Advancing safer alternatives to nicotine

*Experts at Global Forum on Nicotine 2021 say public health, tobacco control must unite in fight against smoking-related deaths, diseases

International public health specialists, scientists, medical practitioners, tobacco control experts, industry and investment analysts and consumers convened for the Global Forum on Nicotine 2021 (#GFN21) on Thursday, June 17 and Friday June 18, 2021 in Liverpool, United Kingdom (UK) and streamed free online, to highlight the vital role of safer nicotine products in the fight to reduce global smoking-related deaths and diseases.

Since the start of the pandemic, the world has lost an estimated 3.75 million people to COVID-19; a devastating figure that remains under half the annual death toll from smoking. Every day, 1.1 billion smokers still light up around the world, a figure that has stalled for over 20 years despite decades of tobacco control efforts. Eighty per cent of the world’s smokers live in low and middle-income countries (LMIC), least able to cope with the disease burden of smoking, and in higher income countries, smoking is a major cause of health inequalities.

People smoke to obtain nicotine, a comparatively low risk substance, but are harmed by thousands of toxins released when tobacco burns. Experts at the Global Forum on Nicotine discussed an approach called tobacco harm reduction; people who cannot quit nicotine are encouraged to switch from dangerous combustible or oral products to safer nicotine products including vapes (e-cigarettes), pasteurised snus, non-tobacco nicotine pouches and heated tobacco products. Compared to continued smoking, all are significantly less harmful to health.

Despite an estimated 98 million adult smokers having already switched to safer nicotine products worldwide, public health and tobacco control remains deeply divided on the role of tobacco harm reduction. The Global Forum on Nicotine gave consumers a voice, with many participating as speakers and delegates and a consumer-focused panel on day two. GFN also offered a platform for debate and information sharing – while remaining focused on the ultimate goal: accelerating the end of smoking-related death and disease.

GFN director, Gerry Stimson, emeritus professor at Imperial College London, said, “Up to 98 million consumers worldwide have already made the switch to safer nicotine products. In England, health authorities support vaping to quit smoking and vapes are now the most popular quit aid. Tobacco-related mortality in Sweden, where snus has almost replaced smoking, is the lowest in Europe. And in Japan, cigarette sales have dropped by a third since heated tobacco products came to market. Manufacturers must now ensure safer alternatives are affordable to people in LMIC, not just consumers in high-income nations.”

Stimson continued: “Worryingly, international tobacco control leaders are doggedly pursuing an irresponsible prohibitionist approach to tobacco and nicotine, while the World Health Organisation (WHO) actively perpetuates misinformation on new nicotine products. Public health will not be served nor lives saved by a war on nicotine, as doomed to failure as the war on drugs. The WHO must refocus its efforts on supporting 1.1 billion adult smokers to quit by all available means.”

Three keynotes were delivered to honour the memory of Professor Michael Russell, psychiatrist, research scientist and pioneer in the study of tobacco dependence and the development of treatments to help smokers quit. Russell’s observation in the British Medical Journal in 1976 that “people smoke for nicotine, but they die from the tar” remains highly influential within the field.

Indeed, amid a packed and varied programme, the message from the 30 speakers who joined the Global Forum on Nicotine 2021 in person or online was very clear. Policymakers in public health and tobacco control need to listen to both the science on tobacco harm reduction and the experiences of consumers who are benefiting from it every day; ideology must be set aside to prioritise progress towards the common goal of ending smoking.

People smoke to obtain nicotine, a comparatively low risk substance, but are harmed by thousands of toxins released when tobacco burns. Experts at the Global Forum on Nicotine were discussing an approach called tobacco harm reduction, in which people who cannot quit nicotine are encouraged to switch from dangerous combustible or oral products to safer nicotine products including vapes (e- cigarettes), pasteurised snus, non-tobacco nicotine pouches and heated tobacco products. Compared to continued smoking, all are significantly less harmful to health.

Professor Gerry Stimson, Emeritus Professor at Imperial College London and a founder of the Global Forum on Nicotine, spoke after the conference: “Much of what I have seen and heard over the last couple of days has been encouraging; it feels as though we’re on the right trajectory. Consumers all over the world are becoming aware of the opportunities offered by safer nicotine products, and innovations in the market will, I believe, lead to the eventual obsolescence of combustible cigarettes. The question is how to speed up the process and scale up, so that tobacco harm reduction reaches all smokers, everywhere, as quickly as possible.”

Multiple panel discussions took in subjects ranging from safer nicotine product regulation, tobacco harm reduction in LMICs, and orthodoxy and dissent in science. Speakers’ pre-recorded presentations for the panel sessions will remain available online at the conference website.

Fiona Patten MP and Leader of the Reason Party, Australia opened proceedings with the first Michael Russell Keynote with her speech – ‘Science and politics: an often fractious relationship’ – from which the following short quote is taken.

Patten said: “In Australia, governments have consistently stated that drug use must be treated as a health issue not a criminal one.

But when it comes to nicotine, they are actively making criminals out of users. And not all nicotine users. Just those who are trying to end their deadly relationship with combustible tobacco.

“Most political parties refuse to accept donations from big tobacco – yet they still protect it. For decades they ignored the science about the dangers of smoking, but today they argue that there is not enough science to sanction alternative nicotine products.

The ‘listen to the evidence and the experts’ mantra has been on high rotation in all politicians speaking notes over the past 18 months. So now may be the time to extend this new-found respect for science and health experts to change tobacco harm reduction policy in Australia.”

Jon Fell, a founder of investment company Ash Park, gave the second Michael Russell Keynote entitled ‘Investment in nicotine innovation: risks and rewards for public health’. Acknowledging the discomfort that industry involvement causes many who are concerned with the health impact of combustible tobacco, Jon put forth a considered defence of active engagement with the industry, rather than divestment: “I respect those whose personal moral views mean they don’t want to own tobacco stocks. But I equate the divestment-in-all-circumstances approach with a bit of an abdication of responsibility: it might make the seller feel good, but it doesn’t really address the underlying problem.

“Shareholder engagement with controversial companies recently hit the headlines in the fossil fuels sector, with activists winning battles against ExxonMobil, Chevron and Shell. Is tobacco uniquely toxic as an industry – even compared to oil and gas? In the same way that we want oil companies to transition their business models towards cleaner energy and reduced carbon emissions, don’t we also want to encourage tobacco companies to shift their business as much as they can towards reduced-harm forms of tobacco and nicotine use?

“The critical thing to note is that investors do care. The market is putting a much higher valuation on companies that are making that transition away from combustible products. And companies certainly notice that.”
Dr. Derek Yach, an anti-smoking advocate for more than 30 years, is the president of the Foundation for a Smoke-Free World. His Michael Russell Keynote addressed the question ‘Why has the WHO FCTC failed to reduce adult smoking and its health impact?’

Yach noted: “From a scientific perspective, the hard work has already been done, but what remains is the difficult cultural and political work.” He continued:

“All bodies following the science appear to have arrived at the same conclusion: harm-reduced products (HRPs) can play an important role in combatting the world’s tobacco crisis. By contrast, institutions attached more to ideology than evidence remain opposed to innovation in this space. There now exist two distinct silos in tobacco research: one in which the evidence for harm reduction is robust and growing; and one in which such evidence does not exist.

“In some cases, opponents cite clause 5.3 of FCTC to justify the wholesale rejection of industry research. This clause is appropriately intended to prevent conflicts of interests among parties to the FCTC – which is to say, among governments. But the clear implementation guidelines for clause 5.3 do not mention bans, prohibitions or boycotts. And they certainly don’t endorse the harassment of scientists.

“Ad hominem attacks on industry researchers are unacceptable. In addition to lacking in integrity, these practices impede the adoption of measures that could save the lives of current smokers. Clinicians and policymakers need easy access to the full body of science if they are to make informed decisions about clinical care and public policy.”

Paddy Costall of KAC Communications, conference organiser, said: “By putting on a hybrid event for the first time, we took a leap in the dark, but we’ve been rewarded immensely with the outcome. Content at #GFN21 was wide ranging, in the GFN Fives, in the pre- recorded presentations from panelists and during the discussions from both stage and commentary team. We see hybrid events as the future for this field and others, and hope that we can continue to play a leading role next year and beyond.”