There are 1,1 billion smokers worldwide and combustible tobacco products continue to kill more than 8 million of its consumers per year. Although most smokers want to quit, only 4% succeed. For those adult smokers who are unwilling or unable to quit smoking, non-combustible, nicotine-based alternative products now offer a "fire-escape". These products represent "Harm reduction strategies", envisioned in Article 1(d) of the WHO's Framework Convention on Tobacco Control (FCTC). What are the regulatory hurdles to accelerating tobacco harm reduction, as adjuvant to tobacco control? What regulatory principles need to be established, scaled and leveraged to save more lives of adult smokers? How can we harness harm reduction innovation to make preventive tobacco control more efficient, and free up resources for global healthcare?
We were joined for a virtual dialogue by a distinguished panel of harm reduction experts;
The RESET framework was discussed by the panel. The below information shines some light on what exactly this framework entails:
R = Risk - based regulation (labelling, packaging, promotion)
E = Ensuring intended use (prevent youth access, safety)
S = Safety and Quality (ingredients, product standards, testing + conformity with chemical and electronic regulation)
E = Environmental Considerations (lifecycle of ENDS, regulating environmental impact, align with ESG standards)
T = Traceability and Fiscal Policies (regulation ensuring product authenticity throughout supply chain, risk-proportionate fiscal polices)
The webinar recording can be seen here.
This month, we mark three important events: International Harm Reduction Day on 7 May, World Vape Day on 30 May and World No Tobacco Day on 31 May. In spite of the dualistic impression one derives from the war-like language that often mars discussion between ‘tobacco control’ and ‘tobacco harm reduction’ (THR) communities, they actually share a common goal: to minimise tobacco-related disease and premature death.
The harm reduction approach is already enshrined in Article 1d of the World Health Organisation’s (WHO) Framework Convention on Tobacco Control (FCTC). And yet their policies and public discourse do not reflect this. In a recent update of the WHO website’s Q&A section about e-cigarettes, they continued to assert the following: • E-cigarettes are ‘dangerous’, ‘harmful’, and ‘toxic’ – with no reference to the relative risk compared to combustible cigarettes • E-cigarettes provide a gateway for youth to cigarettes – this claim is not backed by any robust evidence, and has in fact been refuted by numerous public health experts • Vaping can cause lung injury, misnamed ‘EVALI’– a misrepresentation that is 'killing people' • “To date, evidence on the use of ENDS as a cessation aid is inconclusive” – please refer to the Cochrane Collaboration’s living systematic review indicating that e-cigarettes do help smokers quit cigarettes, and probably more effectively than nicotine replacement therapy.
This misrepresentation of facts is squandering the opportunity to help millions of smokers switch to much less harmful products, such as nicotine vapes and pouches. Herein lies the difference in approach amongst THR advocates; backed by evidence and pragmatism, THR supports the provision, rather than prohibition, of safer alternatives to those who are struggling to quit cigarettes. Here are six ways in which harm reduction differs to prohibition:
In the FCTC’s biennial Conference of the Parties (COP) meetings, ministers from around the globe convene to share their progress on implementation of tobacco control measures. These fora provide an opportunity for international cooperation. The problem is that they exclude any perspective sympathetic towards harm reduction, despite reasoned imploration from hundreds of independent experts. Within these ideologically confined meetings, awards are given to those who toe the dogmatic line of condemning vaping. Astonishingly, in 2019 India’s health minister was lauded with special recognition for his country’s ban of e-cigarettes, despite robust evidence that they are at least 95% safer than cigarettes. Rather than viewing all nicotine use with irreconcilable hostility, harm reduction advocates acknowledge that nicotine is not the enemy. They are open-minded about the continuum of risk of products, with the ultimate aim of helping people move away from the most harmful ones.
After a recent ban of e-cigarettes in Hong Kong (despite evidence that they are helping reduce smoking rates), two people were recently arrested for selling nicotine vaping products. Whilst the sale of cigarettes remains legal and widespread, the cost of selling e-cigarettes is up to 6-months imprisonment. In contrast, on the Isle of Man, a 2008 ban on tobacco in prison led to inmates smoking illicit materials, including banana peels, tea bags, and nicotine patches. In response, a pilot scheme introduced the provision of regulated e-cigarettes for inmates to use in their cells and outdoor spaces. Since the trial began, there have been 58% fewer behaviour warnings, a 25% increase in intention to quit smoking, and an annual saving of £8500 on nicotine patches.
Riding in a car is an activity with inherent risks. Reasonable steps can be taken to minimise driving-related harm, such as seat belts and speed limits. Similarly, harm reduction proponents accept that e-cigarettes, like driving, are not completely risk-free. However, there is increasing evidence, beyond reasonable doubt, that they are significantly safer than cigarettes. Bearing this in mind, and the fact that merely 4-7% of smokers succeed in quitting using traditional measures, the pragmatic approach is to offer safer alternatives. A randomised trial published in 2019 showed that using e-cigarettes nearly doubled the chance of quitting smoking compared to nicotine replacement therapy.
As described earlier, the WHO’s current stance is that “evidence on the use of ENDS as a cessation aid is inconclusive”. This statement is ideologically driven, rather than evidence-based. In contrast, a growing list of reputable and independent public health organisations and experts are acknowledging the tremendous potential of vaping to displace smoking and improve individual and population health. Two former directors of non-communicable disease control at the WHO, Prof Ruth Bonita and Prof Robert Beaglehole, have said: “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.”
At the recent E-Cig Summit in Washington D.C., Marc Slis delivered a memorable address as an ex-smoker, vaper, and vape shop owner. Commenting on the anti-vaping lobby’s scaremongering campaigns, he said: “Smokers are treated as acceptable collateral damage in a war against Big Tobacco. You trained the public to despise us. You trained us to despise ourselves”. It does not need to be this way; harm reduction practitioners are committed to meeting people ‘where they are’ in their lives without judgement. Harm reduction focuses on motivating positive change through facilitation rather than coercion.
A prime example of prohibitionists’ authoritarian approach is how the International Network of Nicotine Consumer Organisations (INNCO) has been repeatedly denied observer status to the FCTC’s COP meetings. Rather than engaging with the very people impacted by their decisions on a daily basis, WHO continues to exclude them from the conversation. Conversely, harm reduction strategies emphasise the importance of empowering people to have control over their own health in order to live healthier lives. It respects people’s consumer rights, including the right to choose.
Call for evidence deadline: 17th June
The EU commission would like to hear your views on the modern ways to manage and curb smoking addiction. Future tobacco regulation must be based on sound data and evidence to ensure risk – proportionate regulation is adopted for new product categories.
The Commission will evaluate the tobacco control legislative framework, namely the promotion, sponsorship, product regulation and advertising, in the broader context of other related tobacco control policies. This comes in response to the rapid rise of recent technological advancements in emerging products.
This evaluation will assess to what extent the framework has fulfilled its goals and whether it is able to support a ‘Tobacco-Free Generation’ by 2040, as announced in the Europe’s Beating Cancer Plan.
Most respondents were concerned that banning vaping would increase the black market and they would strongly welcome a law ensuring risk - proportionate regulations of alternative nicotine products (as long as evidence showed that they helped smokers to switch from cigarettes) and forbidding sales to minors. In late 2021, Kantar undertook a study in Taiwan regarding usage and attitudes towards vaping, tobacco products and cigarettes. In addition, Kantar worked on the survey design, analysis and reporting of results.
Survey Approach and Findings
An online approach was used with respondents contacted via Kantar’s consumer panel and screening questions were used to ensure participants met agreed definitions for target groups in each country. A total of 1001 people were interviewed in Taiwan.
Survey recruitment was based solely on e-cigarettes usage, so all respondents were vapers. Among them more than a third used a heated tobacco product (38%) and/or used an oral tobacco product (36%).
Questions covered a range of topics including current usage and perceptions of products including attitudes towards quitting smoking and methods used to help giving up.
Vaping alone was used as a way to cut down on smoking by as much as 25% of respondents and after trying to quit smoking on several occasions. However, the most common approach used in these previous attempts was without any medication or substitute. As many as 34% use any replacement product to cut down the amount smoked and 18% will use ANY replacement product to stop smoking entirely.
All in all, while vaping is, on balance, more likely to receive approval from peers and family than smoking cigarettes or using heated or oral tobacco products, it is notable that many vapers still expect to receive disapproval for using e-cigarettes.
There is a need for risk - proportionate regulations for e-cigarettes, in particular focusing on quality and usage by minors, as well as a correction of misinformation related to any over-perceived harms of vaping and nicotine.
To read the summary report, click HERE.
It is notable that many vapers still expect to receive disapproval for using e-cigarettes, however on balance, vaping is still MORE likely to receive approval from peers and family than smoking cigarettes or using heated or oral tobacco products.
In late 2021, Kantar undertook a study regarding usage and attitudes towards vaping, tobacco products and cigarettes in Malaysia. In addition, Kantar worked on the survey design, analysis and reporting of results. The study was completed with those people who used e-cigarettes and/or other tobacco products. Questions covered a range of topics including current usage and perceptions of products including attitudes towards quitting smoking and methods used to help giving up.
Survey Approach and Findings
An online approach was used with respondents contacted via Kantar’s consumer panel and screening questions used to ensure participants met agreed definitions for target groups in each country. A total of 500 people were interviewed in Malaysia.
In Malaysia, where recruitment was based on e-cigarettes and oral tobacco usage, four out of ten vapers are also using a heated tobacco product and one in five vapers were also using an oral tobacco product. For those who chose to vape because they like the taste, fruit (61%) and mint (44%) were the most enjoyed flavours.
In general, people agreed that e-cigarettes should be made available to smokers on the basis of being a less harmful product. Respondents agreed with the promotion of e-cigs as a less harmful alternative to smoking tobacco cigarettes.
Support for Regulations
Government regulation of e - cigarettes is strongly supported by the respondents. There is also strong support for regulation of quality and sales to minors.
There is strong support for a tax on e-liquid used in vapes, however, the tax (as announced during the Budget 2022) was perceived as too high.
To read the summary report, click HERE.
In our era of big data and hyperconnectivity, “we are drowning in information but starved for knowledge”, as John Naisbitt once said. Since the inception of the like and share buttons on social media over 10 years ago, the fragmentation of societal perspectives into echo chambers has intensified. To counterbalance this catalysation of our instinctively tribalistic tendencies to organise ourselves into groups with shared beliefs, we need rational thinkers who communicate clearly to challenge the status quo.
In tobacco control, the decades-long status quo has been to view any nicotine use, regardless of delivery method, through a moralistic, binary lens. Out of this was borne the ‘quit or die’ approach traditionally employed by well-meaning health professionals in their interactions with smokers. However, as Dr Colin Mendelsohn explains in chapter 3 (‘Busting the Myths about Nicotine’) of his book, nicotine does not cause cancer, lung disease or heart disease. Backed by over 400 scientific publications, and over 30 years of experience as doctor with a specialist interest in smoking cessation, Dr Mendelsohn articulates compellingly how health professionals and smokers alike need to target the smoke from combustible tobacco as the noxious agent, not nicotine.
By spearheading this revolution in thinking in Australia, Dr Mendelsohn represents one of a growing list of eminent global expert individuals and organisations who support tobacco harm reduction as a pragmatic, compassionate, and innovative solution to the world’s leading preventable killer: smoking, not nicotine.
We spoke to Dr Delon Human, Physician and CEO of the Africa Harm Reduction Alliance, about Dr Mendelsohn’s book. He praised its primary aim – to help smokers, as well as its appeal to a diverse audience: “Public discourse about vaping and tobacco harm reduction has become increasingly polarised. In such a dogmatic environment, smokers are left wondering in the lurch about what the truth is. Dr Mendelsohn’s book cuts through the noise to provide a compelling and hysteria-busting case for nicotine vaping as a viable and life-saving alternative to combustible tobacco. His authority and clarity of communication is informed by a lifetime professional commitment to helping smokers quit or switch to safer alternatives, and a balanced consideration of scientific evidence; his book references over 400 scientific publications. Dr Mendelsohn’s rational, articulate and compassionate approach will appeal to smokers, their families, health professionals, and policymakers alike.” – Dr Delon Human.
Not only does Dr Mendelsohn’s book provide a comprehensive and practical how-to guide for smokers considering vaping as a safer alternative to smoking, but it also delves into a deeper analysis into societal beliefs around vaping. In Part 3 (‘Controversies and Solutions’), Dr Mendelsohn dissects how we have reached a point in the debate where an appreciation of the scientific evidence supporting vaping is not enough to overcome the vehement backlash: “Much of the opposition is not about the evidence. It is driven more by hidden ideological, moral, political, and other agendas. [Part 3] explores how anti-vaping groups defend the indefensible and justify their position without the support of science”.
For health professionals, this book’s status as ‘required reading’ is cemented by the fact that the vast majority of doctors in a recent study incorrectly believed that nicotine causes cardiovascular disease, COPD, and cancer. In contrast, evidence published this month from an Australian national survey found that using nicotine vapes to quit smoking increased the odds of success by 68%-124% compared to not using a vape. Dr Mendelsohn’s quest to share the healthy truth about vaping as a tool to help smokers quit is commendable; we highly recommend reading his book.
Enlightening interview with Dr Derek Yach by Taco Tuinstra from Tobacco Reporter, in which Dr Yach explains how the innovation of THR represents the single most impactful public health opportunity. In his remarks, he described how independently verifying the science underpinning reduced-risk products transformed his thinking with regards to engaging with industry:
"The history of distrust is very deep, and very difficult to overcome. In my mind, the way I overcame it was by actually looking at the science, and looking at the evidence, and realising that the benefits for public health were so big that I needed to overcome my initial concerns.
It doesn’t require you trusting industry to move ahead, it requires you verifying what they are saying they are doing: verify the quality of the science, verify it in terms of long-term studies, look at the genomics, the metabolomics, the epidemiological and clinical studies. There’s no trust involved in that - just an independent ability to judge the science." - Dr Derek Yach
Full interview HERE 👇
AHRA (Africa Harm Reduction Alliance) hosted a Twitter Chat with the prominent THR advocate Aishat Alaran (@alaranaishat) to learn more about one of the women behind the Campaign for Safer Alternatives (C.A.S.A) organisation. Aishat spoke openly and candidly about why it is important to have equal representation of females and males in THR, saying that ‘smoking is not limited to one gender, so the fight to reduce smoking should not be restricted to a single gender’.
She also told AHRA about her mother, who has constantly been a source of inspiration for her, “She sets positive examples for me that constantly reminds me to strive to become the best version of myself.”
When asked how she pushes for systemic change around ideas that are new or not popular, she speaks candidly about what she feels needs to be done to “change the status quo”. She also cites another prominent THR advocate named Professor Marewa Glover as being another source of inspiration, especially when working under her leadership during a Tobacco harm Reduction Scholarship. Impressively, Professor Glover has 100 publications to her name.
Click HERE to access the new E – Book.
In a change that will favour vaping consumers today, Italy has adjusted its tax on e-liquids for the fourth time in four years.
The tax rate on e-liquids containing nicotine will decrease from €0.175 (U.S. equivalent: $0.19) per millilitre to €0.13, and the zero-nicotine e-liquid tax will fall from €0.13/mL to €0.08. The new, lower tax rates are in line with the levels set in 2021 (these levels had seen an increase in January 2022).
Italy has experienced a turbulent history when it comes to vaping products. In 2014, the Government made vapes as expensive as cigarettes, which meant that 75% of the ‘thriving’ vape industry had been wiped out. The tax was the highest in the EU, which almost doubled the price of e-liquid. This meant that vapers were now seeking the black market and some returned to smoking.
However, in 2019 the vaping community applied pressure to the Parliamentary legislators and they finally reduced the tax rate by 80%, to a far more reasonable €0.08 per mL for e-liquids containing nicotine, and €0.04 for nicotine-free e-juices. However, last year the legislators increased the tax yet again, only to (finally) reduce them today.
This is an opportunity for vapers to be heard before the anti-vaping policy is locked in for the rest of the decade.
The draft strategy lacks urgency. It sets a very modest goal of <10% adult daily smoking by 2025. In sharp contrast, New Zealand recently set a target of <5% daily adult smoking by 2025 for all population groups including Maori and Pacifica groups. Vaping is a key element of this plan.
Please make a submission before the deadline of 24 March 2022. More information about making a submission can be found HERE.
“The main element missing from the draft Strategy is tobacco harm reduction, ie the use of safer nicotine alternatives such as vaping, heated tobacco products, Swedish snus and nicotine pouches for smokers who are unable to quit with other methods”
Vaping is supported by the Royal Australian and New Zealand College of Psychiatrists and Royal Australian College of General Practitioners for smokers who are unable to quit with conventional strategies. However, the draft strategy ignores their advice. In Australia it is easier to purchase a deadly cigarette than a far safer alternative.
Continuing the traditional 'quit or die' approach will result in a continuing sluggish decline in Australian smoking rates and another embarrassing failure to reach the smoking target. Smokers are being thrown under the bus. We need to do better.
The draft strategy sets out the Welsh Government’s vision for a smoke-free Wales by 2030, this means achieving a smoking prevalence rate in adults of 5% or less over the next eight years.
To support this ambition, they will be driving forward work across their three key themes of Reducing Inequalities, Future Generations and a Whole-System Approach for a Smoke-Free Wales.
The consultation will close on 31 March 2022. They want to hear views and get feedback on their plans for tobacco control in Wales from everyone affected by tobacco in Wales, including the public, young people and stakeholders.
They are also planning engagement events during the consultation period. If you would like to be involved, please contact them at: [email protected] for further details.
Government page to read more about the Consultation: HERE
How to respond
Submit your comments by 31 March 2022, in any of the following ways:
Complete our online form
Download, complete our response form and post to:
Risk Behaviours Team Welsh Government Cathays Park Cardiff CF10 3NQ
A group of world-renowned tobacco harm reduction experts spoke at the Africa Tobacco Harm Reduction Forum (ATHRF) a week ago, to discuss a potentially transformational product for the Africa market: #OralNicotine (Is it a gateway to a smoke-free Africa?).
Watch the full event recording HERE on the AHRA YouTube channel!
Misperceptions about the safety of vaping are rife; the misnomer of 'EVALI' is a major contributor. There is no evidence that anyone developed EVALI from nicotine #ecigs. Rather, it was illicit THC products containing Vit E Acetate.
The cost of this misinformation is that only 11.2% of respondents to the National Cancer Institute (NCI)'s 2020 HINTS survey said that e-cigarettes are safer than combustible cigarettes - a fact acknowledged by the Centers for Disease Control and Prevention.
75 public health experts, and Iowa's Attorney General Tom Miller, wrote to the Centers for Disease Control and Prevention in August 2021 petitioning for the lung injury to be renamed Adulterated THC Vaping Associated Lung Injury (ATHCVALI). This name communicates far more accurately to the public what health risks exist. However, the CDC has thus far declined to correct the misnomer of 'EVALI'.
One of the 75 public health experts, Michael Pesko (health economist at Georgia State University), said to reporter Marc Gunther: "The CDC made a gross error. The CDC's miscommunication is actually killing people, in my opinion."
The UK's Health Secretary, Sajid Javid MP, believes it is a “moral outrage” that England’s richest people are living for up to a decade longer on average than the poorest.
To help tackle this disparity, he is plotting a #vaping revolution, writes Caroline Wheeler in yesterday's edition of The Sunday Times.
"England will become the first country in the world to prescribe e-cigarettes on the NHS to help smokers quit as part of plans to increase life expectancy for the poorest.
Sajid Javid, the health secretary, believes it is a “moral outrage” that England’s richest people are living for up to a decade longer on average than the poorest.
He will announce plans to address the root causes when he unveils his health disparities white paper this spring. It is understood this will include a “vaping revolution” that will allow GPs to prescribe e-cigarettes on the NHS."
Dr Konstantinos Farsalinos’ multidimensional report on vaping flavours titled “The case for flavours in tobacco harm reduction to save lives” examines the science, consumer insights, risks and regulatory considerations relating to vaping flavours.
The review concludes that restrictions on vaping flavours would risk seriously reducing the life-saving potential of these innovative products.
Unfortunately, last week scaremongering headlines circulated worldwide, based on an abstract from an unpublished study. Subsequently it has been WITHDRAWN by the American Heart Association, who said: "This abstract will no longer be presented at Scientific Sessions 2021. Unfortunately, the researchers were not able to complete their presentation". The study claimed that e-cigarette users have a 15% higher risk of having a stroke at a younger age. However, after peer review and SCRUTINY of the data, this claim was shown to be methodologically flawed. Click HERE to read more on prominent experts' reaction to the flawed claim.
“People who regularly use vapes have much higher smoking cessation rates” explained Prof David Levy at the recent No Smoke Summit.
This is the key to the lifesaving potential of promoting nicotine vaping products to smokers who are struggling to quit cigarettes. Prof Levy’s newly published SAVM simulation model calculates deaths avoided and life years gained by 2060, if adult smokers switched to significantly less harmful vapes. The result? 1.8 million lives saved, and 38.9 million life years gained.
Click HERE to watch the Lives Saved video
In Germany’s population of 84 million, 1 in 4 people still smoke cigarettes. According to their ministry of health, smoking is the biggest preventable cause of death and disease in Germany. Meanwhile, there is mounting evidence that nicotine vaping products are significantly less harmful than combusted tobacco, and provide a viable escape route for smokers who want to quit, but can’t.
What would happen if Germany’s smokers switched to less harmful nicotine vaping products? At the No Smoke Summit in September 2021, Prof David Levy from Georgetown University explained with reference to his newly developed SAVM simulation model - 4.7 million life years saved, and 300,000 deaths avoided by 2060.
Click HERE to watch his presentation
Events which might help shape tobacco harm reduction (THR) science, policy, consumer engagement and products.
Recommended sites to learn more of tobacco control and harm reduction.
CANADA’S PROPOSED RESTRICTIONS ON FLAVOURS IN VAPING PRODUCTS COULD NEGATIVELY AFFECT MILLIONS OF ADULT SMOKERS, WARN INTERNATIONAL EXPERTS
Health Canada have sought comments on their proposed ban on vaping flavours, click below to read the comments.
WHO recognition of Tobacco Harm Reduction in the Framework Convention on Tobacco Control (FCTC). FCTC is the global legal treaty used to shape tobacco control policy.
Several individual and organizational public health influencers impact the debate on tobacco harm reduction science and policy. Please note that there are no links between this website and the bloggers, and do let us know if there are any individuals or groups we should add.
The European Union TPD is the regulatory framework concerning the manufacture, presentation and sale of tobacco and related products. Novel products and electronic cigarette regulation are addressed in Articles 19 & 20.