Introduction: Tobacco harm reduction and the right to health

The focus of this GSTHR briefing is Asia. Sixty per cent of the world’s smokers live in this region and almost half the global deaths from smoking occur here. Asia is also home to nine in every ten users of smokeless tobacco, leading to high rates of oral cancer in the region. In a number of countries, public health is severely undermined where governments either control or have a significant stake in domestic tobacco companies. New solutions are needed to tackle the public health threat from smoking and tobacco use in Asia.

Harm reduction as a public health principle grew out of a health and social justice movement in the USA and Europe during the early days of the HIV/AIDS epidemic in the 1980s. Activists in the gay and injecting drug-using communities began distributing condoms and needles and syringes attempting to reduce the spread of the virus.

The public health impact was undeniable. Those countries who embraced harm reduction saw significant falls in HIV rates among affected communities. In turn, this reduced the risks for the wider population.

There is a direct link from the history of drug and HIV harm reduction to the beginnings of THR. As far back as 2006, local communities of smokers and small manufacturers from around the world used the internet to spread information and advice about a new generation of products which allowed smokers to consume nicotine without the dangers associated with cigarettes. After this peer-to-peer support saw many smokers successfully quit using these new products, the idea of THR began to filter upwards, to health professionals and policymakers. Now, some governments endorse the use of nicotine vaping as a smoking cessation tool.

In addition to cigarette smoking, Asia has a substantial population who use smokeless rather than combustible tobacco products. These products cause death and disease

from oral cancers. However, in Sweden, the use of much safer pasteurised snus has led to significant falls in smoking-related cancer. If the same manufacturing techniques could be adopted by smokeless tobacco (SLT) producers in Asia, the risks to health could be dramatically reduced.

Many people want to quit smoking or using tobacco, and many do so. But many others cannot. A global public health commitment to encourage smokers and users of dangerous SLT to switch to SNP - rather than simply telling them to quit - could significantly contribute to reaching overall targets aimed at reducing death and disease from the use of dangerous tobacco products.

The World Health Organization (WHO), some influential NGOs, major philanthropic foundations and governments do not accept this principle of substituting harmful tobacco products with SNP. Some governments in Asia have enacted outright bans on SNP. Yet in the WHO’s own Framework Convention on Tobacco Control (FCTC), there is a statement about the role of harm reduction as part of the strategic response to tackling smoking. Article 1 (d) of the FCTC specifically states that tobacco control means, “a range of supply, demand and harm reduction strategies that aim to improve the health of the population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” [emphasis added].¹

There is also a commitment to “promote measures of tobacco control based on current and relevant scientific, technical and economic considerations”.² The FCTC was drafted and enacted before vaping, heated tobacco products (HTP) or nicotine pouches became widely available. However, there is no evidence that the WHO intends to review the FCTC positively in light of the development of new products, whose benefits are supported by independent scientific and clinical evidence.

But there are even wider public health principles at play here. The spirit of THR is embedded within several international treaties: these major on addressing marginalisation, discrimination and general health inequalities by empowering people to take control of their own health and ensuring that nobody is left behind.

The preamble to the FCTC quotes the Constitution of the WHO itself, which states, “that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”.³

By making it difficult, if not impossible, for current adult smokers to access SNP, governments are illegitimately interfering with an individual’s right to health. The WHO colludes in this, by failing to provide a clear definition of harm reduction in the FCTC. Moreover, it refers to the human right to be protected from the tobacco industry, rather than the right to take steps to protect ones’ health.