One billion lives at stake

Tobacco harm reduction is a pragmatic and compassionate response to one of the biggest health crises facing our world. It offers tens of millions of smokers who either cannot quit by other means, or who want to continue using nicotine, the opportunity to avoid premature death and disability.

Many millions of nicotine users have already adopted safer nicotine products, leaving combustible tobacco behind, with negligible cost to governments and taxpayers. If integrated as part of the response to tobacco use, tobacco harm reduction could make a major contribution to ending smoking.

So why is tobacco harm reduction encountering opposition from many quarters, instead of more widespread adoption and implementation?

The WHO’s resistance to tobacco harm reduction

World leaders and policymakers look to the WHO for guidance on how to care for the health of their populations; its role is defined “as the directing and co-ordinating authority on international health work.”⁴⁷ For low- and middle-income countries especially, with healthcare systems that may still be developing, the WHO offers an essential source of technical and policy support and practical and financial input – and its actions and leadership in many areas of health have saved hundreds of thousands of lives.

However, the WHO’s relationship with harm reduction strategies is complex. The organisation and UN drug agencies resisted harm reduction in their response to the spread of HIV/AIDS and blood borne viruses among people who inject drugs. They cited unproven (and now debunked) claims that, for example, provision of clean needles was simply condoning drug use, or that harm reduction was actually a Trojan horse for the legalisation of drugs.

tobacco harm reduction is a pragmatic and compassionate response to one of the biggest health crises facing our world

So far, the WHO has remained implacably opposed to tobacco harm reduction through the use of safer nicotine products. The organisation continues to urge signatories to the international legislation concerned with tobacco control, the Framework Convention on Tobacco Control (FCTC), to instigate outright product bans. The alleged Trojan horse in this context is that tobacco harm reduction is a tobacco company ruse to encourage former smokers and young non-smokers through a new product gateway either to return to, or to graduate to, smoking tobacco.

signatories to the international legislation concerned with tobacco control, the Framework Convention on Tobacco Control (FCTC), to instigate outright product bans. The alleged Trojan horse in this context is that tobacco harm reduction is a tobacco company ruse to encourage former smokers and young non-smokers through a new product gateway either to return to, or to graduate to, smoking tobacco.

In the seventh WHO report on the global tobacco epidemic (2019), tobacco harm reduction is positioned as “a manipulative tobacco industry strategy”, with the potential to “misinform and mislead consumers and confuse governments” and disrupt “genuine initiatives to assist tobacco cessation”.⁴⁸

Unfortunately, this approach is then reflected in the WHO’s efforts to tackle noncommunicable diseases. In December 2019, the WHO published the final report of the Independent High Level Commission on NCDs.⁴⁹ The report references the “common understanding” reached at the UN General Assembly in 2018 that “progress and investment to date is insufficient” to reduce premature death and disability from NCDs by 2030 (SDG 3.4).⁵⁰

On tobacco – a leading cause of NCDs – the Commission’s final report offers nothing but demand reduction. To reach the goal of reducing deaths from NCDs among the 30 – 69 age group by one third by 2030 (SDG 3.4.1), the Commission predicts that a massive 50% prevalence reduction in tobacco smoking worldwide is required.

But no countries have ever achieved a 50% drop in smoking using mainstream tobacco control measures. It cannot be done – especially as the Commission also notes that MPOWER is currently fully implemented for less than 0.5% of the world’s population.⁵¹ The only other mention of tobacco is in reference to the continued “exclusion of the tobacco industry and non-State actors that work to further the interest of the tobacco industry in line with the WHO Framework Convention on Tobacco Control (FCTC).”⁵²,⁵³ However, the WHO does not try to exclude countries from participating in FCTC meetings even if their governments own substantial shares in the tobacco industry.

The scale of the problem, and the limitations of current tobacco control measures, points to the urgent need for tobacco harm reduction to become part of the solution.

Given its leadership and influential role in global health policy, the full benefits of tobacco harm reduction in tackling non-communicable diseases – especially for the 80% of smokers who live in low- and middle-income countries – can only be realised if the WHO overcomes its antipathy towards it.

Harm reduction and the WHO Framework Convention on Tobacco Control

A close look at the WHO FCTC reveals there are, in fact, three strategies the Convention defines as making up tobacco control:

From its inception, the FCTC – the WHO’s cornerstone document on tackling the tobacco crisis – has acknowledged that ‘tobacco control’ should include harm reduction strategies.

The WHO must shift the balance to incorporate a strategy that it already – apparently – endorses.

When ‘better safe than sorry’ isn’t better

The ‘precautionary principle’ codifies the adage ‘better safe than sorry’ for policymakers of all kinds: it advocates for the adoption of precautionary measures when evidence is uncertain, and the stakes are high.

The global public health world is divided on tobacco harm reduction and for many, the ‘precautionary principle’ wins out. Citing uncertainty over a range of issues, such as short- and long-term health harms of safer nicotine products, the risk of gateway progression to smoking or nicotine dependency in young people, or continued smoking through dual use, many in public health would rather apply the precautionary principle than adopt tobacco harm reduction measures.

Rational application of the precautionary principle is right and proper in many areas of human activity. In tobacco harm reduction, however, application of the precautionary principle is not rational. It ignores the extraordinarily high and well-documented stakes of the status quo – seven million lives lost to tobaccorelated disease every year. It also dismisses a significant and constantly growing international evidence base addressing many of the concerns. Being extremely cautious about potential risks, while ignoring huge and likely potential benefits, is not an appropriate way to implement the precautionary principle.

in tobacco harm reduction, application of the precautionary principle is not rational

Just because we don’t know everything, does not mean that we don’t know anything about safer nicotine products.

A rational approach to ‘Big Tobacco’

Reasoned suspicion of the tobacco industry and its motives mean that many understandably find it difficult to accept that the market – and the industry which caused so many problems – could be part of the solution.

But as the market for their products wanes in higher income countries, due in no small part to the implementation of tobacco control measures, the industry has recognised the disruptive power of innovative products to reduce their profits. They still manufacture and sell cigarettes, but many are also investing in new riskreduced products.

Product research and development in order to support innovation of this type requires sustained, significant investment. That investment is not currently forthcoming from philanthropy or public health.

Perhaps a more rational approach accepts that “businesses can adopt business practices and market products that are either health harming or innovative products that are health-improving or displace health-harming products. Sometimes the same companies can do both.”⁵⁵

A rational approach to nicotine

Public health thinking has been dominated by the tobacco control narrative for decades so that all tobacco use is seen as a problem. The lens through which professionals have viewed the issue has been ‘anti-tobacco’ for so long that it is understandably challenging to abandon this view to move towards a ‘neutral’ stance on nicotine use without tobacco combustion.

But is objection to the use of nicotine rooted in moral or ideological constructs rather than clinically-based health concerns?⁵⁶

Global public health has made enormous strides in combatting infectious diseases; two have been eradicated, smallpox and rinderpest, with programmes now tackling polio, yaws and malaria.

Five more infectious diseases have been identified as potentially eradicable. One of them is measles. Yet the proliferation of fake news communicated by lay anti-vaccine groups has had a very real impact on many thousands of lives. Myth and misinformation about the measles vaccine has seen increases in outbreaks in both high- and low-income countries, reversing the trends towards eradication in higher income countries.

Anti-tobacco harm reduction information, on the other hand, has come from official government, medical and public health sources in many countries and from within the WHO itself.

There is an underlying philosophical problem here. Aside from misguided activists, few could argue that everything should be done to eradicate a communicable and infectious killer disease.

But when it comes to non-communicable diseases, which are often seen in public health ranks as the result of lifestyle choices, then the battle can be framed in moral terms rather than health pragmatism. For some in public health, the pleasurable aspects of nicotine consumption for consumers can be hard to embrace.

People who use nicotine in properly regulated safer nicotine products do so without causing themselves or society significant harm.

The response to the global public health crisis of tobacco-related illness could be transformed if policymakers separated ‘nicotine use’ from ‘tobacco consumption’.

Medical myth, misinformation and media muddle

The tobacco industry has a long history of egregious duplicity over the consequences of smoking. This history, combined with an underlying antipathy to the non-medical use of nicotine, has led to the creation of a broad coalition of academics, clinicians, anti-tobacco campaigners and government and medical agencies who unite to condemn tobacco harm reduction. Their campaigning is often well-funded by philanthropic and international bodies.

Independent harm reduction evidence and its authors have been vilified, for example, with misrepresentation of evidence about the dangers of vaping compared to smoking, and disputes over the role of safer nicotine products in aiding smokers to switch from smoking or quit altogether. Much of the media, interested only in ‘bad news’ stories, often focuses its attention here. This causes confusion and mistrust among both smokers and health professionals.

Deaths and illness linked to vaping in the US in 2019 – wrongly and consistently attributed solely to vaping nicotine liquid – are a case in point. Investigating agencies, and therefore mainstream media, took months to identify and communicate clearly that the majority of affected users were vaping THC liquids containing additives harmful to human health if inhaled, including thickening agent Vitamin E acetate.⁵⁸,⁵⁹ Some surveys have shown that more current smokers now believe vaping is as dangerous as smoking – with the inevitable outcome that they continue smoking tobacco.⁶⁰

The inconvenient truth is that proponents of tobacco control who argue against access to safer nicotine products are paradoxically perpetuating the sale and use of the very thing they are trying to eradicate: the tobacco cigarette. They are supporting the industry they are focused on destroying, to the detriment of wider public health concerns. The inescapable truth is that antipathy to tobacco harm reduction protects and supports much higher risk cigarettes.