Harm reduction is the strategy of reducing the harms associated with drug use, not necessarily by reducing the amount that people use but by reducing the harms associated with use. Providing syringes to people who use injectable drugs is one example. This may not reduce the amount of drugs used, but it reduces the harms associated with use. For example, people who have access to unused syringes are less likely to contract infectious diseases such as HIV and hepatitis C.

Harm reduction as a general strategy is immensely influential and widely adopted within medicine and public health. Here I want to consider a particular kind of intervention that seems to divide advocates of harm-reduction measures. This debate points to two very different ways in which "harm reduction" can be understood.

 

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Consider the use of vaping or "e-cigarettes." At the most general level, this is a technology that allows people to inhale a drug without the risks traditionally associated with inhaling that drug. For example, by vaping nicotine, one can get the effects of nicotine while avoiding the harms associated with inhaling burned tobacco leaves, including lung cancer and many other cancers and health risks. Given the definition we began with, this would appear to be a textbook example of harm reduction.

Yet, it is controversial. Some are concerned about the risks of vaping products themselves. The American Thoracic Society, for example, holds that "e-cigarettes are not ‘safe’ and the claims that e-cigarettes are a harm reduction tool remain unproven." Others are concerned by who is funding these technologies. Professor Timothy Dewhirst, for example, writes: "harm reduction, which is typically overseen by clinicians, nurse practitioners and outreach workers, represents a movement that tends to be community-based, activism-driven and concerned with human rights." On the other hand, writes Dewhirst, "the underlying goal for the tobacco industry is the maximization of sales, profit and return to shareholders, which places them at odds with serving a mandate of harm reduction."

Provider and User Perspectives

This equivocal attitude toward vaping suggests that harm reduction is not in fact as simple an idea as it can at first seem. There are, in fact, two perspectives one might take on harm-reduction approaches, which might be called the provider perspective and the user perspective. Debates about vaping can be understood in terms of a conflict between these two perspectives.

From the provider perspective, harm reduction is a matter of introducing certain interventions into the world of the addicted person that will tend, on balance, to make her better off. These interventions are held to the same standard as medical interventions generally: Their side effects are known and manageable, and their delivery is tightly controlled. From this perspective, vaping can seem unlike more familiar kinds of provider interventions, such as prescription medication.

From the user perspective, harm reduction is a matter of obtaining a certain substance without incurring associated costs. Many people, for example, have a strong preference for nicotine, but none of those people want to raise their risk of cancer. From this perspective, it is more acceptable if some unknown risks remain, provided they likely are outweighed by the known risks of tobacco. (A panel of independent experts finds that tobacco smoking is at least 20 times more harmful than nicotine vaping.) And it is a matter of relative indifference, from this perspective, who is providing the interventions.

Our attitude toward vaping will often depend, I suggest, on our perspective on harm reduction. From the provider perspective, vaping can seem like a dubious intervention, one whose proponents are often profit-motivated and whose risks are not fully enumerated. From the user perspective, however, these same considerations are far less significant. Whatever the costs of vaping, if a user's choice is between vaping and tobacco, the choice is clear. Vaping may well be a product with some associated risks, peddled by people who are attempting to maximize profits—but then so, too, are many consumer goods.

Who is right? There may be no answer to this question. In some sense, "harm reduction" is a term of art, defined in different ways by different people. The foregoing is, at best, a diagnostic of how providers and their patients tend to understand it differently, and so come to different conclusions about a measure such as vaping.

We can ask, however, how much weight we should give to these two perspectives. Often, given the influence of medicine and public health in our collective responses to addiction, it is the provider perspective that is foregrounded. This priority will seem appropriate if we think of addiction primarily as a disease. It is providers—such as physicians and public health experts—who are ultimately responsible for the treatment of disease. If addiction is a disease, it makes sense to put the provider perspective first.

Addiction as a Disability

But we should, I believe, reject this view of addiction. I have argued that we should instead understand addiction as a disability and understand "harm-reduction" measures in terms of accommodations for a disability. From this point of view, it is the user perspective that is the more appropriate one. Consider accommodations for other disabilities. Often the most popular accommodations are driven by for-profit enterprises, such as accessibility innovations driven by technology companies such as Apple and Freedom Scientific. At the same time, accommodations that are advocated by the medical community, such as cochlear implants, are received more equivocally by the disabled community. Medical input is just one source of information into a decision that is to be made by disabled people.

So it should be, I want to suggest, for addiction and harm reduction. Our decisions about harm reduction measures should defer strongly to the user perspective, or the perspective of addicted people themselves. From this perspective, the case for vaping is clear.