The scale of the problem
Despite all the efforts of tobacco control, there are still 1.1 billion smokers worldwide [i] and many hundreds of thousands of people who use other dangerous tobacco products. Smoking causes eight million deaths a year with a projected one billion lives set to be lost by 2021. The smoking epidemic is a global issue, but eighty per cent of the world’s smokers live in low and middle-income countries (LMIC), and they are bearing the brunt of the deaths and diseases.[ii]
The World Health Organization (WHO) claims its monitoring and evaluation tobacco control strategy MPOWER (Monitoring tobacco use and prevention policies, Protecting people from tobacco smoke, Offering help to quit tobacco use, Warning about the dangers of tobacco, Enforcing bans on tobacco advertising, promotion and sponsorship, Raising taxes on tobacco) ‘protects’ or ‘covers’ 5.3 billion people from the deaths and diseases caused by smoking.[iii] In reality, the bureaucratic and political processes of passing tobacco control legislation protect nobody unless there are the necessary financial resources to implement that legislation, a particular problem in LMIC where resources are stretched.
Harm reduction with safer nicotine products - the solution
There is now a substantial body of global independent evidence that safer nicotine products (SNP) are significantly safer than any combustible, and many types of oral, tobacco products.[iv][v] Many smokers successfully quit smoking using cessation support or nicotine replacement therapies. But for those who either cannot or do not want to quit nicotine, switching to safer nicotine products offers a substantial potential public health benefit for adult smokers, their families, and bystanders, at little cost to governments. GSTHR research shows that in 2020, an estimated 98 million people worldwide had already switched to safer nicotine products.[vi]
Unfortunately, the WHO and its non-governmental organisation (NGO) allies are still engaged in an historic battle against the tobacco industry and are using this as a pretext to undermine the role of harm reduction for tobacco. This is despite the emergence of new technologies and a growing body of scientific research that shows safer nicotine products are both significantly less risky than combustible tobacco and have a role to play in harm reduction.
The phoney war on nicotine - with adult smokers as collateral damage
The refusal to endorse safer nicotine products for smoking cessation suggests that the WHO has little concern for the health of the world’s 1.1bn current adult smokers. Efforts are almost entirely focused on the acceptable political ground of prevention aimed at young people.
It appears the goal of international tobacco control has shifted from protection against tobacco and smoking, to protection against nicotine itself. As this change of focus has taken place, innovative non-combustible nicotine technology and the supporting evidence of its potential has moved forwards at pace. In contrast, tobacco control policy remains frozen in time.
Public health is not served by discouraging adult smokers from switching from deadly combustibles to safer nicotine products, nor by implementing overly restrictive regulations that prevent these products being appropriate, accessible and affordable to existing consumers. In these scenarios, the traditional tobacco industry will be the only winner, with the endgame for combustible cigarettes disappearing yet further into the future.
This ‘mission creep’ of international tobacco control from protection against tobacco smoke to a war on nicotine in all its forms is particularly egregious as the global campaign against SNP is funded by neo-colonial western philanthropic interests pursuing their own agenda. And yet it is LMIC, whose populations are the most significantly impacted by smoking-related harms, who stand to lose the most.
Tobacco control: fear of scrutiny, fear of transparency - and fear of critical voices
As things stand, we believe the Framework Convention on Tobacco Control (FCTC) Secretariat and its WHO-accredited NGOs have an undue and unhealthy influence over the deliberations before and during the FCTC Conference of the Parties (COP) meetings on international tobacco and nicotine policy, as well as on the post-COP implementation and interpretations of the meeting’s decisions.
It is also unacceptable that the COP, as an international meeting of government officials ultimately funded by citizens’ taxes, should be shrouded in a secrecy comparable to the UN Security Council, with consumers and affected populations, the public and the media all excluded. Such a lack of transparency is unacceptable for an international meeting of this importance.
Furthermore, the Guidelines to Article 5.3 of the FCTC are over-interpreted. Article 5.3 itself reasonably states that governments need to be open and transparent in their dealings with the tobacco industry.[vii] The Guidelines add detail to this, but the intention of the FCTC was never to entirely close dialogue between public health and industry, let alone be the justification for the growing range of attacks and no-platforming experienced by tobacco harm reduction advocates.
What needs to happen next?
International tobacco control must refocus on delivering tangible outcomes that reduce death and disease from smoking among adult smokers. A radical overhaul of the FCTC is unlikely, nor is it required, but much can be achieved through recalibration and shifts in how the Convention is implemented at a national level.
Parties (countries) need to exercise their control of the FCTC, rather than leave it to the Secretariat to take leadership. All options for widening the off-ramp from smoking must be examined. A Working Group on Tobacco Harm Reduction should be established. A primary aim would be to make a clear distinction between combustible and non-combustible safer nicotine products. The FCTC entered into force before SNP became widely available and it follows that there needs to be a greater focus on the harm reduction element contained in the FCTC.
The MPOWER implementation strategy should be reconfigured to rectify the current deficits in international tobacco control policy. MPOWER should become EMPOWERED with the addition of Engage with affected communities, Encourage smokers to switch to SNP and Deliver accurate information about safer alternatives.
Harm reduction is embedded in the WHO response to drug use and HIV/AIDS. Indeed, it is explicitly named as the third pillar of tobacco control alongside demand and supply reduction in the FCTC. Yet the WHO has remained implacably opposed to harm reduction for tobacco despite the fact the number of smokers now is the same as it was twenty years ago. Something is clearly not working in tobacco control: harm reduction is the way forward to bring an end to smoking.
This GSTHR Briefing Paper summarises the key messages of Fighting The Last War: The WHO and International Tobacco Control, a report published by the GSTHR on 27 October 2021. For further information about the Global State of Tobacco Harm Reduction’s work, or the points raised in this Briefing Paper, please contact [email protected]
About us: Knowledge·Action·Change (K·A·C) 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. K·A·C 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, as well as smoking prevalence and related mortality, in over 200 countries and regions around the world. For all publications and live data, visit https://gsthr.org
Our 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.
[i] WHO. (2019). WHO global report on trends in prevalence of tobacco use 2000–2025, third edition. World Health Organization. https://www.who.int/publications/i/item/who-global-report-on-trends-in-prevalence-of-tobacco-use-2000-2025-third-edition
[ii] Factsheet: Noncommunicable diseases, WHO. (2021). https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
[iii] WHO. WHO report on global tobacco epidemic: addressing new and emerging products 2021. WHO, 2021. https://www.who.int/teams/health-promotion/tobacco-control/global-tobacco-report-2021
[iv] Royal College of General Practitioners Position Statement on the use of electronic nicotine vapour products (September 2017). https://www.rcgp.org.uk/-/media/Files/Policy/2017/RCGP-E-cig-position-statement-sept-2017.ashx?la=en
[v] Public Health England (2020) Vaping in England – 2020 evidence update summary. https://www.gov.uk/government/publications/vaping-in-england-evidence-update-march-2020/vaping-in-england-2020-evidence-update-summary
[vii] The Framework Convention on Tobacco Control (2005): https://www.who.int/fctc/text_download/en/