{"id":9277,"date":"2026-02-09T14:55:19","date_gmt":"2026-02-09T13:55:19","guid":{"rendered":"https:\/\/snusforumet.se\/?p=9277"},"modified":"2026-02-09T14:59:22","modified_gmt":"2026-02-09T13:59:22","slug":"mark-tyndall-the-harm-reduction-doctor-who-took-on-tobaccos-last-taboo","status":"publish","type":"post","link":"https:\/\/snusforumet.se\/en\/mark-tyndall-the-harm-reduction-doctor-who-took-on-tobaccos-last-taboo\/","title":{"rendered":"Mark Tyndall: The harm reduction doctor who took on tobacco\u2019s last taboo"},"content":{"rendered":"\n

In this instalment of our Harm Reduction Heroes series, Snusforumet talks to Mark Tyndall, the Canadian infectious-disease physician who helped pioneer pragmatic responses to HIV and overdoses \u2013 and who now argues that the world\u2019s refusal to embrace safer nicotine is a public-health failure hiding in plain sight.<\/strong><\/p>\n\n\n\n

In public health, it\u2019s easy to forget the people who are already inside the burning building.<\/p>\n\n\n\n

That, Mark Tyndall believes, is the mistake tobacco control has made. For decades, he watched harm reduction save lives by meeting people where they actually were \u2013 sex workers who couldn\u2019t negotiate abstinence, drug users exposed to HIV, opioid users facing fentanyl poisoning. In those settings, the goal was never to moralise over \u201cbad choices.\u201d It was to prevent avoidable deaths.<\/p>\n\n\n\n

So when Tyndall began advocating for safer nicotine, he assumed the logic would translate. Cigarettes kill. Smoke-free alternatives are vastly less harmful. Give smokers something that helps them step down the risk ladder.<\/p>\n\n\n\n

Instead, he ran into an old enemy wearing a new uniform: moral certainty.<\/p>\n\n\n\n

\u201cI couldn\u2019t believe it,\u201d Mark Tyndall says of the early pushback he got when he started talking publicly about vaping.<\/p>\n\n\n\n

\u201cIt\u2019s still just so simple in my mind that people are dying of this and we have something else to offer them. Not doing so is totally unethical.\u201d<\/p>\n\n\n\n

From HIV to harm reduction<\/h2>\n\n\n\n

Tyndall started medical school in 1982, when HIV was still emerging as a lethal mystery. His first clinic involved haemophiliacs dying of an unknown disease. Then it appeared among gay men.<\/p>\n\n\n\n

His career, he says, was shaped by the feeling that medicine was failing in real time.<\/p>\n\n\n\n

In the 1990s, infectious diseases took him to Nairobi, where he worked on HIV prevention with painfully limited tools.<\/p>\n\n\n\n

\u201cThe harm reduction idea really was condoms. That was basically all we had to offer,\u201d he recalls.<\/p>\n\n\n\n

Even that provoked fierce resistance, on the grounds that providing condoms would encourage promiscuity \u2013 an argument that echoes in today\u2019s debates about vaping and other safer nicotine products. \u201c<\/strong>People somehow had a problem with people using condoms and having sex without any consequences. It was absolutely ridiculous. Yet the consequences of unprotected sex was HIV, which meant death.”<\/p>\n\n\n\n

\n

There was probably five years of pushback against condoms. Just think how many millions of unnecessary deaths happened as a result?<\/p>\n<\/blockquote>\n\n\n\n

From needle exchange to safer nicotine<\/h2>\n\n\n\n

By 1999, Tyndall had moved to Vancouver, where HIV was spreading among people who injected drugs. The Downtown Eastside \u2013 a dense pocket of poverty, homelessness, and drug use \u2013 became a testing ground for harm reduction in North America.<\/p>\n\n\n\n

Tyndall evaluated Vancouver\u2019s needle exchange and helped build the evidence base around Insite, the first supervised injection site in North America, which opened in 2003.<\/p>\n\n\n\n

Harm reduction, in those years, wasn\u2019t a slogan. It was a series of practical questions: What reduces disease transmission? What reduces overdose? What keeps a person alive long enough to have another chance?<\/p>\n\n\n\n

A matter of life and death \u2013 again<\/h2>\n\n\n\n

Tyndall\u2019s shift towards tobacco harm reduction began almost accidentally. While running a cohort study in Ottawa involving people living with HIV or at high risk, he noticed something unexpected.<\/p>\n\n\n\n

\u201cThere were no HIV deaths,\u201d he says. Instead, year after year, the same conditions kept appearing: cardiac disease, COPD, lung cancer.<\/p>\n\n\n\n

\u201cThey all smoked,\u201d Mark Tyndall says.<\/p>\n\n\n\n

In 2011, he offered people in the cohort vaping products.<\/p>\n\n\n\n

\u201cThey liked it,\u201d he adds.<\/p>\n\n\n\n

He wrote an op-ed describing vaping as a kind of cure for cigarettes \u2013 nicotine delivery without combustion.<\/p>\n\n\n\n

He expected enthusiasm. Instead, he encountered resistance.<\/p>\n\n\n\n

\u201cIf you had told me that 14 years later we\u2019d be in this mess and facing continued pushback from safer products, I wouldn\u2019t have believed it,\u201d he says.<\/p>\n\n\n\n

\u2018The goalposts moved to nicotine\u2019<\/h2>\n\n\n\n

For Tyndall, the frustration lies in how familiar the pattern feels.<\/p>\n\n\n\n

Initially, tobacco control focused on the devastation caused by combustible smoking. But as evidence accumulated that vaping and oral nicotine products were far less harmful, he noticed the argument shift.<\/p>\n\n\n\n

\u201cThe tobacco control people have moved the goalposts,\u201d he says.<\/p>\n\n\n\n

\u201cTheir aim is now the elimination of combustible tobacco and nicotine.\u201d<\/p>\n\n\n\n

When the alternative could no longer be credibly framed as just as dangerous, nicotine use itself became the problem.<\/p>\n\n\n\n

Tyndall channelled his frustration by writing a book. Released in 2025, Vaping: Behind the Smoke and Fears<\/em><\/a>, traces the rise of vaping and the consequences of the moral panic that ensued. Part of his motivation in writing the book was to drive home the point that \u201cnicotine isn\u2019t the problem\u201d. <\/p>\n\n\n\n

He of course acknowledges that nicotine can be addictive. But he questions whether addiction, in isolation, constitutes a public-health emergency when it isn\u2019t paired with catastrophic harm.<\/p>\n\n\n\n

\u201cNicotine is actually a pretty stable addiction,\u201d he explains.<\/p>\n\n\n\n

\u201cIf you start off smoking a pack a day, you don’t automatically jump to eight packs a day.\u201d<\/p>\n\n\n\n

He adds that nicotine dependence doesn\u2019t lead to the spirals people associate with addiction \u2013 financial collapse, broken relationships, escalating use.<\/p>\n\n\n\n

\u201cIt just doesn\u2019t work that way,\u201d he says, comparing it instead to caffeine.<\/p>\n\n\n\n

The puritan instinct<\/h2>\n\n\n\n

If Tyndall has a unifying explanation for why harm reduction repeatedly triggers backlash \u2013 whether around condoms, opioids, or nicotine \u2013 it\u2019s discomfort with the idea that people might get pleasure without punishment.<\/p>\n\n\n\n

He sees it in the way critics fixate on nicotine\u2019s dopamine hit, as if \u201cit feels good\u201d disqualifies it as an intervention.<\/p>\n\n\n\n

\n

That really is at the core of it. Why should we give people a pleasurable substance without any consequences?<\/p>\n<\/blockquote>\n\n\n\n

Tyndall is careful not to romanticise nicotine or encourage youth use. He\u2019s a father who doesn\u2019t want his son to start. But he believes claims that nicotine \u201cdamages young brains\u201d are often exaggerated and rooted in weak evidence.<\/p>\n\n\n\n

\u201cIt all comes from studies on mice that received megadoes of nicotine,\u201d Mark Tyndall says.<\/p>\n\n\n\n

\u201cAnd it’s really hard to interpret what a mouse is doing when it\u2019s given really heavy things or displays weird behaviour in a cage. It really has nothing to do with kids.\u201d<\/p>\n\n\n\n

Sweden, snus, and cultural reality<\/h2>\n\n\n\n

A recent visit to Stockholm reinforced his view that widespread nicotine use and low smoking prevalence can coexist.<\/p>\n\n\n\n

\u201cIt just showed that you can have quite a successful society when a proportion of people are using nicotine,\u201d he says.<\/p>\n\n\n\n

But he\u2019s clear that the Swedish experience isn\u2019t something to copy-paste.<\/p>\n\n\n\n

\u201cEach country will probably have to find its own way based on the culture and the history,\u201d he says.<\/p>\n\n\n\n

In Canada, vaping may offer a more natural off-ramp from cigarettes than snus, because it more closely mimics the behavioural and social aspects of smoking. The lesson, he argues, isn\u2019t that every country should become Sweden overnight \u2013 but that harm reduction works when societies allow it to.<\/p>\n\n\n\n

The free intervention nobody wants<\/h2>\n\n\n\n

What frustrates Tyndall most is that tobacco harm reduction doesn\u2019t require massive public spending.<\/p>\n\n\n\n

\u201cThis intervention is free,\u201d he says. \u201cIndustry will do it and consumers will do it. We don\u2019t need some huge new public health investment. We just need to tell people the truth and most will march right into it.\u201d<\/p>\n\n\n\n

Instead, he sees institutional inertia \u2013 political, professional, and financial.<\/p>\n\n\n\n

\u201cThere\u2019s so much vested interest in the way it is now,\u201d he says.<\/p>\n\n\n\n

Then he returns to the clinician\u2019s ethic that underpins his argument.<\/p>\n\n\n\n

\u201cIf you have somebody in front of you who is smoking cigarettes and you\u2019re not offering them a safer product,\u201d Mark Tyndall says, \u201cto me it\u2019s like not offering them\u2026 treatment.\u201d<\/p>\n\n\n\n

Current smokers as collateral damage<\/h2>\n\n\n\n

Tyndall believes public health has relied too heavily on repetition \u2013 telling people to quit as if insistence were a treatment plan \u2013 while accepting the early deaths of those who don\u2019t or can\u2019t quit.<\/p>\n\n\n\n

\u201cThe 3.5 million Canadians who currently smoke are just collateral damage,\u201d he says.<\/p>\n\n\n\n

\u201cThe sooner current smokers die, the thinking goes, the better off we’ll be because we’ll get our prevalence down. Like we can get to zero once everybody dies. And to me that’s not really a good plan.\u201d<\/p>\n\n\n\n

Despite growing real-world evidence supporting tobacco harm reduction, Tyndall isn\u2019t optimistic that entrenched opposition will dissolve soon.<\/p>\n\n\n\n

\u201cThe anti-tobacco people have dug in so deep and came out so early against safer nicotine products, they\u2019re simply not going to change,\u201d he says.<\/p>\n\n\n\n

Still, his prescription remains the same one he learned in the early years of HIV: tell the truth about risk, offer what works, and refuse to confuse morality with medicine.<\/p>\n\n\n\n

\u201cI think we can continue to disincentivise combustible tobacco and continue to give people options,\u201d he says.<\/p>\n\n\n\n

\u201cOur goal should be to get people off combustible cigarettes. Period.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

In this instalment of our Harm Reduction Heroes series, Snusforumet talks to Mark Tyndall, the Canadian infectious-disease physician who helped pioneer pragmatic responses to HIV…<\/p>\n","protected":false},"author":11,"featured_media":9288,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[254],"tags":[251,469,643,621,296,345,262],"class_list":["post-9277","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-opinions","tag-harm-reduction-2","tag-harm-reduction-heroes","tag-hiv","tag-mark-tyndall","tag-nicotine-2","tag-public-health","tag-vaping"],"acf":[],"yoast_head":"\nMark Tyndall: The harm reduction doctor who took on tobacco\u2019s last taboo - Snusforumet<\/title>\n<meta name=\"description\" content=\"Mark Tyndall explains why tobacco harm reduction and safer nicotine alternatives like vaping could save lives\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/snusforumet.se\/en\/mark-tyndall-the-harm-reduction-doctor-who-took-on-tobaccos-last-taboo\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Mark Tyndall: The harm reduction doctor who took on tobacco\u2019s last taboo - 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