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CHAPTER 7The right to health and the people left behind

Chapter 7

The right to health
and the people left behind

The notion of non-smokers’ right to health – especially bystanders and children – underpinned much of tobacco control developments through the 1980s and 1990s. Those involved in the campaigns, especially in the US, saw themselves as warriors battling the economic and political interests of tobacco companies. Backed by the evidence of the damage caused by smoking and the increasing efforts to ban public smoking, campaigners seized the moral high ground as smokers became the new social pariahs.

But the tables have turned; those whose rights need protecting now are those who want to switch away from smoking and towards the use of safer products. Sabotaging these rights are many of the same individuals and organisations (along with new actors) who heavily influenced national and international tobacco control policies leading up to the FCTC. And like the tobacco companies, the anti-THR lobby has vested financial and political interests in maintaining the tobacco control status quo. There is funding from anti-THR bodies like Bloomberg Philanthropies (BP) who have power and influence around the policy table, coupled with the economic interests of Big Pharma and some domestic tobacco industries both lobbying to legislate SNP out of existence.

The fundamental purpose of tobacco control – to reduce the harm from smoking – seems lost in a miasma of competing interests inimical to the human rights aspects of public health.

Man with a cigarette in his hand
Image: Hosein Emrani on Unsplash

The fundamental purpose of tobacco control – to reduce the harm from smoking – now seems lost in a miasma of competing interests inimical to the human rights aspects of public health. Yet there is a clutch of international treaties cementing universal health for all as a fundamental human right. The FCTC in its own words declares its commitment to these fundamental rights in:

“Recalling Article 12 of the International Covenant on Economic, Social and Cultural Rights, adopted by the United Nations General Assembly on 16 December 1966, which states that it is the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,

"Recalling also the preamble to the Constitution of the World Health Organization,which states that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition,

“Recalling that the Convention on the Elimination of All Forms of Discrimination against Women, adopted by the United Nations General Assembly on 18 December 1979, provides that States Parties to that Convention shall take appropriate measures to eliminate discrimination against women in the field of health care.

“Recalling further that the Convention on the Rights of the Child, adopted by the United Nations General Assembly on 20 November 1989, provides that States Parties to that Convention recognize the right of the child to the enjoyment of the highest attainable standard of health.”

Those whose rights need protecting are those who want to switch away from smoking towards the use of safer products.

Although undefined, Article 1 of the FCTC specifically states that tobacco control means “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” [emphasis added]. There was also a commitment to “promote measures of tobacco control based on current and relevant scientific, technical and economic considerations”.

International trade law and policy expert Marina Foltea writes:

“The fact that health is recognised as a right under international law demonstrates that public health is of the utmost importance for most nations. It amounts to a universal recognition that the protection of human health is a responsibility that must be undertaken by all States.”

She goes on to say that “States are obliged to abstain from illegitimate interference with the rights of individuals to protect their own health”, rather they have “to take deliberate and active steps towards the full realization of human rights”.245

By making it difficult, if not impossible, for current smokers to access SNP, governments are illegitimately interfering with an individual’s right to health. The WHO is colluding in this by not clearly defining what it means by ‘harm reduction’ in the FCTC, and by narrowly defining human rights as the right to be protected from the tobacco industry.

This absence of a properly-defined and implemented harm reduction ‘pillar’ in the FCTC to sit alongside the three established pillars to prevent initiation, promote cessation and protect from environmental impact was criticised by Meier and Shelley as far back as 2006.

In the light of the fact that many nations were failing to deliver on what the authors call the first three pillars of the FCTC, they wrote in a period before the global take-up of SNP that:

“unlike cessation efforts, nations need not do anything to introduce a harm reduction strategy; private corporations already are developing and marketing… products without government encouragement…Countries can work together within WHO to address issues of tobacco harm reduction, aiding each other in disseminating these results of basic science and translating these results into novel behavioural treatments, pharmacological regimes and tobacco products”.246

By making it difficult if not impossible for current smokers to access SNP, governments are illegitimately interfering with an individual’s right to health.

THR offers a global opportunity for one of the most dramatic public health innovations ever to tackle non-communicable disease and at minimal cost to governments. In a time of COVID-19 when global health and public finance systems are stretched to breaking point and may not recover for some time, the imperative to drive forward with THR has never been more urgent.

Old man walking in the road
Image: Akhila KATURI on Unsplash

THR offers a global opportunity for one of the most dramatic public health innovations ever to tackle noncommunicable disease and at minimal cost to governments.

In this report, we also ‘recall’ the 1986 Ottawa Charter on Health Promotion which categorically stated:

“Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources…People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health.”

Regarding the death and disease toll from smoking (among many other health issues), there seems little evidence of ‘equity in health’ for a very broad spectrum of the global population including specific groups who are demonstrably ‘left behind’.

THR and the people left behind

All smokers can benefit from switching away from using combustible tobacco products. But some groups are especially vulnerable to the consequential risks of smoking because smoking levels in these groups are higher than the wider population. These comprise groups we call ‘the left behind’.

At a global level, the ‘left behind’ include those living in social and economic poverty and deprivation. Most of the world’s smokers live in the poorest countries where there is little or no access to SNP as the products are not available at prices that the poorest can afford. Even in higher income countries, compared with the price of cigarettes, SNP are generally only available to those with sufficient disposable incomes, located largely within middle class communities.

‘The left behind’ are those especially vulnerable to the risks of smoking and least able to access SNP.

One area of concern which appears completely ignored in this debate is the economic impact of smoking deaths and disease on families in the poorest countries. These countries house the world’s largest populations of smokers, who are invariably men. It is men who are typically the main breadwinners while women remain at home looking after the family and household. Should the breadwinner be lost to smoking-related disease, the situation for women, already in a precarious economic situation can only worsen.

More specifically, the left behind can be identified as those living in marginalised and stigmatised groups like the LGBTQ+ and minority ethnic communities; those suffering mental health problems, homelessness, drug and alcohol problems; and those who are incarcerated. And these are not discrete issues; for millions of individuals, life is a daily struggle against intersecting discrimination and stigma. Individuals in these communities and social groupings suffer disproportionate levels of physical and mental ill-health compared to the general population looking for ways to cope with stress and anxiety and as a vector for socialising and communication. Smoking helps fulfil these psychological and social needs.

As Dr Marewa Glover and colleagues recently commented:

“The WHO target [of reducing global tobacco use] is unintentionally, but effectively, misdirecting the sector from focusing on how to reduce the incidence of smokingrelated diseases, which is the real goal. The dictum to focus on reducing global tobacco use encourages a utilitarian focus on achieving behaviour change among as many people as possible for the least cost, regardless of unexpected negative consequences for the few. The least costly interventions are laws, regulations, taxes and mass media campaigns – blunt instruments applied state-wide or nationally. In this strategy, effectiveness is measured at a population level, using averages that erase outliers, such as disproportionately high smoking prevalence among subgroups. The policies are assessed for their potential to benefit the many, that is the most populous group, and this is usually the politically dominant group. …Policies and laws designed to benefit the politically dominant group, inevitably leave aside the effects on minorities”.247

In an editorial in The American Journal of Public Health, Daniel Giovenco commented that:

“harm reduction approaches…have the potential to accelerate the smoking ‘endgame’ and reduce inequalities more rapidly and effectively than traditional control initiatives…Without radical changes in our approach to tobacco control, unacceptable disparities in smoking-related disease and death may persist for decades”.248

Separating out the diversity of left behind and vulnerable groups is somewhat artificial because they share many common problems. But for the purposes of illustration in this report, we draw attention to four groups; indigenous communities; LGBTQ+ communities; prisoners and those suffering mental illness, a substance use problem or are homeless.

“Without radical changes in our approach to tobacco control, unacceptable disparities in smoking-related disease and death may persist for decades.”

Indigenous populations249

Indigenous or first nation people live in over 90 countries, numbering around 370 million, making up 5 per cent of the global population. Largely due to the multiple negative social, racial, political and economic impacts of colonisation over centuries, they account for about 15 per cent of the global poor.

One consequence of being left behind outside of the political mainstream is the paucity of data about many aspects of indigenous life, including smoking. But such data as exists indicates high prevalence of smoking among indigenous peoples. So, 83 per cent of Yolŋu men in remote Arnhem Land communities in Australia smoke. In Russia, there are 47 different recognised groups with much variation in smoking rates, the highest possibly among Nenets men at 74 per cent, living in the northern Arctic region.

Many of these populations living in North America, Oceania, and Pacific regions have long-standing tobacco-using traditions with social and cultural landscapes very different from those observed in non-indigenous communities. For example, in New Zealand, smoking rates among Māori women are much higher than non-Māori women.

In 2019, Dr Glover made a submission to the Danish government concerning the Kalaalit Nunatt people of Danish-administered Greenland pointing to all the diverse ways in which colonisation has impacted on the health and wellbeing of the people (compared to other Nordic countries) and how one-size-fits-all Nordic tobacco control policies are potentially damaging to this population. Smoking rates are very high; similar to smoking among Māori people, more women smoke (57 per cent) than men (43 per cent). Lung cancer is the most prevalent form of cancer in the country while 35 per cent of pregnant women smoke.

In light of the high rates of smoking-related diseases suffered by the people, Dr Glover outlined all the key arguments in favour of THR, referencing the dramatic fall in cigarette sales in Norway and Sweden where snus is allowed and the more liberal approach to vaping control in Iceland.

Dr Glover cites much criticism of tobacco prevention measures which fail to take account of the varieties of traditions which exist among indigenous populations despite one of the principles of the FCTC being “the need to take measures to promote the participation of indigenous individuals and communities in the development, implementation and evaluation of tobacco control programmes that are socially and culturally appropriate to their needs and perspectives” (Article 4.2c ). In reality, there has been little or no progress globally. Not surprisingly, attempts to superimpose dominant template mainstream interventions have little or no impact.

That said, there are some encouraging green shoots around THR. The Sami people from northern Scandinavia and Finland have been making the transition from smoking to snus. In New Zealand, one of the few countries to adopt a more pragmatic and proportionate legal response to THR, Māoris have opened vape shops. As part of the process of encouraging Māori smokers to switch, a small programme called Vape2Save has been running for years and is currently being evaluated.250

Three vaping devices
Image: Olivier Le MOAL on Adobe Stock

LGBTQ+ communities

In western countries, smoking rates among LGBTQ+ communities have often been reported at twice that of the heterosexual population. Common to all groups under this heading are the daily stresses and strains of being subjected to discrimination and even violence due to gender and sexual identity differences. Not surprising then, that these groups suffer high rates of anxiety, depression and suicide accompanied by high levels of smoking, drinking and drug use. There were some additional factors favouring smoking; in gay men for example, fear of weight gain has been cited.251

LGBTQ+ flags
Image: Tristan BILLET on Unsplash

The literature is very sparse on levels of SNP among LGBTQ+ communities252,253 although one US study suggested that levels of ever-vaping tended to match that of younger people in the general population.254 Equally sparse are studies relating to smoking cessation interventions. Where community members have been surveyed, the general view seems to be that, given the diversities within the LGBTQ+ community, quite specific culturally-appropriate interventions are required.255,256 Where some cessation interventions have been studied, the primary tools have been counselling, NRT and medications.257 It does not appear that any studies have been published comparing cessation intervention which include SNP.

Prisoners

Prison
Image: Tomasz ZAJDA on Adobe Stock

Smoking is an entrenched part of prison culture, not least because tobacco itself is a currency in many prisons. Coming largely from economically and socially disadvantaged communities, most of those subject to jail time are already smokers. Studies from different countries put smoking levels at up to 80 per cent.258

Smoking helps prisoners deal with the manifest stresses of incarceration: boredom, isolation from family as well as the constant risk of violence and intimidation.259

Prison is a difficult environment in which to conduct smoking cessation sessions, but surveys have shown that many prisoners want to feel they have achieved something inside and stopping smoking can be quite high on the list.

Since 2018, UK prisons have become smoke-free, but at the same time the potential benefit of allowing vaping was recognised. Ahead of the ban in Scotland, free tamperresistant vaping kits were handed out where vaping itself had previously been banned. Pilot projects involving SNP were rolled out in England and Wales from 2015. As a recent ASH UK briefing reports:

“Initially only disposable e-cigarettes were available but after trials, rechargeable devices were introduced. In addition, an advance purchase scheme was introduced for prisoners with insufficient funds to purchase e-cigarettes to reduce debt and other associated problems. The provision of e-cigarettes is considered by HM Prison Service to be a game-changer in helping facilitate a successful transition to prisons being smoke free. Prior to the project starting, around 50,000 prisoners were buying tobacco, as of July 2018, prison shops were selling over 65,000 vaping products weekly to over 30,000 prisoners and sales have continued to increase since then”.260

In the US, there are vape companies with contracts to supply modified vaping devices throughout the prison system, a trend which started as early as 2014.261 Prison officials have said that allowing vaping has reduced the amount of cigarettes and tobacco being smuggled in following smoking bans and consequently reduced levels of violence.

Prison officials have said that allowing vaping has reduced the amount of cigarettes and tobacco being smuggled in following smoking bans and consequently reduced levels of violence.

THR for people with mental health issues

In the UK, 40-80 per cent of people with a mental health condition smoke and they consume 42 per cent of all tobacco, smoking more heavily and frequently. While smoking prevalence among UK adults has dropped to around 15 per cent, smoking rates among those with mental health problems have remained stubbornly unchanged for around 20-30 years.262

In one meta-analysis across 20 countries, those with a diagnosis of schizophrenia had an average smoking prevalence of 62 per cent while a study of US veterans with PTSD had a smoking prevalence nearly double that of veterans without PTSD.263

It is hard for people with a diagnosis of mental illness to break the smoking habit – there is a fear of change and a low motivation to quit amid competing and more immediate priorities. Cigarettes perform useful functions in daily life; dealing with boredom; regulation of emotions; development of routines around smoking; and opportunities for socialisation by sharing cigarettes similar to office workers gathering around the coffee machine or water cooler. But these benefits come at a price.

Smoking is the primary cause of the 15-25 years mortality gap between users of mental health services and the general population. Bearing in mind that the highest levels of smoking correlate with the most deprived areas in the UK (and elsewhere), data on health inequalities similarly reveals that rates of chronic obstructive pulmonary disease (COPD) and asthma are significantly higher in those most deprived regions. Respiratory and cardiovascular death rates for those under 75 with a diagnosis of severe mental illness are 4.7 and 3.3 times higher per 100,000 people than the general population respectively.264,265,266

Smoking is the primary cause of the 15-25 years mortality gap between users of mental health services and the general population.

English health authorities have taken a progressive view on allowing vaping in mental health settings. Encouraged by the guidance on THR provided by Public Health England and the NHS, vaping is being studied and trialled in smoking cessation interventions with mental health service users. In a survey of NHS mental health trusts conducted in 2019 by ASH, 91 per cent allowed the use of vaping devices alongside other cessation interventions, mainly NRT.267

One Italian pilot study involved 40 outpatients with a diagnosis of schizophrenia spectrum disorders (who were not motivated to quit smoking) and using high nicotine content JUUL. After 12 weeks 40 per cent were determined to stop smoking and 52 per cent were determined to cut down. Across the board there were improvements in blood pressure, heart rate and exhaled carbon monoxide. Encouragingly, no significant side effects and negative changes in symptoms of schizophrenia were experienced.268

South London and Maudsley NHS Foundation Trust (SLAM) in England provides both mental health and substance use services. Despite going totally smoke free from October 2014, the Trust has allowed vaping across the whole organisation, going a step further in February 2017 from allowing only disposal devices to widening the type of devices used subject to individual risk assessment. Patients can vape in single bedrooms and anywhere outdoors in the hospital grounds.

THR for people with substance use issues

There is also a high level of smoking among those with substance use problems which can exacerbate drug-related health issues. Services around the world report in excess of 85-90 per cent of those attending for treatment also smoking tobacco.

In recent years, drug-related deaths in the UK have been rising, particularly among older, long-term users also suffering from smoking-related diseases such as COPD which generally ranks high in the list of co-morbidities for those addicted to opiates. In a cohort study of 845 users in residential substance use treatment in the USA, around a quarter died during the course of the study, with smoking-related causes outstripping those related to drugs and alcohol.269

Treatment staff are often reluctant to engage clients in discussions about smoking, not least because a high percentage of staff are also smoking but also because they feel that dealing with alcohol or drug problems is enough for the person to cope with. Clients can be left with the feeling that either the drug worker didn’t think smoking was much of a problem or had no confidence in the client’s motivation or ability to change. But often users are well aware of the risks of smoking and are often keen to quit, but like the general population of smokers do not find traditional cessation interventions that useful.

SLAM in London have also been engaging with drug treatment clients using a range of vaping devices. Client feedback was encouraging; after the second session, 77 per cent reported that the devices were easy to refill and charge and nearly half rated the experience, ranging from “a little” to “much more satisfying than smoking”. Reported feedback included:

“I’m so grateful that I’ve been given this opportunity…it’s saved my life.”

“This was the last thing to go. I’ve kicked everything else.”270

In a cohort study of 845 users in residential substance use treatment in the USA, around a quarter died, with smoking-related causes outstripping those related to drugs and alcohol.

THR for people experiencing homelessness

The health fall-out from smoking is no less a problem for homeless people for whom the cigarette provides the whole panoply of benefits including emotional calming, relief from boredom and socialising aspects.271,272 However, the desire to quit smoking seems no less for homeless people than for other disadvantaged groups, but of course their homeless status makes it even more difficult for cessation services to intervene.

In Ireland, the Waterford Institute of Technology ran a small three month SNP-based intervention with homeless people who were accessing services. The researchers faced a number of challenges over the four-week period of the study, including that several participants were simply too ill to attend. But many of those who attended had never tried to quit before; some reduced smoking by more than 50% and as one participant remarked, “It’s really helped me financially. It’s helped my health. I can breathe better”.273

***

While there are millions of smokers in the poorest countries who are unable to access SNP, there are substantial numbers of others in all parts of the world struggling with marginalisation and discrimination because of ethnicity, gender and gender identification, mental health and substance use problems in the community, on the streets or in prison. For all these reasons which often combine and overlap, smoking prevalence is substantially higher than in the general population. They would clearly benefit from using SNP but are denied access through an increasingly prohibitionist environment which shows little compassion for those most in need. This is exacerbated by the lack of affordable products.

Yet, there are ways of moving forward where THR can become part of the stated WHO drive to tackle the smoking epidemic. But it demands THR being regarded as an opportunity rather than a threat and an end to anti-nicotine theology masquerading as public health. In the final chapter we suggest what those ways forward might be.

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  2. Meier, B. M., & Shelley, D. (2006). The Fourth Pillar of the Framework Convention on Tobacco Control: Harm Reduction and the International Human Right to Health. Public Health Reports, 121(5), 494–500. P. 494-500.
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  4. Giovenco, D. P. (2019). Different Smokes for Different Folks? E-Cigarettes and Tobacco Disparities. American Journal of Public Health, 109(9), 1162–1163. https://doi.org/10.2105/AJPH.2019.305250, p. 1162-63. This author was also the lead author of a study which looked at sales of combustible tobacco products and SNP in socio-demographically diverse part of New York City. The authors concluded, “The marketing of inexpensive, combusted tobacco products disproportionately saturates low-income, minority communities, while potentially lower risk, non-combusted products are more accessible in largely White and higher income neighbourhoods. This pattern may exacerbate tobacco-related inequities. Public health policies should prioritize reducing the appeal and affordability of the most harmful tobacco products to help reduce health disparities”. Giovenco, D. P. et al. (2019). Neighborhood Differences in Alternative Tobacco Product Availability and Advertising in New York City: Implications for Health Disparities. Nicotine & Tobacco Research, 21(7), 896–902. https://doi. org/10.1093/ntr/nty244
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  17. Walters, E. (2014, July 19). Texas Sheriffs Mull Selling E-Cigarettes to Inmates. The New York Times. https://www.nytimes. com/2014/07/20/us/texas-sheriffs-mull-selling-e-cigarettes-to-inmates.html;
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  21. Likelihood of smoking four times higher in England’s most deprived areas than least deprived. (2018, March 14). Office for National Statistics. https://www.ons.gov.uk/ peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/articles/ likelihoodofsmokingfourtimeshigherinenglandsmostdeprivedareasthanleastdeprived/2018-03-14
  22. Health profile for England: 2018. (2018, September 11). Public Health England. https://www.gov.uk/government/ publications/health-profile-for-england-2018/chapter-2-trends-in-mortality#premature-mortality-among-people-withserious- mental-illness-smi
  23. Progress towards smokefree mental health services. (2019, October 29). Action on Smoking and Health. https://ash.org. uk/information-and-resources/reports-submissions/reports/progress-towards-smokefree-mental-health-services/
  24. Pasquale, C. (2019, June 14). Role of a new generation e-cigarette on smoking displacement in smokers with schizophrenia spectrum disorders (SSD): a single arm pilot study. Global Forum on Nicotine, Warsaw. https://gfn.net.co/ downloads/2019/presentations/Pasquale_Caponnetto.pdf
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  28. Matthews, C. (2019, March 5). Smoking and the Homeless: There is Hope. Vaping Daily. https://vapingdaily.com/support/ homeless-community/
  29. Scheibein, F. (2019, June 14). A 3-month ENDS-based intervention with people accessing Irish homeless services: efficacy, challenges and opportunities. Global Forum on Nicotine, Warsaw. https://gfn.net.co/downloads/2019/ presentations/Florian_Scheibein.pdf