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Tobacco harm reduction and the right to health

Tobacco harm reduction: the potential

No longer just ‘quit or die’, but ‘quit and try’

From the 1980s onwards, the main tobacco harm reduction product was nicotine replacement therapy (NRT) – products including patches, gum and inhalators. NRT is now the medically approved way to consume nicotine without t obacco and is on the WHO’s List of Essential Medicines. Given this, it is easy to refute any claims that the harmful chemical in a cigarette is the nicotine . Though still banned or tightly regulated in some countries, in others NRT is widely available, and in many places, it can be obtained without prescription, including by young people.

Since the mid-2000s, however, an entirely new harm reduction front for tobacco has opened up. There has been widespread uptake of nicotine vaping products among consumers in many countries, together with the realisation of significant public health gains from the switch from combustible tobacco to smokeless tobacco (snus) in Sweden, and a proliferation in the range of newer products, such as heated tobacco products and oral nicotine pouches (containing no tobacco).14

Tobacco products
Image: GoogleImage: Wikimedia Commons

In comparison to conventional tobacco control initiatives, uptake of safer nicotine products has largely occurred without any overall public health input – without encouragement or investment from governments, tobacco control experts or tobacco control NGOs. However, following consumer uptake, the UK and New Zealand gave strong policy support to this development. A few other governments are beginning to be supportive, but again, this has come after initial consumer interest.

Safer nicotine products

There is substantial international, independent evidence that the new products are demonstrably and significantly safer than traditional cigarettes.

There is no more dangerous way to consume nicotine than by smoking a tobacco cigarette.

Nicotine vaping products (also known as e-cigarettes)

These products allow the user to inhale nicotine in a vapour which contains no tar or carbon monoxide. All vaping products have three basic elements: the battery, which heats up the coil or atomiser, which turns the flavoured liquid into a vapour to be inhaled.

Most e-liquids contain four ingredients: vegetable glycerine (VG) which provides the vapour, propylene glycol (PG) which carries the flavour (although PG-free liquids are available as some people are allergic to this ingredient), nicotine, and flavouring.

“With vaping, you get […] the action of smoking, you get the inhalation, the exhalation, you can choose what nicotine level you want, you can choose what flavours you want.”


The first modern e-cigarette came onto the market in 2003. Since then, there have been numerous product developments. Vaping products range from very simple disposable or partially disposable devices through to more complicated devices which consumers can customise for themselves using different component parts or settings.

Using vaping products instead of combustible tobacco cigarettes reduces the users’ exposure to multiple toxicants and carcinogens present in tobacco smoke. This means that vaping products are at least 95 per cent safer than cigarettes.16 There is no evidence so far that second-hand vapour causes harm to bystanders.17

Case study: e-cigarettes in the UK – official endorsement, rapid consumer uptake, smoking in continued decline

The UK has taken many steps to embrace tobacco harm reduction. As early as 2007, use of safer forms of nicotine was endorsed by the Royal College of Physicians,18 an endorsement that was repeated in 2016.19 The evidence reviews by Public Health England that conclude ‘e-cigarettes are 95% less harmful to your health than normal cigarettes’ have been very influential.20,21

In the UK, e-cigarettes are tightly regulated for quality and safety. Most of the anti-smoking and health NGOs and many trusted medical bodies endorse the use of e-cigarettes as a way to help people stop smoking tobacco. These include ASH (Action on Smoking and Health),22 Cancer Research UK,23 the British Heart Foundation,24 the Royal College of General Practitioners,25 and the Royal College of Psychiatrists.26 The importance of innovation and less harmful alternatives has been adopted within government,27 with the Department of Health (in England) setting the ambition to go ‘smoke-free’ by 2030 “with smokers quitting or moving to reduced risk products like e-cigarettes.”28 A recent randomised controlled trial in a UK NHS smoking cessation service showed that vaping was almost twice as effective as NRT in supporting smokers to quit smoking.29

As of 2019, an estimated 7.1% of the total UK adult population – 3.6 million people – use e-cigarettes. Over half (54.1%) of current e-cigarette users are exsmokers, a proportion which has grown year on year, while the proportion of dual users (people who vape who also smoke) has declined to 39.8%. Ex-smokers report using e-cigarettes to help them quit (31%), to prevent relapse (20%), because they enjoy it (14%) and to save money (13%). Dual users report using e-cigarettes to cut down on tobacco (21%), to save money compared to smoking (16%) and to help them stop smoking (14%).31

Bottles on the table
Image: Antonin FELS on Unsplash

Concerns that young people would take up vaping in large numbers have not been borne out in Great Britain. Anti-smoking charity ASH’s Smokefree Great Britain Youth Survey found that among 11 – 18 year olds who had never smoked, 5.5% have tried e-cigarettes at some time, 0.8% are current vapers, only 0.1% vape more than once a week. Not a single ‘never smoker’ reported vaping daily.33

“I had an e-cig that the Stop Smoking Nurse gave me. I tried it a couple of times and thought, yeah, this is all right – because I think it was more the habit of the smoke that I needed – so I thought, I’m gonna give it a real good go. E-cigs are the best thing that I’ve ever discovered. They’ve changed my life.”


Heated tobacco products

A new generation of devices called heated tobacco products has reached the market recently in many countries. These devices heat tobacco below the level of combustion to a temperature of no more than 350°C, which is sufficient to release nicotine in a vapour containing significantly reduced levels of toxins compared to combustible cigarettes.34 Tobacco for use in heated tobacco devices is powdered and mixed with glycerine, guar gum, and other ingredients.

Heated tobacco products generate significantly lower levels of harmful constituents compared to cigarettes; in terms of cancer potency, a review of extant studies of toxicological risk and likely daily exposure indicated that cancer risk from heated tobacco products is between one and 10% that of cigarettes.35

Case study: Japan – rapid rise in sales of heated tobacco products, rapid fall in cigarette sales

According to the WHO, 19% of Japan’s adult population were daily smokers in 2015, with smoking higher among men (30%) than women (9%). T hese levels are much lower than the extraordinarily high percentage of male smokers in Japan back in 1968, at 78%. But the decline had, until r ecently, abated.

Japan does not have an overtly hostile approach to tobacco . Until 1985, the tobacco industry was a state monopoly and it still owns one-thi rd of Japan Tobacco, Inc. (JTI), remaining the largest shareholder. Recently voluntary bans have been introduced by some companies and a street smokin g ban introduced by some cities.36 For the 2020 Tokyo Olympics there will be smoking bans in all indoor and outdoor venues and in the perime ter areas of venues.37

Since the tobacco industry introduced heated tobacco products to the Japanese market, in pilot areas from 2014, before a nationwide rollout in 2016, cigarette sales have dropped by an astonishing 33%.38 Such spectacular results have never been seen as a result of the implementation of any tobacco control measure, anywhere in the world.

This dramatic transformation in cigarette sales has been brought about simply by selling a safer alternative to smoking, the use of smart marketing, and consumers deciding to switch from smoking to heated tobacco. No action was required on the part of public health and tobacco control, except perhaps to help create a climate where smokers wish to quit; it has been at no direct cost to the Japanese taxpayer.


In contrast to the new safer nicotine products, snus has been used for over 200 years, but only recently has its relative safety compared to cigarettes been confirmed by independent clinical and epidemiological investigation. Snus is a moist to semi-moist smokeless tobacco product, made from ground tobacco leaves and food-approved additives. The final product is placed in the mouth (not chewed).

Image: Swedish Match file photo

Loose snus is pinched into shape before being inserted into the mouth, often under the upper lip. ‘Portion snus’ is sold in small teabag-like sachets.

The nicotine content of snus varies between brands, with the most common strength being 8 mg of nicotine per gram of tobacco. Stronger varieties can contain up to 22 mg of nicotine per gram of tobacco.

“I have not smoked in five years using snus. Once I got over the ritual habits of smoking, I have found snus superior in every way to cigarettes.”

Snus user39

Tobacco-free snus is a recent addition to the range. These products use other plant fibres impregnated with nicotine instead of tobacco.

Swedish snus is the dominant form of smokeless tobacco in the Nordic countries. It is illegal to sell snus in all European Union countries except Sweden. In Canada and several regions of the USA, it is sold alongside American-produced forms of snus, and in October 2019, the US Federal Drug Administration (FDA) granted the first ever modified risk orders to eight Swedish snus products, meaning they can be advertised with specific information about the lower risks of certain health effects compared to smoking cigarettes.40

A European Commission review concluded that complete substitution of smokeless tobacco products for tobacco smoking would ultimately prevent nearly all deaths from respiratory disease currently caused by smoking, and reduce the cardiovascular mortality that currently arises from smoking by at least 50%.41 There is no significant association between snus and premature deaths, diabetes, pancreatic and oral cancers, heart disease or strokes.

substitution of smokeless tobacco products for tobacco smoking would prevent nearly all deaths from respiratory disease caused by smoking

Substituting Swedish snus for high risk oral or chewed smokeless tobacco (SLT) products could be transformative to health in many LMIC. In India, for example, the use of high risk SLT products is common, especially among women, for whom it is less socially acceptable to smoke; around 70 million girls and women in India aged 15 or over are thought to use SLT on a regular basis. India has the highest global rate of oral cancer due to the high prevalence of SLT use, accounting for around 400,000 deaths annually.42

Case study: Sweden and snus – low rates of smoking and the lowest level of tobacco-related mortality in Europe

Sweden provides a unique case study of the impact of snus on smoking. It is the only country in the EU where snus may be sold legally. Snus dominated tobacco use in the country until the early 1900s, when the invention of the cigarette rolling machine popularised the cigarette. However, from the 1960s, the trend reversed and use of snus increased. In 1996, snus became more popular than cigarettes; the reduction in smoking was faster in men than women.

According to the European Commission's Eurobarometer report in 2017, on average, just 5% of Swedish adults now smoke daily – a level that is less than one fifth of the EU average of 24%.43

Sweden has, for men, the lowest tobacco-related mortality rate in Europe at 152 per 100,000. The rate is less than one third of the European average of 467 per 100,000.44

The long-term epidemiological evidence provided by this natural experiment gives us information on the uptake and plausible impact of snus on smoking and tobacco-related disease. It also acts as proof of concept for the potential efficacy and effectiveness of tobacco harm reduction, as identified by the UK Royal College of Physicians:

“The availability and use of […] snus in Sweden […] demonstrates […] that a substantial proportion of smokers will, given the availability of a socially acceptable and affordable consumer alternative offering a lower hazard to health, switch from smoked tobacco to the alternative product.”45

As a non-EU member, snus is legal in Norway. Fewer Norwegians smoke (11%) than use snus (12%). Among young women aged 16 to 24, smoking has all but disappeared (1%).46

  1. Foulds J. et al. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 12:349-359
  2. Catherine is a UK vaper interviewed for The Switch, a video made by the New Nicotine Alliance (NNA) and the National Centre for Smoking Cessation Training (NCSCT). All videos accessible at the NNA website:
  3. McNeill, A. et al. Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. PHE, 2018
  4. McNeill, A. et al. Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. PHE, 2018
  5. Royal College of Physicians, Tobacco Advisory Group. Harm reduction in nicotine addiction: helping people who can’t quit. RCP, 2007
  6. Royal College of Physicians, Tobacco Advisory Group. Nicotine without smoke; tobacco harm reduction. RCP, 2016
  7. McNeill, A. et al. E-cigarettes: an evidence update: a report commissioned by Public Health England. PHE, 2015.
  8. McNeill A. et al (2018). Evidence review of e-cigarettes and heated tobacco products 2018. A report commissioned by Public Health England. PHE, 2018
  9. Action on Smoking and Health (ASH) website (accessed December 2019) Harm reduction
  10. Cancer Research UK website. Our policy on e-cigarettes (2019)
  11. British Heart Foundation Smokers who switch to vaping see improvements in their blood vessel health – a press release about the VESUVIUS study, funded by the British Heart Foundation (November 2019)
  12. Royal College of General Practitioners (RCGP) website (accessed December 2019):
  13. Royal College of Psychiatrists Position statement: The prescribing of varenicline and vaping (electronic cigarettes) to patients with severe mental illness (2018)
  14. UK Department of Health (2019) Towards a smoke-free generation: the tobacco control plan for England p. 15, p. 27.
  15. UK Department of Health (2019), Advancing our health: prevention in the 2020s – consultation document.
  16. Hajek, P., Phillips Waller A., Przulj, D. et al. (2019) A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy New England Journal of Medicine (DOI: 10.1056/NEJMoa1808779).
  17. Action on Smoking and Health (ASH) (2019) Use of e-cigarettes among adults in Great Britain
  18. Action on Smoking and Health (ASH) (2019) Use of e-cigarettes among adults in Great Britain.
  19. Glen is a UK vaper interviewed for The Switch, a video made by the New Nicotine Alliance (NNA) and the National Centre for Smoking Cessation Training (NCSCT). All videos accessible at the NNA website:
  20. Action on Smoking and Health (ASH) (2019) Use of e-cigarettes among young people in Great Britain.
  21. Committee on Toxicity (2017). COT Meeting: 4 July 2017.
  22. Stephens E (2018) The role of emissions in the debate on health effects across the spectrum of nicotine delivery. Global Forum on Nicotine, June 2018, Warsaw.
  23. Mark A Levin (2013) Tobacco control lessons from the Higgs Boson: Observing a hidden field behind changing tobacco control norms in Japan. American Journal of Law Medicine. 39 p.471–489
  24. Paralympic Games website (2019): Tokyo 2020 venues will be smoke-free
  25. The decline in sales has been calculated from Japan Tobacco Inc monthly sales and share of market.
  26. Reddit user Gunter73 (December 2019), answering a thread comparing snus use to cigarette use
  27. Federal Drug Administration (FDA) (2019). FDA authorizes modified risk tobacco products.
  28. European Commission (2008). Scientific Committee on Emerging and Newly Identified Health Risks. Health effects of smokeless tobacco products. Health and Consumer Protection Directorate.
  29. Gupta PC, Arora M, Sinha DN, Asma S, Parascandola M (eds.); Smokeless Tobacco and Public Health in India. Ministry of Health & Family Welfare, Government of India; New Delhi; 2016.
  30. European Commission (2017) Special Eurobarometer 458: Attitudes of Europeans towards tobacco and electronic cigarettes
  31. WHO (2012) WHO Global Report: mortality attributable to tobacco
  32. Royal College of Physicians (RCP) (2016). Nicotine without smoke; tobacco harm reduction. A report by the Tobacco Advisory Group of the Royal College of Physicians. Retrieved from:
  33. The Norwegian Directorate of Health (2017) Statistics Norway: 2017 data