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We all make mistakes. These will be of varying degrees and seriousness, but all of us can look back on judgements that proved to be wrong, decisions made in error or things we would, in hindsight, have done differently. Sometimes it may be that we just didn’t understand the impact of a particular factor or event. The same also applies to organisations. Neither good intentions nor past success provides immunity. Of course, the larger and more influential an organisation, the more the consequences of mistakes are likely to be magnified. Businesses may pay for these mistakes in terms of profit, share value or even their survival. We may want to ponder the consequences when health bodies make significant errors.

Work to reduce the massive toll of death and illness caused by smoking is an important component of national and global public health strategies. The rationale driving this is simple. A 100 million premature deaths in the 20th century were due to smoking tobacco. Currently its responsible for around 7 million deaths per year. The toll in life and disease is immense. Despite some successes this figure is predicted to continue rising. As countries such as Denmark, Iceland, Norway, Paraguay, Argentina and the UK have seen significant drops in smoking rates as many parts of the developing world are seeing rates rise. The World Health Organisation suggests that in many low and middle-income countries big tobacco is able to frustrate government and health agency attempts to reduce smoking. But there are other factors to consider.

In the UK we have seen great success in seeing smoking rates drop. Those who do smoke are consuming less cigarettes. But rates of smoking are higher amongst those who earn least, and pockets of very high usage can be found within vulnerable groups, for example the homeless or those with a mental health diagnosis. It has become clear that traditional approaches; increasing taxes, restrictions on smoking, limiting advertising and public health information campaigns are starting to deliver diminishing returns. Traditional approaches appear to have run their course. Concern and focus increasingly dwell on the illicit cigarette markets, which of course, in part, being driven by the significant increases in taxation.

But over the last few years we have seen a new phenomenon emerge, vaping. This is arguably one of the greatest contributions to reducing smoking we have seen in many years and, with the honourable exceptions of Public Health England and a few far sighted individual areas and practitioners, it has occurred outside the realm of traditional tobacco control.   While there are other tobacco harm reduction products with an impressive pedigree, look at the Swedish experience of snus (and please do look this up), this is geographically limited to Scandinavia. Vaping is a global phenomenon which has unsettled the established order.

The fact tobacco companies themselves have seen the potential for these less hazardous products has allowed many to oppose these products as being just another work of the devil (and I hold no brief to defend their historic record). However, this leads to some abysmal and tragic positions. It also makes the mistake of ignoring the different aspects, views and interests of a complex range businesses and individuals. We see many countries where public health officials have worked to ban or restrict access to lower risk products, indeed somewhere those selling e-cigs risk jail, yet cigarettes remain freely available and often poorly controlled. This situation benefits traditional big tobacco, it may make some public health officials feel virtuous, it certainly ensures that there will continuing avoidable deaths and illness.

Last weekend I overheard a conversation where advocates of smoking cessation where lamenting the adversarial situation that had developed between the world of tobacco harm reduction and the tobacco control world. With the toll of smoking related disease set to increase as the century progreses, with the harms disproportionately felt within the developing world and in vulnerable communities it is surely time to embrace all approaches which offer the chance to significantly reduce harm. This should always be led by evidence, but not losing sight of the costs of delay. Public health needs to move at pace, slowing and delaying changes plays in to the hands of their opponents. It also comes at massive human cost. Millions of lives a year are surely enough of a prize to encourage some fresh thinking around nicotine?

Tuesday, July 16, 2019
Last week I met with someone who, having just completed a Masters in Epidemiology, is keen to work in the health field. Over a hot chocolate I outlined my perception of the current big issues relating to substance misuse, our most vulnerable populations and the policies and structures we have in place to address these issues.
Tuesday, July 02, 2019
Absolutely outstanding. That’s my carefully considered assessment of the Global Forum on Nicotine in Warsaw that I was fortunate enough to attend two weeks back. I say this despite the mosquito bites and the fact that the weather was rather warm for me. The event was one of those that provide a buzz and an energy that comes back to the workplace with you. This was fuelled by an outstanding array of speakers and a vibrant audience mix. Discussion and argument were not limited to the auditorium or breakout rooms, but instead could be heard throughout the venue, over lunch, during coffee breaks. There were attendees from every continent (well, ok, I didn’t actually meet anyone from Antarctica). Academics, clinicians, researchers, harm reduction advocates, retailers, product developers, policymakers, and- most importantly - vapers and users of other tobacco harm reduction products, all mixed together sharing views, experiences, and- as we should expect- differences of opinion. It certainly lived up to the conference strapline Its Time to Talk About Nicotine and the rich promise of a genuinely horizontal approach.
Monday, May 27, 2019
The value of partnership approaches and joint working to tackle major health public policy issues is widely accepted, if more rarely practised. Even where there is engagement with other professions or disciplines there is a tendency to work with those whose outlook is not too challenging and are closest to us in practice and approach. City Health has been at the forefront in challenging this and others are also working to weaken the silo walls. In the last two weeks I have been a spectator and a participant in two very different events which highlighted how important it is to include the end user, the public, our communities when developing and delivering services.
Wednesday, May 15, 2019
The confidence we have in our health systems is at the core of how we use and, hopefully benefit, from them. If we lack confidence in the benefits of going to see our GP for a health check, seeing a nurse about a travel vaccination or asking advice from the local pharmacist why would we bother? In terms of dealing with drug and alcohol problems the importance of a positive therapeutic relationship or alliance is recognised not just as being a pleasant “extra” but being central to aiding recovery. It has an important role across all fields of treatment. There are also benefits where a society has faith and confidence in those that oversee and provide healthcare systems and treatments at a population level. By and large, despite many complaints and challenges, the National Health Service in the UK remains a highly valued and trusted part of our society. And rightly so. But that doesn’t mean we should shy away from acknowledging where things have gone horribly wrong.

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CITY HEALTH INTERNATIONAL EVENTS

CHI Melbourne 2019

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CHI Liverpool 2019

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CHI Odessa 2018

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CHI Basel 2017

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CHI London 2016

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CHI Barcelona 2015

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CHI Amsterdam 2014

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CHI Glasgow 2013

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CHI London 2012

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City Health International
Founded in 2012 City Health International is a network of individuals and organisations engaged in the study of and response to structural health issues and health behaviours in the urban environment.
For the first time in history the majority of the world’s population now live in urban environments and the proportion continues to grow. As national governments struggle to deal with the pressures and demands of growing urban populations against a backdrop of financial deficits and uncertainty, it is increasingly left to those working at a city level to provide the leadership and support needed to tackle key health issues.