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Harm Reduction in the U.S. – A Sea Change is Underway

By: John de Miranda

Def. Sea change or sea-change is an English idiomatic expression which denotes a substantial change in perspective, especially one which affects a group or society at large, on a particular issue.

Some time ago I wrote an opinion piece titled: Dirty Words: Smoker, Vaper, Harm Reductionist? In the article I expressed my frustration that in government and NGO leadership circles publicly embracing harm reduction policy in the U.S. was still politically dangerous. Unfortunately, demonization of smokers, vapers or clean needle exchange programs is more likely to resonate with the public than nuanced discussions of proportional risk or the benefits of tobacco harm reduction strategies.

But, as they say, elections have consequences and the Biden administration has sent an unmistakable signal that harm reduction policy will be a priority. According to statute, during the start of a new administration the President’s drug policy priorities must be submitted to the U.S. Congress. Priority 3 of 7 reads: enhancing evidence-based harm reduction efforts. Supporting research on the effectiveness of “emerging harm reduction practices in real world settings” and a priority of advancing racial equity indicate a sea change is underway. As a 45-year observer and advocate I cannot remember the term harm reduction appearing in any official pronouncements from senior governmental leadership within the substance use disorder sector.

As an example of putting your money where your mouth is, it may not be coincidental that in March the U.S. Centers for Disease Control and Prevention announced grants totaling $750,000 to 16 explicitly harm reduction-oriented organizations.

In the U.S. we have Big Tobacco, Big Pharma and what I term Big Tobacco Control which demands that the only way to approach the problem of cigarette smoking is through cessation ideology. Taking a page from the total abstinence philosophy of our failed drug war, any mention of tobacco harm reduction is a non-starter. Another sea change may be on the horizon with tobacco harm reduction.

Kevin McGirr is an Associate Professor of Nursing at the University of California San Francisco. With a grant from the Foundation for a Smoke Free World he is investigating how persons with behavioral health challenges can benefit from tobacco Harm reduction strategies.

At the risk of sounding pollyannaish, this policy shift could be the great leap forward. Ideas such as “disease model, loss of control and abstinence only” are being pushed aside for a broader understanding of what contributes to substance use, as well as how people make changes in their use. More recent understandings situate health behaviors in a structural and social context. The behavioral health field is just beginning to learn and accommodate to what health consumers want and find helpful. We are seeing this across many substances including tobacco use with the increasing popularity of safer forms of inhaled nicotine products.

Preceding the change of administrations, a shift was also occurring at the U.S. Food and Drug Administration regarding tobacco harm reduction strategies. This involved the recognition that some products which reduced risks should be available to the public. From the federal Tobacco Control Act definition:

The term 'modified risk tobacco product' means any tobacco product that is sold or distributed for use to reduce harm or the risk of tobacco-related disease associated with commercially marketed tobacco products.

The first iteration of this policy change involved eight Swedish Match USA Inc. snus smokeless tobacco products sold under the “General” brand name. The action authorized the manufacturer to market these specific products with the claim “Using General Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.”

Subsequent authorizations of modified risk reduced exposure claims have been granted to Philip Morris for the IQOS system and allows the claim:

Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.

Tom Horvath Ph.D. is a clinical psychologist and a founder of SMART Recovery. A long-time advocate for harm reduction approaches his service Practical Recovery is in San Diego, California.

In the US addictive problems have often been approached from an all-or-none perspective: You are in recovery or not, you are an addict/alcoholic or not. Tobacco has not escaped this perspective, until now. If these new harm reduction policies are well carried forward by congruent regulations, a massive change is underway. With luck these kinds of changes will permeate the entire field of addictive problems. Might the US someday be among the world's leaders in resolving addictive problems, rather than in having them?

In the Biden administration harm reduction is no longer a dirty word. Instead, by embracing and promoting harm reduction as a policy priority the Biden Administration has taken decisive action to support harm reduction tools and approaches that will improve the health of U.S. citizens.

John de Miranda is a Knowledge-Action-Change Tobacco Harm Reduction Scholarship recipient. He is currently developing a THR toolkit for treatment programs and persons with substance use disorder. More information about his work is available at His e-mail address is

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