While an intense battle continues globally – led by anti-smoking NGOs, some national governments, and the World Health Organization (WHO) – an increasing amount of research is being done on effective new harm reduction technologies for smokers, reports NE Global.
Ultimately, they have the potential to save many lives – and support public health more effectively – than coercive measures aimed at direct prohibition of smoking.
In September, a Spanish NGO launched a petition to ban nicotine consumption in Europe for those born after a certain year. Considering how Prohibition in the US went, we can imagine how damaging a nicotine ban in the EU would be.
The WHO itself is projecting more than 1bn smokers globally in 2025, approximately the same number as now. According to OECD data, smoking-related diseases are still one of the leading causes of death, as was the case 20 years ago.
It seems that tobacco control measures, which focused solely on prevention and cessation, have not reached their objectives.
Some encouraging signals came from the European Parliament that, during February’s plenary session, adopted the report of its Committee on Beating Cancer, including references to tobacco harm reduction. This was the first time an EU institution has accepted its relevance in an important policy-forming document.
Despite this, the Commission, which has successfully applied risk reduction-oriented regulation in alcohol, sugar, salt, including fuel, and cars, is adamant in not doing so for tobacco.
Regulation and consumer demand
Even assuming global cigarette consumptions continues its gradual decline in some places, consumer demand for tobacco and nicotine-based products seems to be here to stay – making the battle lines between industry and EU and WHO tougher to hold on the regulators’ side.
In researching this article NE Global uncovered a 2016 WHO Report on Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS) produced for a global meeting promoted by the WHO every two years to debate and provide guidance on what’s next for tobacco control. This report includes a statement on novel products, which is simple and clear:
“If the great majority of tobacco smokers who are unable or unwilling to quit would switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement. This would only be the case if the recruitment of minors and non-smokers into the nicotine-dependent population is no higher than it is for smoking, and eventually decreases to zero.” The next sentences explain how public health communities were divided back then between prohibitionists and risk reduction champions.
Between 2016 and 2022, while the WHO has not commissioned any scientific research, or a review of all published science on the relative harms and benefits of new nicotine products, it has encouraged and supported a policy of countries banning non-combustibles.
For example, India’s Minister for Health received a WHO award for his role in banning e- cigarettes in India. So, what are millions of Indian smokers who have failed to quit going to do after being denied access to products that pose a fraction of the risk of smoking? Continue smoking?
It appears the public health debate to which the WHO alluded focusing on new products’ role in steering smokers away from cigarettes has not been won either by prohibitionists, though they appear to have a lead, nor by the risk reduction advocates.
NE Global was invited to tour the research facilities in Neuchatel Switzerland operated by Phillip Morris International (PMI), also known as “The Cube”, where the bulk of PMI’s research into new reduced-risk products is conducted. The research focuses only on the development and assessment of alternative smoke-free products.
What is harm reduction?
“Harm reduction” is a broad strategy seeking to reduce the potential harm caused by a dangerous activity rather than banning the activity itself. In tobacco, harm reduction strategies include the development of less harmful and science-based products. These scientific advancements must be supported by government strategies – like differentiated taxation policies and updated regulations regarding sale and use of these products – to have a positive impact on consumers and society.
This is very far from what is proposed in many current anti-smoking campaigns and policies. In fact, some countries seem still blind to the public health potential of these products and the progress they represent. In some cases, they are even banned while the smoking rates remain stable or increase.
Following a scientific approach
The scientific approach to harm reduction followed by PMI is based on acknowledged research conclusions that the use of products that do not involve combustion is less harmful than cigarettes. Nowadays, a wide body of research supports the conclusions that the main cause of harm comes from the chemicals generated by smoke when a cigarette is burnt.
For example, the UK’s Royal College of Physicians stated: “Harm reduction works by providing smokers with nicotine without the tobacco smoke responsible for almost all of the harm caused by smoking.”
PMI’s efforts in the smoke-free space steadily expanded in 2008 – when the company was spun off from its US owner (Altria) – and today counts 930 R&D experts in various fields. Last year, the company became the 45th largest patent filer in the EU, and the only tobacco company in the EU’s top 100.
Scientific evidence’s impact on progress
Tommaso di Giovanni, PMI’s vice president for international communications, told NE Global how some stakeholders, like international organisations, or regulators and NGOs, will require more time before they accept the idea that people who continue smoking are entitled to science-based policies. We should also consider how many people will continue smoking, despite the price, by buying cheaper illicit cigarettes.
Considering the billions invested by PMI so far into transforming into a technological, scientific and health and wellness corporation, and how, on their corporate website they say they want to get rid of cigarettes, they must have expected a different reaction from international organisations, states, and society.
PMI states that its transformation is a response to the calls from these organisations, which have spent years demanding PMI and others come up with a safer product. These same organisations claim that a new generation of tobacco products will provide a lifeline to an ailing industry, as these products attract more consumers.
Risk reduction solutions are never accepted until they are, which is why Di Giovanni indicated that the resistance from some governments and NGOs had recently begun to decrease and that “there is movement in the right direction”. The more than 50 independent studies and government agency assessments that confirmed important elements of PMI’s research – such as the US FDA, the Dutch Health authority (RIVM), the German Risk Assessment institute (BFR) – certainly played a role in this direction.
Di Giovanni added: “It is encouraging to see that a growing number of countries have adopted a regulation clearly differentiating nicotine and tobacco products based on their relative risks. Differentiated regulation can drive consumers to adopt better alternatives if they do not quit, and companies to invest in innovation. It is unfortunate that some countries prefer to focus on fears of potential unintended consequences of these products and neglect the clear scientific evidence showing that e-cigarettes and heated tobacco products are a better choice than cigarettes. Smokers who don’t quit should not be left behind.”
Like all tobacco giants, Phillip Morris included, they are supposed to have advocated a few decades ago that smoking was not addictive or harmful. It is understandable why tobacco companies have spent the past few decades atoning for what they did, and that explains the way tobacco products are regulated, and perceived by the public.
It was and still is not easy to have public and transparent conversations with scientists and other organisations leading tobacco policy debates. Di Giovanni prefers to focus on the present and future, stressing how PMI is prepared to speak to everyone. “It is time that opponents to pragmatic solutions start to see and understand the growing evidence out there.”
As scientific evidence accumulates, safer products will dominate
University of Ottawa Adjunct Law Professor David Sweanor told NE Global that as the scientific evidence is generated and released, public health priorities will unquestionably change. But there is a long way to go.
“It is beyond question that there are nicotine products which are massively less hazardous than cigarettes,” he said. “There remains a need for evidence to show that people who would otherwise smoke cigarettes will move to these alternatives in sufficient numbers to make it a public health priority. To date, this data is held back by what appears to be a classic ‘bootleggers and Baptists’ problem in that cigarette companies have the best insights on substitution effects but refuse to cooperate on releasing such data, and much of the anti-tobacco movement is too wedded to an abstinence-only ideology on nicotine use to be willing to fund independent work.”
Sweanor said changes in nicotine product usage is happening already. “But we are seeing substitution effects in any event. Countries like Japan (heated tobacco) and Norway (snus) are great examples. As more data become available, and especially if a major tobacco company truly pivoted to a position of seeking to speed the global transformation away from cigarettes as rapidly as possible, the evidence will be impossible to ignore. Abstinence-only campaigns will then take the same path to embarrassed oblivion as has happened to so many similar campaigns on other products and behaviours. “
Sweanor believes we are only at the beginning of a major product substitution cycle away from cigarettes.
“To date, product substitution effects that have dramatically reduced cigarette sales have been based on only a narrow range of alternative products being available, little public information on relative risks and no coordinated policy measures to encourage switching. Indeed, safer products have been strongly opposed by many health bodies. As data accumulate and countries compete to lower smoking rates, we can anticipate efforts to facilitate a range of low-risk alternatives with marketing and tax/price advantages over cigarettes and active efforts to empower people to make informed decisions. The decline in cigarette smoking could be truly dramatic, on par with past public health revolutions, like the move to sanitary food and water.”
See more from MedicalBrief archives:
Unlike cigarettes, electronic nicotine delivery shows no increased risk of CVD – US study
Smokers’ misconceptions regarding e-cigarettes deter harm reduction behaviours
E-cigarette Summit – Unlocking the harm reduction potential of e-cigarettes