Former WHO officials highlight harm reduction as a key strategy for tobacco control

Lancet article by Robert Beaglehole & Ruth Bonita shares successful public health strategies

NEW DELHI, Feb. 8, 2024 /PRNewswire/ -- As WHO FCTC Conference of the Parties 10 (COP10) is underway to discuss the road map for global tobacco control efforts, The lancet, a leading medical journal published an article by former WHO directors Robert Beaglehole and Ruth Bonita. The article highlights how harm reduction is a successful public health strategy & suggests that it should be a central strategy of the WHO Framework Convention on Tobacco Control (FCTC) in addition to the measures for demand and supply reduction which are necessary, but not sufficient.

WHO FCTC has been influential in encouraging a global response to tobacco control, but it has been challenging to show a strong and consistent association between the implementation of FCTC measures and smoking prevalence and cigarette consumption outcomes. The FCTC does not prohibit harm reduction approaches but leaves it up to countries to decide how to regulate e-cigarettes and other novel nicotine products. WHO's lack of endorsement of tobacco harm reduction limits healthier choices for the 1•3 billion people globally who smoke and who are at an increased risk of early death. 

There is no scientific justification for WHO's position that e-cigarettes and other novel nicotine products should be treated in the same way as tobacco products. This position overlooks a risk-proportionate approach. We believe WHO needs to provide positive leadership and technical support to countries as they consider the use of e-cigarettes and other nicotine delivery devices. WHO's current approach to these lower-risk product is to reward countries, such as India, for banning e-cigarettes; thirty-four countries, primarily low-income and middle-income countries, now ban e-cigarettes.

In some countries, substantial reductions in smoking prevalence have coincided with the uptake of novel nicotine products. In New Zealand, for example, the prevalence of adult daily smoking plummeted from 13•3 per cent in 2017–18 to 6•8 per cent in 2022–2023 after e-cigarettes became widely available, a 49 per cent decline in 5 years. In the same period, and with the support of the government and regulation of vaping, the prevalence of adult daily vaping increased from 2•6 per cent to 9•7 per cent. New Zealand's recent decline in smoking occurred in the absence of any other major tobacco control policy, apart from the annual cost-of-living price increases. The decrease in smoking during this period in New Zealand shows what can be achieved and exceeds the WHO smoking prevalence reduction goals of 30 per cent over 15 years from 2010 to 2025.

The New Zealand 2022 smoke-free legislation includes a "tobacco-free generation", a 90 per cent reduction in smoked tobacco retail outlets, and compulsory denicotinisation of retail tobacco. The New Zealand Government, elected in November 2023, is committed to reaching the Smokefree 2025 goal of 5 per cent (or less) smoking prevalence for the adult population, but intends to repeal the 2022 smoke-free legislation. However, because of the implementation timelines, fears that this repeal would jeopardise the Smokefree 2025 goal can be allayed; none of the three headline measures would be expected to have an impact before 2025 and might have had negative unintended consequences. Based on recent progress, New Zealand's Smokefree 2025 goal looks likely to be reached by consent rather than coercion and by further support for switching to smoke-free nicotine products.

Other high-income countries have also succeeded in reducing smoking prevalence in association with the use of a range of lower-risk nicotine delivery devices to complement FCTC demand and supply reduction measures. Sweden, with a long tradition of snus use, has the lowest prevalence of adult daily smoking in the world, down to 6 per cent in 2022, accompanied by low mortality from tobacco-related diseases. Norway has had similar success with reducing smoking prevalence in the context of increased use of snus and e-cigarettes, and in England vaping is helping adults to quit smoking. The substantial decline in cigarette consumption in Japan is associated with the rapid uptake of products that heat, rather than burn, tobacco. Less progress has been made in low-income and middle-income countries where tobacco control capacity and political will to advance tobacco control measures are weaker, and the potential of tobacco harm reduction is not being realised.

Two concerns suggest why tobacco harm reduction is not more actively embraced, despite its association with reduced smoking prevalence. The first is that, compared with cigarettes, where the damage has been known for more than half a century, the long-term effects of e-cigarettes are unknown. Although vaping may not be risk-free, especially for people who do not smoke, the risks of there being substantial long-term harm from the constituents of e-cigarettes are likely to be low, especially when compared with the damage caused by smoked tobacco.

The second concern is that the widespread availability of e-cigarettes in the absence of adequate controls and regulations encourages youth nicotine dependence and enables the vaping industry to act unethically. There is little evidence to suggest that vaping leads to smoking among youth, and although the proportion of non-smoking youth who vape is increasing, it remains at a fairly low level. Stricter regulations, including enforcing sales restrictions, and appropriate health promoting campaigns are needed to prevent vaping by young people, but these measures must be balanced with the health needs of older adults who smoke and require support to quit.

There is understandable skepticism about the motives of the tobacco industry in selling smoke-free products while continuing to expand tobacco markets in low-income and middle-income countries. To remain profitable, the tobacco industry will eventually need to migrate its global business to less harmful alternatives since cigarettes will no longer monopolise the delivery of nicotine.

The WHO FCTC Conference of the Parties 10 (COP10), the governing body of the FCTC, is being held in Panama from Feb 5–9, 2024. The critical background papers to COP10 recommend treating nicotine products as equivalent to cigarettes and regulating them in a similar way. This approach is a retrograde step because they are not comparable products in terms of the damage they cause; after all, it is the burning of tobacco that causes harm, not nicotine. Worse, such a strategy would ultimately favour the global cigarette market and may discourage vaping.

The focus must remain on the central public health problem—the damaging health effects of tobacco consumption. Reducing cigarette smoking is the most effective way to prevent tobacco-related deaths and tobacco harm reduction is the fastest and fairest way to lower smoking prevalence. WHO needs to embrace these innovations in nicotine delivery. Countries that are reaping the benefit of tobacco harm reduction, such as New Zealand, Sweden, Norway, England, and Japan, should encourage participating countries at COP10 to support proposals that will quickly reduce smoking rates. The world's 1•3 billion people who smoke, half of whom will die early, deserve this leadership.

About The Lancet Group

The Lancet started is an international weekly general medical journal in 1823. It continues to make science widely available so that medicine can serve and transform society through its 24 journals that are a part of The Lancet Group today.