Globally 1.1 billion people continue to smoke, 80 per cent of whom live in low and middle income countries. There are 8 million smoking-related deaths worldwide each year. While millions are spent on tobacco control efforts, the number of smokers is the same as it was twenty years ago. Prevalence rates have declined in some countries, but populations have increased.
Despite the evidence in favour of tobacco harm reduction (THR) using safer nicotine products (SNP) such as vaping devices, snus, nicotine pouches and heated tobacco products, the World Health Organization (WHO) remains opposed to the approach. In July, the publication of the WHO report on the global tobacco epidemic 2021 focused on the ‘threats posed by new nicotine and tobacco products’, instead of the opportunities they offer for adult smokers to switch.[i]
From 8 - 13 November 2021, the WHO will be hosting the Ninth Session of the Conference of the Parties to the Framework Convention on Tobacco Control (FCTC) otherwise known as COP9.[ii] Indications are that the WHO intends to further harden its stance against THR and that the FCTC Secretariat is set to encourage Parties to enact restrictive legislation or regulation or outright bans on SNP.
To date, the UK has successfully pursued elements of a THR policy and is rightly considered a global leader in the field. Yet the UK has not compromised its strong reputation in tobacco control. This Briefing Paper notes opportunities for the further development of THR in the UK, and explores why we believe the UK Government delegation has a crucial opportunity at COP9 to display its THR credentials on the global stage and influence the international response to the smoking epidemic. The Briefing precedes a longer report, Fighting the Last War: The FCTC and International Tobacco Control, to be published by the GSTHR on 27 October 2021.[iii]
Tobacco harm reduction in the UK: a good news story
Setting the scene
The UK has taken many steps to embrace harm reduction for tobacco. The use of safer forms of nicotine as alternatives to smoking was endorsed by the Royal College of Physicians (RCP) back in 2007 before vaping was well known and again in 2016 and 2021. The evidence reviews by Public Health England that conclude that ‘e-cigarettes are at least 95% less harmful than smoking’ have been very influential on tobacco harm reduction both domestically and globally. Within the UK, most anti-smoking and health NGOs and medical bodies endorse the use of e-cigarettes as a reduced risk alternative for adult smokers. The importance of innovation and less harmful alternatives was included in the tobacco control plan published by the Department of Health back in 2017. [iv]
The regulatory and policy environment in favour of vaping for smoking cessation has seen millions of former smokers successfully switching away from combustible tobacco. Around 7 per cent of the adult population in Great Britain currently vapes (around 6 million people). The year on year increase in vaping is matched by the continuing major reduction in smoking in the UK with under 15 per cent of the adult population currently using combustible tobacco. Public Health England (PHE) estimates that in 2020, vaping was the most popular quit aid, with over a quarter of people who made a quit attempt using a nicotine vaping device.[v]
In 2021, a number of reports from internationally respected institutions based in the UK have demonstrated sustained support for the use of safer nicotine products in reducing the harms caused by combustible tobacco products. Published in April by the Royal College of Physicians (RCP), Smoking and Health 2021 states that “e-cigarettes are an effective treatment for tobacco dependency and their use should be included and encouraged in all treatment pathways”.[vi] The RCP recommends media campaigns should encourage switching from smoked tobacco to e-cigarettes, “redress false perceptions about the safety of e-cigarettes compared with cigarettes”, and provide balanced information on other harm reduction options such as heated tobacco. The report further recommends that “health warnings on e-cigarette packs include a statement that e-cigarette vapour is likely to be substantially less harmful than tobacco smoke”.
The highly respected Cochrane Review on vaping was also updated in April, concluding that, while more evidence is still needed, “nicotine e-cigarettes probably do help people to stop smoking for at least six months”, adding “they probably work better than nicotine replacement therapy and nicotine-free e-cigarettes”.[vii] And the National Institute for Clinical Excellence (NICE) with Public Health England (PHE) published comprehensive draft guideline recommendations to tackle the health burden of smoking in June.[viii] The expert committee stated that, while the long-term health effects of vaping are still uncertain, “they are substantially less harmful than smoking”, and they recommended that healthcare staff should advise patients “on where to find information on nicotine-containing e-cigarettes”.
Progressing THR in the UK
After the EU: next steps for tobacco and nicotine policy after the TPD
The potential of harm reduction in relation to tobacco is only partially realised in the UK. Vaping does not suit everyone; the UK’s approach to harm reduction currently favours vaping over other categories of product. Consumers may find that instead of vaping, it is using snus, oral nicotine pouches or heated tobacco products that helps them to make the switch away from combustible tobacco. It may take time for people to discover which safer nicotine product suits their needs. And in contrast to how people typically smoke (often using one preferred brand), consumers who have switched to safer nicotine products may move between different product categories depending on the situation or setting they are in.
Restrictions placed on UK policy by the EU Tobacco Products Directive (TPD) have constrained the UK’s approach. Following the UK’s departure from the EU, the UK Government is reviewing the Tobacco and Related Products Regulations (TRPR), the legislation that brought the EU TPD into UK law. Our submission to the Department of Health and Social Care consultation can be accessed at our website.
Specific areas which had a constraining effect include, but are not limited to, the ban on snus (see below); the 20mg/ml nicotine limit on e-liquids; the limit on vaping device tank size to 2ml; the increased burden of regulation placed on heated tobacco products as tobacco-containing products; and restrictions on advertising or promotion which prohibit comparative risk communication.
By embracing a genuinely comprehensive and proactive approach to tobacco harm reduction, the UK could achieve the stated smoke-free goal of five per cent or less in England, possibly by the target date of 2030. Much of this could be achieved with minimal additional cost to the taxpayer.
Hastening an end to smoking should also be seen as central to the Government’s achievement of the ‘levelling up’ agenda. Disproportionately high smoking rates among socioeconomically deprived communities are a major contributor to health inequalities, and in August 2021, new estimates from Cancer Research UK suggested that smoking is responsible for twice as many cancer cases in lower income groups compared to higher income groups.[ix]
Encouraging signs: Government review of snus
In June 2021, the Parliamentary Under-Secretary of State for Health and Social Care, Jo Churchill MP, announced the Government’s plans to carry out a review of snus.[x] Currently banned in the UK and the EU, except for Sweden, pasteurised snus is substantially less risky to health than smoking, with decades of epidemiological evidence to support this assessment. Thanks to the popularity of snus in Sweden, the country has the lowest rate of smoking-related mortality in Europe and half the average EU rate for smoking-related disease. In Norway, there is also a strong association between the rise in the use of snus and the disappearance of smoking among young women, where the prevalence of smoking among women aged under 25 has dropped to 1%.
The UK ban on snus is unusual internationally. Snus bans are predominantly concentrated within the countries of the EU. Now that the UK has left the EU, the UK has the opportunity to reverse this legislation. There is no scientific basis for continuing the ban on snus as an SNP and it should be legal to sell snus on the UK market. We believe that all safer nicotine products should be accessible, affordable and attractive to UK adults who smoke, to encourage people to make the switch.
Influencing the international response to smoking
COP9 in November 2021 is the first such meeting that the UK will attend independently, rather than part of the EU bloc. The importance of a strong UK voice representing the huge potential for tobacco harm reduction cannot be underestimated.
The UK delegation has an opportunity to put the country’s tobacco harm reduction credentials on full display on the global stage. It is crucial that the UK Government promotes its achievements, builds alliances with other supportive nations, and uses its influence to prevent any further regressive steps on safer nicotine products at COP9.
The scale of the UK’s financial contribution to international tobacco control is disproportionate. Since 2006, UK has contributed $5m in assessed contributions to the FCTC, making it the fourth largest contributor, behind Japan, Germany and France – and makes up around 6 per cent of the annual donations from all 181 Parties to the Convention. Many of these countries do not pay what they owe.
With its voluntary contributions, the UK has been carrying other countries as well. The UK has provided 72 per cent (2017), 77 per cent (2018) and 68 per cent (2019) of the annual voluntary contributions – amounting to $4,877,487 in 2019. That compares to a voluntary contribution of just $500,000 from the whole EU bloc.
In 2016, the UK Government also invested £15 million of Official Development Assistance (ODA) funding until the end of the financial year 2021. This grant is for the FCTC to provide support to low- and middle-income countries as they aim to achieve the general obligations and ‘the time-bound measures of the WHO FCTC’. A Department of Health and Social Care civil servant has been seconded to the WHO to work on distributing this grant.
These financial contributions from the UK are considerable. And yet increasingly, the FCTC project does not reflect the UK approach to tobacco control. As one of the most consistent and generous financial backers of both the FCTC and the WHO, the UK must be prepared to take a strong line and advocate for policies it has enacted domestically which are demonstrably having a positive impact on the numbers of people successfully quitting smoking.
Actions the UK can take at COP to reduce the global toll from smoking
The UK should be prepared to act robustly on the international stage in support of its domestic approach supporting tobacco harm reduction as a valid component of a modern tobacco control regime. To date, the UK’s financial commitment to the FCTC has been disproportionate. This is now illogical given the divergence between the UK’s domestic policy and the antipathy towards all safer nicotine products and tobacco harm reduction shown by the WHO. We believe the UK Government should:
- use its financial leverage, as a hitherto reliable major funder of the WHO FCTC, to question the direction of travel on safer nicotine products, citing the UK experience of their use in hastening an end to smoking;
- emphasise and promote the evidence base emerging from the UK, including the considerable support for tobacco harm reduction from independent, internationally respected medical and scientific bodies based in the UK;
- make an extension of the ODA grant beyond 2021 conditional on an agreement to implement reforms including giving due prominence to the role of tobacco harm reduction
- ensure the UK Government’s delegation to the COP meeting is balanced and representative and includes safer nicotine product users who can discuss, from lived experience, the positive role of these products in their smoking cessation journey;
- call for improved transparency and accountability at COP meetings, which, aside from a mainly ceremonial opening plenary, are currently held in closed sessions with no access to the public or media – despite the millions in citizens’ tax monies being allocated;
- be prepared to veto poor decisions affecting users of safer nicotine products in the UK and around the world; decisions at COP are taken by consensus, meaning the UK could block actions that could reduce access to safer nicotine products in the UK and worldwide.
To attend the online launch and receive a copy of the GSTHR report Fighting the Last War: The FCTC and International Tobacco Control on Wednesday 27 October (11:00 – 16:00 BST), please register at https://events.gsthr.org/
Knowledge·Action·Change (KAC) is a private sector public health agency that promotes harm reduction as a key public health strategy grounded in human rights. The team has over forty years of experience of harm reduction work in drug use, HIV, smoking, sexual health, and prisons. KAC runs the Global State of Tobacco Harm Reduction (GSTHR) which maps the development of tobacco harm reduction and the use, availability and regulatory responses to safer nicotine products around the world.
Funding: The GSTHR project is produced with the help of a grant from the Foundation for a Smoke Free World, an independent, US non profit 501(c)(3) which, under US law, must operate independently of its donors. The project and its outputs are, under the terms of the grant agreement, editorially independent of the Foundation.
[ii] Ninth Session of the Conference of the Parties to the Framework Convention on Tobacco Control (FCTC) otherwise known as COP9 https://fctc.who.int/who-fctc/governance/conference-of-the-parties/ninth-session-of-the-conference-of-the-parties
[iii] To register to take part in the online launch on 27 October 2021, and to receive a copy of the report, visit:
[iv] p. 50, No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018. (2018) London, Knowledge·Action·Change.
[v] Vaping in England: 2021 evidence update summary, Public Health England (2021)
[vi] The Royal College of Physicians (RCP) report: Smoking and Health 2021 https://www.rcplondon.ac.uk/projects/outputs/smoking-and-health-2021-coming-age-tobacco-control
[vii] Cochrane Review on vaping (updated on April 29, 2021) https://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-do-they-have-any-unwanted-effects-when-used
[viii] NICE and PHE draft guideline recommendations Tobacco: preventing uptake, promoting quitting and treating dependence (update) https://www.nice.org.uk/guidance/indevelopment/gid-ng10086
[x] Westminster Hall debate on the Government’s Tobacco Control Plan https://hansard.parliament.uk/Commons/2021-06-10/debates/7A9F973D-6799-4D16-A598-4E47525353B0/TobaccoControlPlan