Europe must embrace harm reduction post-pandemic

Irish policymakers are facing quite a dilemma ahead of an April 5 decision date on what coronavirus control measures to loosen. On one hand, the population is weary after months of stringent restrictions; on the other, the public health situation in Ireland is now “far worse” than it was shortly before the country reopened for Christmas.

Encouragingly, the measures on the table—scrapping the ban on going more than 5 kilometres from home and encouraging outdoor activity—are precisely those recommended by leading medical experts. Warning that overly strict measures can actually lead to an uptick in cases as pandemic fatigue and rule defiance mount, Trinity College immunologist Luke O’Neill advocated for a harm reduction approach instead, in which blanket bans give way to guidance on how to carry out lower-risk activities as safely as possible. France seems to be moving in the same direction; in contrast to the inflexible “stay at home” message from previous lockdowns, new government messaging recommends limiting indoor activities to household members, but allows groups of up to 6 to gather outdoors, even in the hardest-hit regions.

It’s no accident that European governments are increasingly gravitating towards this approach. As one journalist recently noted, Covid-19’s most enduring public health lesson may be that harm reduction works—and that favouring the pragmatic over the idealistic, yet unrealistic, is a sound policy choice. If the coronavirus pandemic has showcased this on a global scale, decades of scientific research has established that policies centred around harm reduction—needle exchanges to curb HIV rates among drug users, for example—are more effective than prescriptive bans. European policymakers, however, have been far too slow to embrace this strategy across the board.

Europe’s fight against tobacco hampered by inflexible approach

The quintessential example is the EU’s fight against tobacco smoking, a habit which kills an estimated 700,000 people across the bloc every year. Brussels is acutely aware of the severity of the continent’s tobacco problem. In fact, the European Commission’s recently released Beating Cancer Plan takes particular aim at tobacco, which—responsible for between 15 and 20% of all European cancer cases—is the single biggest avoidable risk factor. The EU’s plan to bring about a “tobacco-free generation”, however, makes no mention of alternative products like e-cigarettes, which research have shown are an effective solution to help smokers quit or at least switch to a less harmful alternative.

Other countries around the world have adopted a harm reduction approach by integrating vaping products, which are, studies have shown, at least 95% safer than using combustible tobacco, into their plans to curb tobacco use. Canada, which is aiming for a 5% smoking rate by 2035, is exploring ways to discourage non-smokers from taking up any kind of nicotine product, while encouraging current smokers to replace cigarettes with vaping products to drastically reduce their health risks. New Zealand, which is hoping to become a “smoke-free nation” by 2025, is slated to roll out a “Vape to Quit” campaign imminently, informing smokers about the relative risks of vaping and smoking and encouraging smokers, particularly young Māori women who are disproportionately likely both to smoke and to have difficulty curbing their use of combustible tobacco, to switch to lower-risk alternatives.

Some of the countries which have incorporated vaping into their smoking cessation programmes already have concrete evidence of this strategy’s success – especially since a vast majority of smokers have experienced trouble kicking the habit and are unwilling or unable to quit. A February 2021 report from Public Health England, for example, found that vaping products were both the most popular smoking cessation product and the most successful, with higher quit rates than any other method.

It’s puzzling, then, that the EU has yet to adopt a similar approach to cut down the quarter of Europeans who smoke tobacco. Indeed, the bloc is even considering tighter rules on alternative nicotine delivery devices—banning vaping in public places, or prohibiting the flavoured liquids which studies have shown are key to convincing adult smokers to switch from combustible tobacco to e-cigarettes.

Relative risk vital information for individuals

European policymakers have long been hesitant to embrace a harm reduction approach for fear of endorsing products or behaviours that still carry health risks. This equivocation, however, carries its own public health hazards. In the case of tobacco, surveys have shown that European consumers are singularly misinformed on the relative risks of various nicotine products. In contrast with available scientific evidence, the large majority (70%) of Europeans with little to no experience with e-cigarettes believe that the devices do not help smokers quit. Even more concerningly, many Europeans are completely off base when comparing the risk profiles of e-cigarettes and combustible tobacco; one study found that a staggering 61.8% of respondents incorrectly believed that e-cigarettes were just as harmful as cigarettes, if not more so.

The coronavirus pandemic has illustrated on a global scale how dangerous this lack of understanding of relative risk can be. As early as May 2020, public health experts warned that “risk is not binary”, and that by pushing an unyielding “stay home” message, policymakers were leaving individuals without the knowledge and tools to reduce their risk if they chose not to stay home, as some inevitably would or could not due to mitigating circumstances.

Nearly a year later, governments such as those in Dublin and Paris are finally putting harm reduction at the heart of their coronavirus containment strategy—largely because they have no choice. Nearly two-thirds of French citizens are opposed to a fresh confinement, and compliance with coronavirus rules has sharply decreased since the first lockdown in spring 2020. It’s a similar story in Ireland, where compliance has dropped across the board and social visits to other households have doubled over the course of the current lockdown.

Unfortunately, this necessary policy shift comes after twelve months of delay during which citizens were fundamentally confused about their chances of contracting the disease and, in the absence of clear information about relative risk, often fixated on relatively ineffective measures—such as disinfecting groceries—while eschewing ones that mattered far more, like mask-wearing. Now that the pandemic has shone a global spotlight on the effectiveness of harm reduction, European policymakers should not delay further in implementing it in other key public health areas, such as the fight against tobacco use.



Image from Vaping360, Creative Commons License 2.0

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