So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem. 

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it. But inconsistency is rarely greater than in the spying-out of other people’s economic interests. Motes and beams come to mind.

Let me illustrate this point by a letter from a consultant paediatrician in the same edition of the BMJ. The letter is entitled ‘What hope is there for ethical investment?,’ and draws the attention of readers to the investments of the Wesleyan Life insurance company, which specialises (inter alia) in pension funds of doctors, and claims also to be an ethical investor. But the Wesleyan holds large quantities of shares in tobacco companies. The author of the letter pointed out that tobacco companies were among the top 10 holdings of the Wesleyan’s fund and finished by asking “If investing in tobacco counts as responsible policy in a company specifically catering for doctors, what hope is there for any ethical investment?”