A shift in the way US and UK policymakers regulate tobacco, e-cigarettes and nicotine could promote public health efforts to reduce smoking and usher in a new era of less harmful alternatives, writes Dr Kgosi Letlape of the Africa Harm Reduction Alliance, and president of the Health Professions Council of SA.
Letlape writes: “The US Food and Drug Administration (FDA) recently announced a bold, new plan that places nicotine, and the issue of addiction, at the centre of the agency’s tobacco regulation efforts. This is in contrast to past efforts to reduce smoking that focussed on tobacco as the main target for control. It comes at the same time as the UK Department of Health also issued a new Tobacco Control Plan, recognising the positive role of innovation and technologies such as e-cigarettes in a smoke-free future.
“This shift in policy direction shows a deeper understanding of why people smoke. People smoke combustible cigarettes because they enjoy the effects of inhaling nicotine, but in doing so they are exposed to the harmful chemicals in cigarettes released when tobacco is burnt.
“In his address, Protecting American Families: Comprehensive Approach to Nicotine and Tobacco, new FDA commissioner, Scott Gottlieb acknowledges: ‘Nicotine lives at the core of both the problem, and ultimately, the solution to the question of addiction, and the harm caused by combustible forms of tobacco.’
“The FDA announcement also clearly recognises that nicotine is in itself not responsible for the cancers, lung disease and heart disease that kill hundreds of thousands of people each year and that it is the other chemical compounds in tobacco and in the smoke created by setting the tobacco on fire that directly cause illness and death. He points out that while nicotine is addictive, the bigger problem is in fact the delivery mechanism – how the nicotine gets delivered.
“‘Attach it to smoke particles created by burning cigarettes and the mechanism is deadly. But attach the very same nicotine to a medicinal product without the other chemicals found in tobacco products and these therapeutic products have been found to be safe and effective by FDA in helping smokers quit.’
“For nicotine replacement products such as gum, lozenges and patches, the FDA doesn’t even require a doctor’s prescription for them. As consumers began to demand reduced risk alternatives to combustible cigarettes, literally tens of thousands of alternative nicotine delivery devices have hit the market over the past few years – vaporisers, e-cigarettes and tobacco heat-not-burn technologies. The proliferation of these new devices left policy makers in a conundrum – how to classify and regulate them?
“Last year, the FDA classified e-cigarettes as tobacco products. This would have meant thousands of innovative alternative devices would have had to go through an expensive pre-approval process and their marketing efforts curtailed, preventing new products from coming to market – and consumers from being educated about them. As the research on reduced risk products continues to grow, it’s clear that they can provide smokers with alternatives to combustible cigarettes and help others to quit. For example, devices which heat, not burn tobacco reduce the formation of harmful or potentially harmful compounds compared to combustible cigarettes.
“Other countries have introduced harm reduction policies which have led to major public health gains. Products such as ‘Snus’, a chewable form of tobacco, have a 200-year history of use in Sweden without any verifiable evidence of serious adverse health effects. It also remains the most widely used and successful method in assisting smoking cessation. Sweden now boasts the lowest smoking rate in Europe. The Swedish government released data showing that the proportion of men aged between 30 and 44 smoking fell to just 5% in 2016.
“Overall, just 8% of Swedish men now smoke on a daily basis – itself a record-low percentage – compared with an EU average of just over 25%. There is broad academic consensus that Sweden’s success is directly attributable to the broad migration from traditional cigarettes to Snus. And according to a report published in 2017, EU-wide adoption of Snus may have contributed towards saving over 300,000 lives per year since 1992. The opportunity for tobacco harm reduction is unprecedented.
“There is movement in the right direction in some countries. The new policy approach of regulators such as the FDA, reflects a harm reduction approach to dealing with the negative effects of smoking – recognising the potential for science-based innovation to lead to less harmful products. Instead of banning non-combustible, reduced risk and smokeless-tobacco products, it calls for evidence-based regulation and recognises the positive role they can play in promoting public health objectives.
“In South Africa, there are 8m smokers, with a growing group of e-cigarette users of about 200,000. If our policy makers are concerned about achieving a smoke-free future, the key will be the adoption of sound regulations that can significantly help consumers accelerate switching from cigarettes to reduced risk products.
“All stakeholders in the industry need to embrace the opportunity offered by science and innovation. Governments have a key role to play by encouraging innovation, providing smokers with confidence in claims made by manufacturers and encouraging them to switch to better alternatives.
“Clearly, the best thing for health is to quit tobacco and nicotine use altogether. But for those who don’t, better choices should be made available. Echoing Gottlieb’s recent statement, we need to envision a world where less harmful alternatives, efficiently delivering satisfying levels of nicotine, are available for those adults who need or want them. This requires a bold vision and policy making that emphasises harm reduction and sound innovation.”