Giving people the lesser of two evils -- for drugs, HIV and smoking

My Times column on harm reduction

The UN General Assembly is holding a special meeting on drug policy in April, its first since 1998. The mood of member states, as well as many international agencies, is now much less focused on law enforcement and abstinence, and much more favourably disposed to treating drugs as a public health issue, to be tackled by “harm reduction”, a phrase that was actually banned from use within publications of the UN Office on Drugs and Crime ten years ago. Harm reduction means offering safer alternatives, as the lesser of two evils.

When people behave in harmful ways, how do you stop them? You can punish them in the hope of deterrence, as we do murder, theft and fraud. You can hector them, as we do with tobacco, alcohol and sugar. Or you can try to offer safer alternatives, which is how we tackled HIV infection and heroin addiction in this country in particular, and is how we should deal with tobacco.

In the mid-1980s, confronted with the start of an epidemic of Aids among heroin addicts, Margaret Thatcher’s government, with Norman Fowler in the lead, decided on a pragmatic, rather than moralistic response. They rolled out needle exchanges throughout the country, overruling those who said this condoned drug use, undermined calls for abstinence and sent the wrong message to young people. Aids among injecting drug users was, if not halted, dramatically slowed: there were just 131 new cases of HIV infection among injecting drug users in 2014. Ninety countries now have such needle and syringe exchange programmes.

Belatedly, the United States followed Britain’s example. In New York City, HIV infection rates have halved (to a still high 2,832 in 2013) since needle exchange programmes were started at around the turn of the century. This difference between the two countries goes back a long way. Following the Rolleston report of 1926, Britain adopted widespread opiate prescription, and later methadone treatment, for morphine and heroin addicts. In 1922 the Behrman case in the United States confirmed the illegality of prescribed drug treatment; by 1938 25,000 American doctors had been prosecuted and 3,000 had served prison sentences. Yet America had the bigger drug problem.

About the same time, America’s experiment with alcohol prohibition was a disaster, fuelling crime and leading to the growth of stronger (and more dangerous) spirits at the expense of beer. Drug prohibition has had the same effects. There is little doubt that if the world had followed a decriminalise-and-discourage strategy for the likes of cannabis, it would now be less lethally strong as well as less lucrative to dealers. The only thing that makes me hesitate about advocating wholesale decriminalisation of drugs today is that they are now so powerful. But even when it comes to heroin addiction, methadone or buprenorphine treatment (used in 80 countries now) has proved a success, albeit one with continuing risks and costs.

Harm reduction is now being tried for drugs and alcohol in various other ways. Probably the most controversial are safe injecting facilities for heroin users, pioneered in Vancouver and now copied in 92 places in Canada, Europe and Australia, but not America. They have been successful in reducing crime and saving lives. On the same principle, in Toronto and Ottawa homeless shelters offer hourly glasses of wine, because otherwise homeless people prefer to sleep on the streets. The result has been lower alcohol consumption among the homeless and fewer emergency department visits.

The custom of the “designated driver” and the provision of “free rides home” by some bars are examples of harm reduction. So are driver-awareness courses. So, for that matter, is sex education in schools. The encouragement of condom use, rather than sexual abstinence, to fight the HIV epidemic was another example of harm reduction in action. Again, it was resisted by some, Pope Benedict being one of the last to criticise it, saying in 2009 that Aids “cannot be overcome through the distribution of condoms, which even aggravates the problems”.

We are surrounded by policies designed not to stop us doing things, or stigmatise us, but to encourage us to do them more safely. In the case of addictions, where people find it genuinely very difficult to resist temptation, this surely makes sense.

Which is what makes the attitude of so many public health professionals to vaping so baffling. So ingrained is the view that tobacco smoking — probably the most widespread and harmful of all drug addictions — must be fought with condemnation, that many medics and public policy officials cannot stand the thought that a far less harmful way of satisfying nicotine cravings has emerged from outside the public-health realm, through a consumer product.

Britain is once again leading the way, with more people having quit smoking by taking up vaping than in other countries of the same size. Of the roughly three million vapers, nearly all are smokers or ex-smokers who have drastically reduced their intake of tar, carbon monoxide and all the other harmful constituents of smoke (nicotine is nothing like as harmful). If you value each success in stopping smoking at £74,000, as the government does, that’s tens or hundreds of billions of pounds of benefit to the British economy. All at no cost to the taxpayer.

Yet instead of encouraging vaping, the government is about to implement an idiotic clause in the European tobacco products directive, which will ban stronger e-cigs, the very ones heavy smokers start with if they quit, and burden new vaping products with extra regulation, stifling innovation. Unless very much watered down, this is certain to slow or reverse the rate at which people quit smoking, while encouraging a black market — and might also energise furious vapers to vote “leave” in the referendum.

If public health experts can see the success of exchanging dirty for clean needles in the fight against HIV and hepatitis C, why can so few of them see the benefits of exchanging dirty tobacco smoke for clean nicotine vapour?

It is true that Public Health England said last year that vaping is 95 per cent safer than smoking, but the World Health Organisation remains hostile, so potential vapers still get confused messages. Many public health officials and academics, perhaps irritated that the private sector has made such an impact without their help, seem committed to urging abstinence — an approach as impractical as it would be with sex or drugs.