Harm reduction is a widely accepted tool used to combat negative outcomes of many human behaviours. In the public health arena, we have seen real and measurable benefits by reducing harm when it can’t be entirely eliminated—the principle of harm reduction has proven effective in addressing public health challenges such as HIV/AIDS, drug use, and the COVID-19 pandemic.
Regrettably, where tobacco harm reduction (THR) is concerned, this strategy has historically been opposed by some regulators and even respected organizations like the World Health Organization (WHO). The consequence of this double standard is that hundreds of millions of people who do not quit smoking are prevented from replacing cigarettes with less harmful substitutes.
Countries have a legitimate interest in reducing smoking, to benefit both their populations as well as public health. But smoking rates are not falling fast enough, because population growth erodes the impact, and promoting cessation only doesn’t address the segment of the population that doesn’t quit smoking.
That is why we can see many countries adopting THR policies to regulate and tax safer nicotine products in a way that makes them more accessible and desirable compared to cigarettes. In these countries, we can see that THR policies are helping to successfully reduce smoking rates.
Countries that have taken the THR route include Canada, Greece, Italy, New Zealand, Philippines, Sweden, U.K., Uruguay, and the USA. Governments and regulators in these places have realized that an abstinence-only approach doesn’t work in reducing smoking rates as fast as they want or need to. They have determined that tobacco harm reduction coupled with promoting safer nicotine products for smokers who don’t quit is in line with their national health strategies.
Perhaps the most assertive and innovative of those countries is the U.K., where progressive steps have been taken on the harm reduction path, from last year, when it was announced that physicians would be able to prescribe vapes to adult patients trying to quit smoking, to this year, with the “swap to stop” initiative. In “swap to stop,” 1 million smokers in England will be offered a free vape starter kit alongside behavioral support to encourage people to quit.
As a result of its continued THR efforts, the U.K. has seen lower smoking rates. From 2014 to 2020, the smoking rate in the U.K. dropped 4 percentage points, while the average rate in neighboring EU countries with no THR policies dipped just 2 percentage points.
In New Zealand, vaping is promoted for its potential to help smokers quit cigarettes and consume tobacco in a way that is less harmful. From 2011 to 2021, New Zealand’s daily smoking rates dropped 7 percentage points, compared to rates in Australia, with just a 5.4 percentage point drop. Australia does not encourage vaping to quit smoking, as New Zealand does.
And then we have what has been called the “Swedish experience.” In Sweden, the wide availability and great popularity of snus has been a contributing factor to Sweden being able to boast record-low smoking rates, not to mention the lowest level of tobacco-related deaths among men in Europe.
Japan is creating its own success story, with heated tobacco products (HTPs) replacing smoking at impressive levels. The current adult smoking rate in Japan is just 13.1%, compared to the average in Europe of 19.7%. Even Australia, with its far stricter tobacco control policies, has a higher smoking rate, at 14.7%.
The Czech government recently unveiled its new Addiction Policy Action Plan, based on the harm reduction approach. It is an evidence-based focus on prevention and treatment with ambitions to regulate the market for addictive substances, including for tobacco. According to the plan, taxation on products should take into account the different levels of harm they cause.
These policies diverge from the WHO’s position, i.e., ban all tobacco products or to regulate them like cigarettes—regardless of where these tobacco products fall on the spectrum of harm. The global public health body has gone as far as rewarding and congratulating countries, such as India, that have banned these products while continuing to sell cigarettes. Something is terribly wrong when the global public health body encourages criminalizing better alternatives, while cigarettes continue to be sold.
The scientific evidence supports a harm reduction approach, and many have criticized the WHO for failing to heed the scientific evidence on non-combustible nicotine products and rejecting THR.
Dr. John Oyston, a tobacco control advocate, retired anaesthesiologist, and assistant professor at the University of Toronto, commented: “It’s hard to understand where the WHO thinks it is when it praises India for banning vaping and continuing to sell cigarettes. … I really don’t know where the WHO is … getting its information from, because it’s not following the science by any means.”
It is crucial that countries evaluate the scientific evidence and case studies of countries who are reducing smoking rates faster in part by adopting THR policies, rather than blindly following guidance that prevents or restricts the ability of smokers who don’t quit to change to less harmful products.
The scientific evidence clearly demonstrates that non-combustible nicotine products are better than continuing to smoke cigarettes, and results are clear, too: Countries adopting THR rates are reducing smoking rates faster than those that don’t.
In fall 2021, 100 experts signed a public letter on the failure of the WHO approach to tobacco smoking and public health. Some of those experts spoke out on why they felt the need for such a letter.
Prof. David Nutt of Imperial College London noted: “WHO continues to insist that smokers should just stop, even though we know millions of smokers simply will not do that and millions will continue to take up the habit. There are no other areas of public health where just demanding abstinence or trying to enforce abstinence via prohibition is seen as a credible strategy, but that is exactly what WHO is advocating for nicotine.”
Former WHO directors, Profs. Ruth Bonita and Robert Beaglehole offered this: “A key challenge in global tobacco control is to assist cigarette smokers to transition from burnt tobacco products to much less harmful options that provide the nicotine without the toxic smoke. WHO’s continuing disregard of the
wealth of evidence on the value of these products is condemning millions of smokers to preventable disease and premature death.”
And David Sweanor, chair of the Advisory Board for the Centre for Health Lay, Policy, and Ethics, University of Ottawa, Canada, had this to say: “Effective public health efforts need to be based on science, reason, and humanism. Yet the world’s premier health body is aligning itself against all three when dealing with nicotine. The result is that one of the greatest opportunities to improve global health, separating nicotine use from smoke inhalation, is being squandered.”
All indications point to the fact that the WHO is not following the science when it comes to reducing the harm from tobacco. Scientific evidence and the interests of public health should be uppermost at the WHO FCTC COP10 taking place in Panama this year. Delegates who fail in this regard are failing the world’s 1 billion smokers.
