This year’s GFN looked at past successes and continuing challenges for tobacco harm reduction.
By Stefanie Rossel
“Tobacco harm reduction—the next decade” was the theme of this year’s Global Forum on Nicotine (GFN), which took place in Warsaw June 21–24, 2023. For the first time, the presentations stretched over four full days. Some 220 delegates from 40 countries attended the event, which also marked the 10th anniversary of the conference—a good time for a look back not only on the progress of and the opportunities but also on the challenges facing tobacco harm reduction (THR).
The picture of THR currently is highly fragmented, as became clear during a workshop on global regulation. Regulatory treatment of safer nicotine products varies widely among countries. There’s Australia, where vape products are available on prescription only and just 5 percent of doctors can prescribe nicotine. By contrast, the Philippines, after a 10-year debate, last year introduced a law that treats vapes differently than tobacco products, offering nicotine users easier access to less hazardous products.
In the European Union, there is a double layer of regulation, which relates to the harmonization of the 27 member states and the national adoption of the Tobacco Products Directive (TPD2). Trends influencing legislation include polarizing views of member states, so countries are advocating for more regulatory freedom within the EU. Mexico has banned the sale and production, but not the use, of reduced-risk products (RRPs). Kenya’s RRP taxes are so high that they constitute a de facto ban.
For many countries, tobacco control is a relatively low priority, and smokers have been left behind in the discussion.
GFN participants cited Australia as an example of how not to regulate vaping. Nicotine can be legally bought from pharmacies only with a prescription. This has led to a flourishing unregulated market. Ninety-two percent of Australian vapers source their e-cigarettes from the black market. To curb illicit trade, Australia plans to ban the import of all nonprescription vaping products, including those that don’t contain nicotine. Colors, flavors, volumes and nicotine content of prescription e‑cigarettes will be restricted, and packaging must be pharmaceutical-like.
Consumers trying to get a prescription in Australia face many barriers, many of which are due to the country’s geography. Doctors have an inadequate understanding of smoking and nicotine addiction, and they must be registered as an authorized nicotine prescriber. Once they have the prescription, consumers must convince a pharmacist, who usually has limited stock, to get nicotine. While several Australian states have legalized possession of drugs, vape products are becoming an illicit product. In a survey, 81 percent of Australian vapers said that they would return to smoking if they had no access to vaping.
Tobacco Control: A Substitute Religion
The stigmatization of THR bears a strong resemblance to religion, according to participants in the panel discussion on science, regulation and morality. Bans are about social engineering, and the regulatory wording reveals an ideology of people who want to control others. As an example, panelists cited the imagery used to scare people off vaping (“vaping causes brain worms”).
There is still a lot of disinformation, misinformation and misleading science, and knowledge of THR in the wider harm reduction community remains limited. And although certain debates, such as the cause of e-cigarette or vaping product use-associated lung injury (EVALI), have been settled by science, they remain a topic of discussion, a phenomenon that panelists found very frustrating.
A panel evaluating the past 10 years of science reminded the audience that first attempts at safer products date back 30 years to 40 years, when the first heated-tobacco products (HTPs), Eclipse and Accord, hit the market. The introduction of modern HTPs in 2014 changed the landscape. Snus in Sweden has an even longer history. If this type of oral nicotine was accepted in the rest of Europe, 3 million smoking-related deaths could be avoided, the panelists pointed out.
Thanks to advances in technology, the new generation of e-cigarettes provides safer nicotine delivery than its predecessors. As years go by, data on vaping accumulates. Recently, the Oxford Foundation confirmed there was strong evidence that e-cigarettes help people quit.
Tobacco control advocates apply double standards to nicotine, however: In their minds, the benign nicotine in medical smoking cessation products becomes a lethal, toxic substance as soon as it leaves the pharmacy. This leads to some grotesque situations. In Austria, for example, nicotine-replacement therapies are flavored and can be sold to children from the age of 12.
While in the 1980s and 1990s, tobacco control was about the “endgame” against cigarettes, the war has now turned against nicotine, according to GFN panelists. Countries such as Finland, for example, discuss nicotine ceilings in nicotine pouches. To convince tobacco control that their science is reliable, panelists agreed that the industry must change its communication strategies and talk about science outside of the usual places. Real-data science, which is already available, will make a big difference in the next decade, one speaker predicted. It could help drive the policy debate and improve the reputation of the tobacco industry. Industry science should be based on geographies and sales of RRPs, according to the speaker.
Getting the Message Out
Scientific publishing is important as it creates transparency and builds trust. According to a panel on the politics of such publishing, more than 2 million peer-reviewed articles were published in 2021. Good journals have at least two referee reports; three tend to improve the quality of the article. Rejection rates are high. Most journals have little expertise with the tobacco and nicotine industries. Scientific publishing is a massive, $28 billion-a-year industry built on the backs of volunteers. Despite the barriers to publication, the two largest tobacco companies have published more than 350 manuscripts on RRPs.
Next to the established publications are open access journals. Their selection criteria are purely financial, as each accepted manuscript attracts a fee. While they are looking to publish as much sound science as possible, the downside is that the hurdle to becoming a publisher has dropped, and industry scientists should beware of untrustworthy, predatory journals.
One of the critical issues regarding tobacco industry transformation is the question of whether it is reaching low-income and middle-income countries (LMICs), where around 80 percent of smokers live. Currently, RRPs barely feature in the 137 LMICs, partly due to regulatory restrictions. Twenty-six LMICs, including major markets such as Brazil, India and Argentina, ban RRPs. Many consumers are unaware of reduced-risk options, with some even believing they are more harmful than smoking. If available, RRPs are expensive and difficult to access in LMICs.
While lumped together into a single category, LMICs in fact comprise a collection of very different countries with greatly varying consumer preferences. The World Health Organization, a declared opponent of THR, tends to enjoy considerable credibility in these regions. Other hurdles to RRPs in LMICs include the tendency of regulators to view the terms “tobacco” and “nicotine” as interchangeable and the low awareness in the medical community about the role of nicotine.
BAT’s introduction of modern oral nicotine in Kenya and Pakistan is an example of a promising first step and shows that products need to be designed from the point of view of the consumer.
The Pros of Nicotine
Tobacco control has turned its war on cigarettes into a war on nicotine, but the supposedly evil substance has a vast pharmacological potential, according to one presenter. The positive effect of nicotine in the treatment of Parkinson’s disease or schizophrenia is already known. A more recent studies revealed nicotine to be an efficient therapy for mild cognitive impairment as well.
Other conditions, such as late life depression, also benefit from nicotine stimulation. Nicotine can help modulate aggressive behavior in autistic patients, and scientists are currently examining its efficiency in combating the loss of hearing. In the next six months, researchers will also start investigating whether nicotine could help treat the cognitive syndrome (“brain fog”) that sometimes accompanies Long Covid.
Unfortunately, the progress of THR over the past decade, with more than 100 million people using RRPs today, has also had a less welcome effect in the form of electronic waste. The growing popularity of disposable vapes in particular has led to an increasing number of batteries and other components ending up in landfills and causing fires.
To solve the problem, manufacturers should consider standardizing the materials in their products, looking at biodegradable components for tanks and making the batteries removable, according to GFN panelists. Retailers should offer to take back used products for recycling, and consumers, too, must take their responsibility. One panelist said he wanted to set up a study to find out what motivates people to bring back their devices and to what extent such behavior could be spurred by financial incentives.
Stigmatize, Exclude, Silence
So who has a stake in the THR game? Certainly, the industry should have one, one panelist argued, as it has the will and the money, which unlocks science in toxicology, behavioral research or postmarket surveillance surveys. The industry also knows how to make consumers switch quickly, and it has the scale of manufacturing and distribution to deliver these products to the biggest possible audience in a short time.
Vulnerable communities, which represent a large percentage of smokers, appear to have no such stake, however—an equity issue that needs to be addressed. While article 5.3 of the Framework Convention on Tobacco Control, which aims to protect tobacco control policies against tobacco industry influence—does target smokers, this group remains conspicuously absent from discussions about the tobacco control process.
Medicinal licensing of vape products was not considered a solution by panelists since many smokers don’t view their habit as a medical problem. Besides, such an approach stifles innovation, as the authorization of medicinal products takes a long time, and the resulting products are not necessarily the ones consumers want.
Children, too, should be seen as stakeholders in the debate, according to one panelist. If they lose their parents to smoking-related death, they are traumatized, and this will influence their later relationships. That means THR is a child welfare issue, the speaker claimed, quoting a 2013 study that found that if all tobacco control policies were implemented, there would still be 523 million smokers in the world.
A plenary discussion focused on “the tobacco control playbook” revealed the methods that tobacco control activists have been using since RRP started gaining traction years ago. Measures include attempts to delegitimize, stigmatize, silence and exclude THR proponents and people with ties to the tobacco industry, however tenuous, from smoking cessation conferences.
Academic journals have silenced authors with research funding, however indirect, from tobacco companies. The University of Bath, which on its TobaccoTactics website keeps a running tab of people linked to the industry, has planted stories with journalists, including those it funded.
There have been attempts at making journal editors reject papers published by grantees of the Foundation for a Smoke-Free World (FSFW), which receives funding from Philip Morris International. While in many areas of health, governments consult with consumer groups, vapers are viewed with suspicion and suspected of being on Big Tobacco’s payroll. Academics have suggested links between vapers and tobacco companies where there aren’t any.
Those in tobacco control who think differently but don’t speak up against these methods become accomplices, according to one panelist. Tobacco control, he observed, needs people to blame. In the future, every opportunity should be taken to raise objections—for instance, to university ethics committees who fail to protect people, to journal editors and editorial boards that publish inaccurate articles and to academic institutions that receive funding for activist tobacco control work. Finding enemies is now so embedded in the tobacco control psyche that these activists have no interest in finding common ground. Nevertheless, optimism prevailed in the panel. The question, they argued, is not if but when THR will succeed.
Achievements and Obstacles
For THR to make progress in the future, a look at the past may be useful. In 2012, massive protest by vapers helped avert a ban on vaping in the EU. In 2014–2015, Public Health England acknowledged the relative safety of e-cigarettes, opening many eyes to the promise of vaping as a smoking cessation tool. One year later, Kenya became the first country to regulate vape products. Around this time, the split between pro-vaping and anti-vaping advocates occurred.
In 2016, the U.S. Food and Drug Administration started regulating all nicotine products as tobacco products. This had a domino effect around the world.
Founded in 2017, the FSFW faced strong opposition. In 2018, consumers joined a legal challenge to the EU snus ban. One year later, the Indian government banned vaping while in the U.S., misinformation about EVALI created a panic.
New Zealand embraced vaping in 2021, and in 2022, the EU endorsed vapes as part of its Beating Cancer Plan. Around the same time, the Philippines introduced reasonable vaping regulations. In all three cases, consumer advocates played a vital role.
This year, Quebec introduced a vape flavor ban, Australia announced a crackdown on vaping, and the U.K. launched its “swap to stop” scheme to encourage smokers to switch to e-cigarettes.
The developments in the past decade, panelists concluded, were driven by instinct and moral concern on the policy side, which leads to prohibition. Indifference to different products is a risk. Youth use is heavily emphasized by health activists, and silence has become subordinate to the political agenda. Consumer advocacy, however, has been working in favor of THR. On a global scale, vaping is rising.
GFN 2023 closed with an outlook on THR in the next decade. Participants in the final plenary discussion were confident that THR will happen one day—simply because things always change, RRPs are there, and there’s no going back. Education of the general public is vital to drive the debate. Children’s uptake needs to be solved, and THR proponents should remember that the debate is about more than vaping.
More attention must be paid to THR in LMICs, particularly those that have dictatorships in which criticism means rebellion and informing consumers is impossible.
To free themselves from their guilt from the past and be taken seriously in their claim to create a smoke-free world, tobacco companies should eventually divest their cigarette units.