A public health expert who once served as a director in the World Health Organization (WHO) has explained why a stronger focus on harm reduction is needed in global tobacco control.
Professor Tikki Pang, now part of Jakarta-based Centre for Healthcare Policy and Reform Studies, said 20 years ago the WHO introduced the Framework Convention on Tobacco Control (FCTC), which has been ratified by 183 countries covering 90% of the global population.
He said the FCTC has led to a significant reduction in smoking prevalence around the world, particularly in rich and developed countries, helping to prevent or delay up to 24 million deaths over time.
“Since smoking causes 85% of lung cancers, which in turn account for 20% of all cancer deaths worldwide, this represents a major achievement for the FCTC,” he said at the Asia Forum on Nicotine.
However, Pang said that despite this early success, there were still 8 million deaths annually linked to smoking, with 4 out of 5 of these deaths occurring in lower-middle-income countries.
He said there were two reasons for this, namely the relatively slow implementation of FCTC articles by signatory countries, and the non-recognition of less harmful and alternative tobacco products as a means to curb smoking.
He said this was despite “overwhelming evidence” of the safety, efficacy, and cost-effectiveness of these (alternative) products used by some 130 million people around the world.
“Despite all of this, global health authorities have adopted a very strong anti-tobacco harm reduction (THR) stance.
“(They) actually state that these products are as harmful as combustible cigarettes and call on their member states to ban them and actually give awards to countries which have done so.”
Pang described this resistance as the “elephant in the room” and a “key barrier” to the wider adoption of THR.
He said this was because many lower and lower-middle-income countries looked to the WHO for guidance in terms of setting their own policies.
On the way forward, Pang mooted the establishment of independent, evidence-driven platforms involving key stakeholders to improve dialogue and coordination.
He said such platforms could exist outside the FCTC structure and bring stakeholders, including producers, consumers, and investors, together to achieve five goals.
This, Pang said, included demanding and improving the transparency and inclusivity in global decision-making processes.
“Two, place tobacco harm reduction in the broader context of noncommunicable diseases, the Sustainable Development Goals and universal healthcare.
“Third, aim for more inclusive and effective stakeholder engagement across civil society, industry, consumers, professional societies, etc.”
Another goal would be to broaden the definition of tobacco control and advocate for risk-proportional regulation.
“And finally, work with governments to highlight and disseminate success stories from countries that have been supportive of THR, perhaps through a storytelling approach.”
However, he acknowledged there would be challenges in bringing the various stakeholders together.
Pang ended his keynote, saying he has become a supporter for THR due to “overwhelming scientific evidence” and its value in helping smoking cessation.
He also cited a quote from renowned physician Alex Wodak, that the current opposition to THR was becoming obsolete.
“And I quote Alex – WHO’s position on this issue is now as irrelevant as the position of governments in Eastern Europe and the Soviet Union in the 1980s on the future of central command economies. WHO’s position will collapse at some point, but I don’t know when.”
Meanwhile, in one of the sessions at the forum, Professor Dr. Sharifa Ezat Wan Puteh, who chairs the Malaysian Society of Harm Reduction (MSHR), shared similar sentiments on THR.
She said there was actually nothing new about harm reduction, having been used in HIV prevention and drug therapy.
However, she noted this was not the case for tobacco.
“A lot of Asian countries are also members of the FCTC, so they follow what the WHO says. Anything with tobacco plus nicotine is seen as something harmful.”
She said the way forward would be for tobacco harm reduction to be recognised as part of comprehensive public health strategies, though she admitted this was unlikely.
Ultimately, both experts agreed that reframing tobacco harm reduction as part of broader public health strategies could open the door to more inclusive and effective policies in the years ahead.