should be driven by evidence, compassion, and outcomes—not stigma.
Transcription:
00:00 - 00:40
[David MacKintosh]
There is a conflict there. I have colleagues, friends, who would have no problem at all championing child 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 open 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.
00:40 - 01:16
[Brent Stafford]
It's interesting because, you know, for those in the medical health establishment and public health that have come around to drug 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 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.
01:16 - 02:34
[David MacKintosh]
I think the smokers do seem to be one of the last groups which can be treated in a way that we 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. Actually, these are somehow... And it's because you are talking about the same people. You could be talking... When I'm talking about David and his crack-up 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 to 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.
02:35 - 02:47
[Brent Stafford]
All of this over nicotine. That's a shocking position to be in, considering, of course, your experience dealing with people who are addicted to much more unhealthy drugs.
02:47 - 03:30
[David MacKintosh]
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 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 percent of users do not die from heroin. So at that level, smoking nicotine is... And yet we haven't really deployed the full range, the full arsenal of public health responses.