Addiction isn’t a moral failure

2025-08-05

Addiction isn’t a moral failure – it’s a complex, often lifelong condition with biological, psychological, and social roots. Whether we’re talking about tobacco, alcohol, or other substances, one thing is evident: prohibition alone doesn’t solve the problem. Despite decades of prevention campaigns, millions in Europe still smoke, drink in excess heavily, or live with untreated substance use disorders.

So how can we do better?

Across the world, the most forward-thinking public health strategies are no longer obsessed with achieving total abstinence. Instead, they ask a different question: if addiction emancipation is nearly impossible, how can we reduce the harm that substance use causes?

This approach is not theoretical. Estonia already applies harm reduction strategy in its drug policy. Programs like needle exchanges and substitution therapy have helped reduce transmission of diseases like HIV and hepatitis, and they offer a safer, more dignified path for people who are addicted to drugs. In 2023 alone, nearly 3,900 people used harm reduction services in Estonia, making over 93,000 visits and thus saved lives.

But these strategies are not yet extended to legally available substances like tobacco or alcohol, even though the harm they cause are more widespread. According to the Health Development Institute, tobacco use caused the loss of over 59,000 healthy life years in 2022 in Estonia – more than half due to premature death – and generated at least €55.6 million in direct healthcare costs. Alcohol use added another 53,000 lost life years and €50.5 million in medical expenses according to the official data. The actual costs are significantly higher, as these estimates exclude primary care, medications, and sick leave compensation. Yet, from the annual report of the Estonian Health Insurance fund it becomes clear that the disease prevention budget allocation for counselling to quit using tobacco has been cut by more than 50% compared to 2023.

The European Life Science & Knowledge Institute (ELSKI) offers an evidence-based solution: tobacco harm reduction based on risk management continuity. Ideally, nicotine should be eliminated, but the latest medical evidence shows that switching to lower-risk alternatives (such as e-cigarettes, heated tobacco, or nicotine pouches) for adult patients who have been smoking for many years can significantly reduce health risks and healthcare costs.

ELSKI’s review of more than 250 scientific studies found that e-cigarettes contain 97% fewer toxic substances than traditional cigarettes, and heated tobacco products contain 89% fewer. These products contain little or no carbon monoxide or polycyclic aromatic hydrocarbons, the primary agents of smoking-related diseases. Sweden’s experience is a real-life manifest of effective harm reduction expressed in European’s lowest smoking rate and proportionally higher use of less harmful alternatives resulting in fewer diseases related to cigarette smoking.

By supporting smokers in transitioning to less harmful alternatives and helping heavy drinkers reduce their intake through targeted interventions, long-term health costs can be reduced while improving public health and extending life expectancy at the same time. Yet these tools – whether safer nicotine products or clinical alcohol interventions – are too often dismissed due to political resistance or moral dilemmas, much like needle exchanges were in the 1980s. Estonia’s alcohol policy, though aligned on paper with WHO guidelines, remains fixated on taxation and broad public messaging. But research shows that alcoholics – the group most at risk – are the least responsive to price related measures. Harm reduction approach would refocus efforts on those who need support the most: heavy and dependent drinkers.

Harm reduction is not an excuse for substance use. It is a science-backed strategy to meet people where they stand at in life. That includes acknowledging why people use substances in the first place – often to manage pain, trauma, or stress. Supporting mental health, offering psychosocial counseling, and maintaining trust between patients and healthcare professionals are all essential.

Healthcare professionals must be empowered to speak honestly about addiction and harm reduction options. That means training, legal clarity, and public policy that protects their right to inform patients accurately. ELSKI calls for three competencies: knowledge, skills, and readiness. Without all three, even well-meaning initiatives will fail. This is proved by low percentage of cessation and high rate of addiction relapse.

We may never eliminate addiction. But we can eliminate many of its most devastating consequences. That starts with moving past ideology and embracing what works: public policy rooted in evidence, clinical practice grounded in compassion, and a commitment to save lives, not just make political statements.

Article appearances in Estonian media:

Elski viešumoje

Addiction isn’t a moral failure