Over the past thirty years Scotland, along with the rest of the UK, has adopted the policy and practice of harm reduction for people with addictions. Though controversial, the philosophy behind it is simple: people are strongly addicted, physically and psychologically, to a range of substances such as alcohol and heroin. For many, completely giving up the substance altogether is an impossible goal. Therefore, the idea is for people to reduce the harm they’re causing themselves by decreasing the amount they’re taking of the substance and adopting other measures which will make their behaviour less harmful.
Harm reduction and abstinence are not mutually exclusive. People can still strive to become drug free but take realistic, incremental steps to do so.
For example, heroin users injecting and sharing needles are encouraged to use needle exchanges where they get clean needles and reduce the risks of contracting HIV and other blood-borne viruses such as Hepatitis B or C. Once in treatment heroin users can be put onto a substitute methadone programme, come off heroin and the chaotic lifestyle that normally accompanies it as well as gradually reduce their methadone use to the point where they have stability in their lives and can consider going back to education or getting a job.
Measures such as needle exchanges don’t imply approval of taking heroin; rather that the supply of clean needles is the lesser of two evils and has immense social and public health benefits in reducing crime rates and preventing the spread of HIV and other blood-borne diseases.
Similarly with problem drinkers. Through advice, information and counselling people can be encouraged to reduce their drinking to less harmful levels and cut out the risky behaviours and cues that go along with it.
Harm reduction is pervasive in our society: indeed what are seat belts or laws against drinking and driving, but sensible instructions to reduce risk and take precautions? In all walks of life, therefore, we supply sensible advice to bridge the gap between harmful behaviour and measures to reduce that risk.
Except for one addiction: smoking.
Smoking and smokers are now utterly demonised in our society. Yes, the habit is ‘disgusting’’ and anti-social. Smoking is very addictive and the vast majority of smokers will suffer from some form of chronic, debilitating and possibly life-threatening illness.
But the same is true of people using heroin and chronic drinkers. The difference is that heroin and dependent alcohol users are treated with far greater sympathy and empathy than those dependent on tobacco. We provide needle exchanges for heroin users and wet rooms for chronic alcoholics, but, apart from smoking cessation services and helplines, for those unable or not yet able to quit (or, God forbid, actually enjoy a fag) there is bugger all for smokers except: QUIT. No spaces set aside, not the slightest compassion exhibited: just stub it out NOW!
Scotland is on a crusade to have a “smoke-free society” by 2034. A noble cause, no doubt, but as realistic as achieving a drug-free Scotland or reducing problem drinking to zero in the same time period.
Addictions are stubborn behaviours often impervious to change, no matter what the circumstances. The more you stigmatise, attempt to make unaffordable and generally drive underground an addictive habit, the more you create a hard core of determined addicts (now primarily concentrated among people living in deprived areas), who are willing to pay any price for their supply, placing them in even greater risk of harm at the hands of criminal networks punting tobacco full of impurities as there is no quality control of products in illicit markets, thus making a dangerous substance even more harmful.
That’s what you will really achieve with zealous efforts to enforce a ‘smoke-free’ Scotland, rather than the continual natural decline to a small number of people who will shift in and out of smoking over their lifetime.
And now, in the great tradition of harm reduction, we have, in the form of e-cigarettes and vaporisers, substitutes which could mitigate the most harmful effects of tobacco. Sure, the full health effects of these substitutes have yet to be revealed, but they are unlikely to be as toxic as normal tobacco.
The response from most public health authorities to e-cigarettes and vaporisers? To be virulent in condemning them as harmful as conventional tobacco potentially inhibiting the take-up of very useful harm reduction tools!
There is a zealous, puritan streak in the prevailing public health attitude to smokers. As with heroin users and drinkers we need to start treating our smokers with compassion and empathy rather than despising and shouting at them.
A little more harm reduction please and a little less lecturing and stern injunctions will be a lot more effective in reducing smoking in Scotland.