Furore over tobacco harm-reduction efforts

Most countries all over the world have banned smoking in public places and the popular advice is, “smoking is dangerous to your health… smokers are liable to die young.”

Researches indicate that most deaths due to smoking result from respiratory diseases such as lung cancer, chronic obstructive pulmonary disease and pneumonia.

In Nigeria, most cities including Lagos have outlawed smoking backed with legislation but poor enforcement has been the pitfall. People still smoke in public places in all the nook and crannies in the country exposing the non-smoker and tender ones to secondhand smoke, which has also been associated with cancer of the lung and other ill-health effects.

According to the World Health Organisation (WHO), the tobacco epidemic is one of the biggest public health threats, killing more than seven million people a year. There are currently one billion smokers worldwide, with nearly 80 per cent of them living in low and middle-income countries, where the burden of tobacco-related illness is greatest.

Indeed, several studies have shown that smoking tobacco is the most harmful way of using nicotine, with the tars and gasses in cigarette smoke being harmful to health, however, many people find it difficult to stop smoking because they find it hard to go without nicotine.

A school of thought suggests that making lower risk products available may help people switch from smoking, ultimately helping avoid the risk of smoking known as “tobacco harm reduction”.

Tobacco harm reduction is a pragmatic approach to reducing the harm of smoking related diseases. People smoke because they are addicted to nicotine and seek a “hit”, but it is the other toxins in tobacco smoke that cause most of the harm. Nicotine can be obtained from a range of products, which vary in their level of harm and addictiveness, from smoked tobacco (that is cigarettes) at the top end of the harm/addiction spectrum, to medicinal nicotine (that is nicotine replacement therapy products) at the bottom end.

A harm reduction approach to tobacco control encourages those smokers that cannot, or are unwilling to, stop smoking, to switch to using nicotine in a less harmful form, and ideally would result in them ultimately quitting nicotine use altogether.

Potential harm reduction products include: Smokeless Tobacco (Snus); E-cigarettes; and Nicotine Replacement Therapy (under construction). The use of safer nicotine products is a rapidly evolving area, with many new non-combustible products emerging. The rapid development and use of these products raises a number of challenging scientific questions about their safety, who uses them and why, and the impact on smoking. These products also raise challenges for governments who seek to understand what kind of policy and regulation is appropriate.

To address these issues, the Global Forum on Nicotine (GFN) 2017 was held last month in Warsaw, Poland.

Reflecting commitment to the development and promotion of evidence-based policies and interventions, the theme of this year’s meeting was “Reducing Harm, Saving Lives”, drawing attention to the potential of safer nicotine products, such as e-cigarettes, oral tobaccos and “heat-not-burn” tobacco products, to reduce the global health burden of smoking.

Participants comprised of policy analysts, regulators and standards experts, academics and researchers, parliamentarians, public health professionals, consumer advocates, and makers and distributors of alternative nicotine products – all with an interest in nicotine and its uses.

This year’s programme examined the rapidly developing science in relation to nicotine use and the changing landscape, including policy responses and the influence of different stakeholders in this. The programme comprised plenary sessions, symposia, panel discussions and poster presentations – including video posters.

Several studies have shown that tobacco harm reduction has been controversial and divisive in public health, in particular where the debate has focused on a possible role for other tobacco products such as Snus, within a tobacco harm reduction strategy. One of the reasons harm reduction is a sensitive topic is that it could involve engaging with the tobacco industry, which has a history of manipulating public debate and public health policy.

Critics posit that to fully understand the harmfulness of potentially reduced risk products and their effectiveness for smoking cessation, tobacco industry investments and research into harm reduction and potentially reduced risk products should be carefully scrutinised. Who has paid for the research, which scientists, organisations and institutions are involved?

In fact, a number of scientists leading the debate on harm reduction and/or potentially reduced risk products are allegedly funded by the tobacco industry. Examples include: Jed E. Rose is director of the Center for Nicotine and Smoking Cessation Research (CNSCR) at Duke University in the United States (US), an institution with a long history of tobacco money. He is the inventor of the nicotine patch, and a nicotine aerosol technology. The Center, his research and his career are closely interlinked with the tobacco industry, more specifically Philip Morris.

The story on Duke University, US, and the Tobacco Industry shows Philip Morris actively promoting the nicotine patch as a quitting strategy, with the research funded by the company and with the endorsement of scientists involved.

A 2012 editorial in the public health journal Addiction suggested we should not be fooled by industry investments in potentially reduced risk products like snus, highlighting that Philip Morris US is currently advertising its Marlboro snus “for when you can’t smoke”, thus encouraging dual use instead of smoking cessation.

Further evidence from the US, where smokeless tobacco is freely available, confirms that smokeless tobacco is being marketed as a tobacco alternative in smoke-free environments. This would suggest that contrary to the industry’s discourse on harm reduction, and the favoured approach by public health experts advocating tobacco harm reduction, the industry appears to have little intention of promoting Snus use as a permanent switch from smoking.

However, the GFN is changing that perception. Chair of GFN, Prof. Dave Sweanor from Canada, told participants at 2017 GFN: “GFN is the only international conference to focus on the role of safer nicotine products that help people switch from smoking. Safer nicotine products include e-cigarettes, oral tobaccos such as Swedish snus, and ‘heat-not-burn’ tobacco products. This is a rapidly evolving area with many new non-combustible products emerging.

“The first conference was held in 2014 and this year we see the fourth annual renewal. All the conferences to date have been in Warsaw. The conference is funded by registration fees and does not receive any sponsorship from manufacturers, distributors or retailers of nicotine products, including pharmaceutical, electronic cigarette and tobacco companies.”

Sweanor said the programme is developed by an international programme committee and is supported by a Polish Host Committee. Knowledge-Action-Change (KAC) provides the administration for the conference. New data released at the GFN showed low risk nicotine product snus is 95 per cent safer than smoking and has the potential to stop 320,000 premature deaths across Europe each year.

The latest evidence, presented by Peter Lee, epidemiologist and medical statistician, indicates that snus is at least 95 per cent safer than smoking.

Analysis by Lars Ramström, snus researcher in Sweden, shows that if snus were made available in Europe –where it is currently banned with the exception of Sweden –and similar use levels to Sweden were adopted, up to
320,000 premature deaths could be avoided among men every year.

While 46 per cent of deaths due to smoking result from respiratory diseases such as lung cancer, chronic obstructive pulmonary disease and pneumonia, there is no evidence that using snus increases risk of these diseases. Nor does snus appear to increase the risk of other smoking related diseases including heart disease, stroke and a range of cancers.

In addition, the public health benefits of snus versus cigarettes are not only much lower, but the role of snus in both reducing initiation of smoking and increasing cessation of smoking is a key element in defeating the actual cause of tobacco-related ill-health caused by the cigarette.

Current European legislation does not allow snus to be marketed in any European country except Sweden. However, due to strong evidence behind its potentially life saving benefits, The New Nicotine Alliance (NNA), a United Kingdom (UK) consumer group supporting access to safer nicotine products, is calling for its legalization and has joined legal action case against the banning of snus, which has now been referred to the European Courts of Justice.

Gerry Stimson, Chair of the NNA stated, “Snus is a tobacco product that has consistently been proven to be less harmful to health than cigarettes. The ban on snus limits smokers choices of safer alternatives and has a significant negative impact on public health”.

Phillips Morris International (PMI) in its presentation at the Forum noted: “Harm reduction policies are based on the view acknowledged by virtually all public health organizations that tobacco use will continue well into the future. As the United Nation (UN) stated in 2004, even assuming current rates of decline in consumption, ‘the number of tobacco users would still be expected to increase to 1.46 billion by 2025.’

“The recognition that people will continue to smoke has led many public health authorities to the conclusion that developing tobacco products that have a reduced risk of causing disease is a crucial element of tobacco policy. This is contrasted with those groups who take an abstinence-based approach that focuses solely on preventing people from beginning to use tobacco products and encouraging people to quit using tobacco products.

“Following a harm reduction policy does not preclude governments from pursuing the objectives of prevention of initiation and encouraging cessation. On the contrary, most proponents of harm reduction are vigorous supporters of those important goals. As we see it, tobacco harm reduction should complement prevention and cessation efforts — not compete with them.

“Our support of harm reduction follows two paths: one is through our research and development of products with the potential to reduce the risk of tobacco related diseases. The other path is through our support of regulation based on the principle of harm reduction.”