Author: Taco Tuinstra

  • Smoking Decline Traced to Noncombustibles

    Smoking Decline Traced to Noncombustibles

    Photo: Natalia

    Sweden’s smoking rate is poised to dip below 5 percent, a share that is widely considered the hallmark of a “smoke-free” society, reports The Business Mirror.

    Only 5.6 percent of Swedish adults smoked cigarettes in 2022, down from 49 percent of men in 1960, according Sweden’s public health agency. As a result, Sweden has 52 percent fewer tobacco-related male deaths than Poland and 57 percent fewer than Romania. For male lung cancer, Sweden has significantly fewer deaths than France, Germany, Italy and Poland.

    A report titled “No Smoke Less Harm” by the advocacy group Smoke Free Sweden attributes this achievement to Sweden’s openness to alternative nicotine products, such as snus.

    The report points out that smoking-related diseases are caused primarily by the byproducts of tobacco combustion rather than nicotine, as many mistakenly assume.

    The Swedish experience demonstrates the importance of understanding public misperceptions about nicotine to develop health policies that better protect and inform consumers.

    Karl Fagerström, co-author, ‘No Smoke Less Harm’

    While nearly one in four Swedish adults still use nicotine daily, in line with European averages, Sweden boasts far lower rates of tobacco-related deaths (44 percent), cancer rates (41 percent) and cancer deaths (38 percent) than the rest of the European Union.

    Smoke Free Sweden’s report appeals for the World Health Organization and global public health communities to acknowledge that combustible products, not nicotine, cause harm to smokers.

    “While nicotine is addictive, it does not cause the serious diseases associated with smoking,” Fagerström said. “Our findings support a shift in focus from cessation to substitution with less harmful alternatives for those unable to quit completely.”

  • Malaysia to Enact Age Restrictions this Year

    Malaysia to Enact Age Restrictions this Year

    Photo: Heorshe

    Malaysia will restrict the sale and purchase of tobacco products and tobacco substitutes to those aged 18 and over this year, reports The Star.

    Lawmakers have been alarmed by rising rates of vaping among underage consumers.

    The recent National Health and Morbidity Survey revealed that the rate of cigarette use among adolescents aged 13 to 17 dropped from 13.8 percent in 2017 to 6.2 percent in 2022. For vaping, however, it increased from 9.8 percent in 2017 to 14.9 percent in 2022.

    “This is a wake-up call. The regulations (of the Act) will be enforced to curb this,” said Health Minister Dzulkefly Ahmad at the World No Tobacco Day Carnival in Kuala Lumpur June 2, 2024.

     The war on smoking requires a whole-of-government, whole-of-society approach, he added.

     “This includes non-governmental organizations, teachers, retailers, politicians and enforcement bodies, as well as Malaysians in general. We must be united in curbing the smoking and vaping culture,” he added.

  • French Tobacconists Oppose Price Hike

    French Tobacconists Oppose Price Hike

    Photo: OceanProd

    French tobacconists have objected to a proposal to raise cigarette prices to €25 per pack by 2040, reports Euractiv.

    Cigarettes in France currently retail for around €12.50 per pack, one of the highest rates in the Organization for Economic Cooperation and Development. In Europe, only U.K. and Irish smokers shell out more for their cigarettes.

    Despite the high price, France remains one of the countries with the highest number of daily smokers, and every year tobacco causes 70,000 premature deaths.

    To address this issue, the Senate Social Affairs Committee in a recent report suggested doubling the price over the next 16 years.

    Noting that “the policy of reducing smoking has failed,” the committee recommended increasing the price by at least 3.25 percent every year between now and 2040. According to the Senate, the prevalence of smoking decreases when the price increases by more than 4 percent.

    The Confédération des buralistes, which represents the interests of tobacconists in France, condemned the proposal, arguing that French already leads the way in terms of tobacco taxation. The group said the report disregards the consequences of price, both on the country’s public health and on the network’s economic situation.

    For tobacconists, efforts should focus on the fight against the black market, which account for between 30 percent and 40 percent of cigarettes consumed in France.

    However, this figure is disputed by anti-tobacco association ACT, the directorates of public finances and customs, Observatoire français des drogues et des tendances addictives, who put the figure at around 6 percent.

    France’s 2023-2027 National Tobacco Control Plan, presented in November by former health minister Aurélien Rousseau, currently plans a price of €13 per pack by 2026.

    The EU is likely to review tobacco taxation following the EU elections in June, as the current Commission has not reviewed the 2014 Tobacco Products Directive and the 2011 Tobacco Taxation Directive, as originally planned.

  • Namibia to Regulate E-cigarettes

    Namibia to Regulate E-cigarettes

    Image: sezerozger

    Namibia plans to regulate vapor products and water pipes, reports the Windhoek Observer.

    The country’s Ministry of Health and Social Services wants to amend the Tobacco Act to include those products.

    The goal is to curb the growing use of electronic cigarettes and water pipes across the country. The amendment will also facilitate the development of a comprehensive tobacco strategic plan scheduled for launch later this month.

    Deputy Minister of Health and Social Services Ester Muinjangue stressed the urgency of regulating vaping products, despite existing legal frameworks to combat tobacco use in Namibia. “There is no safe form of tobacco smoke,” she said, rejecting suggestions that vaping and hookah smoking are safer alternatives to traditional cigarette smoking.

    Muinjangue encouraged smokers seeking to quit their habit to utilize existing resources and seek support from health professionals.

  • Bhutan’s Tryst with Health Imperialism

    Bhutan’s Tryst with Health Imperialism

    The author standing with a local in front of a pharmacy stocking NRT gums adjacent to a grocery shop officially selling tobacco. (Photo courtesy of Sudhanshu Patwardhan)

    Without offering locally relevant cessation tools, prohibition is doomed to fail.

    By Sudhanshu Patwardhan

    Bhutan, a country that measures its riches in terms of “gross national happiness,” may have become an unsuspecting victim of a new form of imperialism: health imperialism. A blind copy-paste of Western tobacco control policies, worsened by local gold-plating, may have landed Bhutan in a mess. A visit to the landlocked nation gave the author a unique insight into how prohibition of tobacco without offering locally relevant and innovative tobacco cessation tools threaten this Shangri-la.

    The Forbidden Kingdom

    A series of district-wide tobacco control measures in Bhutan from the 1980s culminated in the declaration of a nationwide ban on the sale of tobacco products in 2004 through a resolution of the National Assembly. Overnight, Bhutan became a poster child of global tobacco control, an emerging David against the Goliath of transnational tobacco companies. Nanny statists got a lifeline, and the “p” word—prohibition—was resurrected after successive failures of over 150 years in alcohol and drug prohibition movements. The Tobacco Control Act of 2010 further enshrined into law restricted access, availability and appeal of tobacco products and gave sweeping powers for arresting those selling or even possessing tax-unpaid tobacco for personal consumption. Bhutan was all set to become a tobacco-free society. A happy nation was also going to become healthier. In theory.

    Market Forces Take Over

    The roller-coaster ride between 2010 and 2019 is captured in the World Health Organization’s regional office’s 2019 publication The Big Ban: Bhutan’s journey toward a tobacco-free society. A big achievement in this period was visible reduction in public place smoking. Otherwise, the optimistic title belies the details of the failed ban confessed in the publication. It is a classic tale of good intentions scuppered by poor execution. A highlight of the data reported there is the difficulty in enforcing the ban, evidenced by availability of tobacco products below the counter in most shops in Bhutan. Tobacco use among 13-year-olds to 15-year-olds went up from 24 percent in 2006 to 30 percent in 2013 based on the Global Youth Tobacco Survey findings. The severe penalties required by the initial law resulted in more than 80 people being imprisoned between 2010 and 2013. There was growing discontent about the disproportionality of the penalties among the people of a nation gradually moving from a benevolent absolute monarchy to a democratic constitutional monarchy. Public furor and rethinking among the lawmakers resulted in amendments and milder punishments, and the law’s “claws (were) trimmed,” states the WHO report. Between 2010 and 2014, permissible quantity for personal possession was steadily increased for both smoked and smokeless tobacco products. The ban and its enforcement were proving ineffective and untenable. And then Covid-19 happened.

    Reversal of a Failed Ban

    The government was obviously losing revenue due to the flourishing black market of smoked and smokeless tobacco products smuggled from India and elsewhere. The fear of tobacco smugglers bringing in the Covid-19 virus was enough excuse to act decisively. In July 2021, the government amended the 2010 Act, thus lifting a decade long ban on local tobacco sales.

    The pragmatism of the politicians who reversed the ban presents a sharp contrast to the previous prohibitionist policy. Today, sales and consumption continue, and based on the most recent (2019) WHO STEPwise approach to surveillance (STEPS) data, 24 percent of those between ages 15 and 60 currently use tobacco products. Sadly, the ban did not make Bhutan a tobacco-free society. Anecdotally, e-cigarettes are also available now in some grocery stores in the capital, Thimphu, and attracting use among smokers and never-smokers. These are not regulated nor used as smoking cessation tools, presenting another area of concern for public health. A ban may not be the answer for these products either. Regulation that balances current smokers’ needs for safer alternatives versus prevention of uptake by the youth and nonsmokers will be key.

    Peering Through an ‘Addiction’ Lens

    I first read about the ban’s overall failure in the 2019 WHO report and then heard about the reversal of the ban during the global Covid-19 pandemic. How did Bhutan land in this situation? There is, of course, economics at play: demand, supply and something to do with a genie being out of the bottle. When I put my doctor’s hat on, a key explanation stares at me: lack of quitting support for the existing 120,000 tobacco users. Reams of self-congratulatory publications and numerous WHO awards to Bhutan since the 1990s have focused on success in awareness-building and restricting access and use. The famous case of the Buddhist monk who was jailed for three years in 2011 for the possession of $2.54 worth of tax-unpaid tobacco misses the point that he was very likely addicted to tobacco and may have needed more than punishment to quit. In the absence of availability of tobacco products, it should have been a human right for him to have access to safer nicotine to manage nicotine withdrawals and achieve craving relief. This assessment should not be used to vilify tobacco users. Instead, it should be a reminder to those in tobacco control that preaching to nicotine-dependent users without offering alternatives is not enough and also unethical. A key demand-side reduction measure, to use Framework Convention on Tobacco Control (FCTC) vocabulary, is that of providing tobacco dependence treatment and services. This is covered under FCTC Article 14 but rarely implemented in low-income and middle-income countries (LMICs), Bhutan included. I saw firsthand recently the country’s struggles with rising tobacco use coupled with a lack of cessation products and services.

    Tobacco Cessation: The Poor, High-Maintenance Cousin

    In Bhutan, like in most LMICs, overall tobacco control is run by public health experts, and tobacco cessation specifically (and separately) falls under the remit of psychiatrists. Neither groups are excited by tobacco cessation for a variety of reasons. Public health professionals often have little or no experience in treating individual patients and have increasingly been sold a unidimensional narrative that the tobacco epidemic is singularly driven by the commercial vested interests of tobacco companies (the “vector”). For them, the tobacco user is a victim of the tobacco industry, should be labeled an addict and then preached at to quit. Psychiatrists, on the other hand, are generally geared toward treating established mental health conditions and severe mental illnesses and even within the “de-addiction” field prioritize substance abuse treatment and alcohol de-addiction over tobacco cessation. Tobacco cessation with nicotine-replacement therapy and other pharmacological interventions are costly and need a level of training and qualification to prescribe—and are therefore cost-prohibitive to be offered at scale. They are also not without their failures, give around 20 percent quit rates at one year in controlled clinical studies and much less success in real-world settings. The success of quitting cold turkey is overrated and often drives policymakers’ wrong beliefs and attitudes about the ease of quitting. Public health tobacco control awareness campaigns and advocacy, on the other hand, are highly visible, scalable, inherently worthy endeavors, and most do not require impact assessment as proof of success. The FCTC’s Article 14 thus remains a neglected tool for reducing harms from tobacco globally and receives little or no funding from international donors and national governments nor any interest from pharmaceutical companies or tobacco companies to innovate in.

    Safer Nicotine Not Widely Available in Bhutan

    Nicotine illiteracy among healthcare professionals and lack of availability of safer nicotine alternatives can translate into poor quitting among tobacco user patients. From my field visits to pharmacies and discussions with frontline healthcare professionals in Bhutan, I noted that 2 mg and 4 mg nicotine gums have only recently become available in some pharmacies in Thimphu, but patches are not stocked. Patients come and buy these over the counter, but there is little record of how long they take it for, their quit and relapse rates and whether their doctors support them in their quit journeys. Varenicline or bupropion are not available for cessation. When called, the “national quitline,” contrary to the claim of the 2019 and 2024 WHO publications, do not deal with tobacco cessation support. Most of the healthcare professionals in Bhutan receive their undergraduate and graduate training in India, Sri Lanka and other nearby Asian countries. Similar to the rest of the world, doctors in Bhutan are not confident about prescribing nicotine-replacement therapy and may harbor misperceptions about nicotine itself. They have not received any tobacco cessation-related training in the past five years, and nicotine-replacement therapy is not available for free or at subsidized prices anymore, unlike other medications in Bhutan.

    Navel-Gazing Time for All?

    The backpedaling by Bhutan on the tobacco ban has not been reported or analyzed widely enough. Bhutan’s failure to rein in tobacco sales and increased use, despite a ban, should be a wake-up call for all parties involved. What was touted as a role model for other countries for eliminating harms from tobacco has instead become a cautionary tale for poor policymaking done to pander to international funders and organizations. The undue influence of a select few Western nations in national health policymaking for LMICs is also a matter of concern as the global geopolitical order rapidly morphs. Projects such as FCTC 2030, funded by the U.K., Norway and Australia, continue to churn out reports such as the Investment Case for Tobacco Control in Bhutan (WHO/UNDP, February 2024), ignoring lessons from the ban, mostly unaware of capacity issues on the ground and not addressing the need of current tobacco users for safer nicotine alternatives. Emergent strong economies such as China and India will no longer tolerate meddling by past colonial powers and imperialist nations in their health policies, but neither should other LMICs.

    Toward Gross National Health

    For a nation of around 750,000 people, tobacco use is claimed to kill between 200 people and 400 people every year—all preventable deaths (side note: the data for the same year varies dramatically between two WHO reports). Global tobacco control has failed Bhutanese tobacco users and their families. For a nation built on principles of sustainability, risky forms of smoked and smokeless tobacco products have no place in society. The mountains, the clean air, the happy smiles and peace-loving people of Bhutan deserve to own tobacco control initiatives, not be made to adopt hand-me-down Western ideologies or policies. That will require the doctors and pharmacists in Bhutan to understand the science of tobacco cessation and harm reduction and make quitting sexy. Availability of nicotine-replacement therapy products, innovation in safer nicotine alternatives and improved cessation services will need to be ensured and incentivized by the government. That has the potential to keep their nation happier and healthier for the coming generations.

    Disclaimer: The author’s work here or elsewhere is dedicated to using ethical and scientific evidence-based approaches to eliminate harms from all risky forms of smoked and smokeless tobacco products. The article is based on the author’s personal conversations with experts and lay people in Bhutan and from shop visits and an analysis of two of the most recent WHO reports on this topic. The intent of this article is to shine a light on a vulnerable LMIC’s experience with unchecked health imperialism to create insight and debate on the impact and implications of such practices. The author holds utmost respect for the nation, the policymakers and the people of Bhutan.

    Sudhanshu Patwardhan is a medical doctor, nicotine expert and health tech entrepreneur from India, based in the U.K. He works on projects around the world to reduce harm from tobacco, especially among the most disadvantaged tobacco user populations.
  • BAT Still Committed to Smokeless Future

    BAT Still Committed to Smokeless Future

    Josh Fett (Photo: BAT)

    On World Vape Day (May 30), British American Tobacco outlined a strategic vision to accelerate progress toward building a smokeless world, especially for the Asia-Pacific region, to encourage adult smokers to switch to smokeless alternatives such as vapor products.

    The smoking prevalence among adults in the Asia-Pacific region is amongst the highest in the world, though it continues to fall each year in some markets. However, with various governments setting goals to be “smoke-free” (defined as smoking prevalence falling to 5 percent or less), BAT says that more must be done to realize their ambitions.

    In its vision, the multinational sets out four principles that it believes should be applied for effective and impactful regulation relating to smokeless tobacco and nicotine products:

    1. Access to consumer relevant products: regulations in all countries where cigarettes are sold should also allow a wide range of smokeless alternatives to ensure that consumers can access these alternatives and make informed choices about switching based on the best available scientific evidence.
    2. Adult-only consumer: the use and sale of smokeless tobacco and nicotine products by and to the underage should be prohibited by law.
    3. Product quality and safety: robust and properly enforced quality and safety standards should be at the heart of regulation, to protect consumers.
    4. Robust enforcement: Regulation should provide enforcement authorities with the necessary powers to apply penalties and sanctions to those who fail to comply with regulations, particularly those who supply non-compliant products and provide product to those who are underage.

    “More than 1 billion people globally continue to smoke despite the serious risks,” the company wrote in a statement. “According to population modelling studies, a significant reduction in premature deaths could be achieved if smokers switched exclusively to reduced-risk alternatives.

    “To capitalize on the public health potential offered by smokeless products, appropriate regulation is required to encourage adult smokers to switch, protect consumers with stringent safety standards and prevent underage access and use.”

    BAT noted that countries that embraced this approach have witnessed significant reductions in smoking rates as smokers opt for noncombustible products. The multinational cited the experience of New Zealand, where daily smoking rates have plummeted to 6.8 percent in 2023 from 8.6 percent the previous year, and 16.4 percent in 2012. The U.K., U.S. and Japan too are reporting their lowest smoking rates on record, while Sweden is on track to declaring itself smokefree this year, 16 years ahead of the 2040 EU target.

    According to BAT, the success of these nations in reducing cigarette consumption is largely a result of widespread awareness, availability and usage of smokeless alternatives, such as vapor products, heated products and nicotine pouches.

    “The migration of smokers to these alternatives is crucial both for countries looking to reduce their smoking rates and for global public health more broadly,” said Josh Fett, BAT’s head of corporate and regulatory affairs in the Asia Pacific Region. “Whether or not governments are able to take advantage of these products and maximize their harm reduction potential depends as much on the implementation of progressive, risk-proportionate regulation as it does on changes in consumer behavior.”

  • Quitting Camel Country

    Quitting Camel Country

    Photo: Medwakh

    Dokha, shisha, vapes: THR in the Middle East region

    By Cheryl K. Olson

    Tobacco has been part of daily life in the Middle East since the 1600s. An archeology journal describes excavations in Istanbul uncovering “massive numbers” of broken clay tobacco pipes from the centuries before the rise of cigarettes. Some of the highest smoking rates in the world are found in Middle East nations. Over half of men in Jordan smoke, for example.

    “The Middle East has got an extremely long culture in terms of smoking. That’s going to be really hard to turn round,” says Harry Shapiro, a U.K.-based educator who reports on global tobacco harm reduction. Based on data from the World Health Organization, smoking was projected to decrease among men in the region by less than 2 percentage points, from 33.1 percent in 2010 to 31.2 percent in 2025.

    Most of the top causes of death in countries in the region are either caused or worsened by smoking. New approaches are urgently needed. Yet there is a frustrating lack of information on where and how to start. A 2024 WHO report on global tobacco use trends notes that data in the Eastern Mediterranean region “are the least robust,” i.e., limited or outdated.

    What’s different about the Middle East when it comes to tobacco use? What’s the need for tobacco harm reduction? And what factors might support or block the uptake of reduced-risk products?

    Shisha, Dokha, Shammah

    A U.S. university professor who has studied tobacco use trends in the region (and asked to remain anonymous) shared his local experiences and findings with me. One issue he faced was collecting information on reduced-harm products not yet authorized by regulators. Given Middle East government policies, researchers can’t ask questions about illegal behaviors. “I could be compelled to give individual-level data regardless of what people signed about confidentiality,” he said.

    After the United Arab Emirates legalized e-cigarettes, his surveys found that vapes were widely used. “People shifted back and forth between cigarettes, e-cigarettes and a local tobacco called dokha, which means “dizzy.” Because you can inhale the equivalent of one cigarette’s worth in one or two quick puffs,” he said (see “Old School, Modern Market,” Tobacco Reporter, August 2014.)

    Tobacco use in the Middle East has largely centered on three products. Cigarettes currently dominate, with use rates hovering around 30 percent for men. In most of the region, smoking is culturally unacceptable for women. Given the reluctance to admit to smoking, reported female use rates of about 2 percent may in reality be several times higher. In Lebanon, the professor noted, women can openly smoke. There, use rates are around 30 percent for both genders. Concerningly, his colleagues in that country feel that Lebanon is the tobacco use trendsetter for the region.

    A second popular regional product is shisha tobacco, smoked through a water pipe or hookah. Use reportedly increased in the 1990s when flavored products emerged. “Previously, it was mostly grizzled old men in coffee shops,” the professor noted, “but the new products weren’t harsh or unpleasant in taste and became trendy among young people.” A 2020 review of research found “alarmingly high” use among university students in the region, including by women.

    Hookah smoking is a social activity. A college student in Abu Dhabi might go out with friends and smoke hookah once or twice a week or once per month. However, some users are addicted and will smoke daily.

    What sets shisha apart is the communal pipe. “There might be multiple hoses, but you’re still breathing through the same water and sharing germs,” the U.S. professor noted. “A session might go on for an hour and generate the same volume of smoke as five packs of cigarettes.” This means exposure to a huge quantity of smoke, even at the secondhand level. Even worse? Inhaling toxins and carbon monoxide from the charcoal burned to heat the waterpipe.

    Finally, there is dokha. This powdered tobacco comes in different varieties and strengths and is often mixed with herbs, spices and other substances. Dokha is smoked in a small pipe (usually wooden) called a midwakh. Some users perceive it as a safer alternative to smoking, but the limited research suggests that dokha may give off more toxins than cigarettes. Despite dokha being as common as cigarettes in countries such as the UAE, published studies on dokha use, effects and cessation have been rare.

    A regional oral tobacco product also merits mention and more study. Shammah is reportedly common in Saudi Arabia and Yemen. Locally made by mixing ground tobacco leaf with flavorings (including lime, ash, black pepper and oils), shammah contains a variety of potential carcinogens, including nitrosamines.

    Reducing Risk

    Several countries in the Middle East (such as Iran, Oman and Qatar) still ban e-cigarettes, and others (e.g., Saudi Arabia) ban snus. But in general, the region has bucked the global trend, loosening regulations on vaping and heated-tobacco products. Nicotine pouches are largely unregulated. (See the Global State of Tobacco Harm Reduction website, GSTHR.org, for country-by-country information.)

    More research is critically needed to help channel information and support to those Middle Eastern subgroups most endangered by their tobacco use behaviors. University students who occasionally smoke shisha, for example, likely face minimal risk.

    Most evidence on vaping originates from North America and Europe. As a recent paper on e-cigarettes in the Middle East points out, studies within the region suffer from “overreliance on university-based samples, the overuse of non-user samples, a lack of studies on behavior change, high variance in existing data and a lack of uniform instruments to measure e-cigarette use.”

    Shisha is a good example of the need for cultural sensitivity in promoting smoking cessation or a switch to less risky alternatives. “For hookah, people smoke very much for the social reason. It’s a social construct, not an addiction construct,” said the U.S. professor. “Most cessation interventions have not really worked because most have thought about hookah like cigarettes, with nicotine-replacement therapy and counseling.”

    As one college student in the UAE told him, “People don’t drink alcohol here. There are no drugs. We need a way to hang out with our friends.” Effective reduced-risk substitutes for waterpipe smoking must deliver that.

    Companies have begun creating reduced-harm products specifically for Middle East countries.

    For example, Dubai-based ANDS (short for alternative nicotine-delivery solutions) makes vaping and heated-tobacco products. A company called OOKA has developed a charcoal-free shisha device. Philip Morris International recently acquired a stake in Eastern Co., Egypt’s largest tobacco producer, with a stated goal of providing alternatives to cigarettes for adults who smoke.

    New technologies can make an attractive contrast to smelly old-fashioned cigarettes. “A lot of the vaping devices are really quite geeky—like a fancy electronic gadget that happens to deliver nicotine,” notes Shapiro. “They have touch-screens, and you can chart use on your laptop. So that’s likely to appeal to the younger generation of more wealthy urban groups” in the region. However, such products are likely to reach few lower income or rural people who smoke.

    Shapiro notes that two things are necessary for reduced-harm nicotine to gain a foothold and start displacing cigarettes. First, “Governments have got to be prepared to get tough on smoking: banning smoking in public areas and such.” Second, there needs to be proportionate promotion of novel products, including lower taxes versus cigarettes, and education that supports the option of harm reduction alongside cessation. As a recent Lancet commentary (by former WHO leadership) notes, “In some countries, substantial reductions in smoking prevalence have coincided with novel nicotine products.”

    “If a country does ban safer nicotine products, look at how much it relies on the tobacco industry—in terms of revenue from taxation or whether the country grows tobacco or exports it,” says Shapiro. “If state regulation is sympathetic, then these products will find a way into the shops.”

    The presence of the World Vape Show in Dubai, starting in 2021, sent a message that these alternatives could be acceptable. I will be part of two panels at the 2024 Global Vape Forum, which accompanies this year’s Dubai vape expo. We will stress the need to save lives by moving people off combustible tobacco, whether through cessation or switching to reduced-risk products.

    Getting doctors on board with harm reduction is another important step. Like their colleagues around the globe, Middle Eastern physicians frequently misperceive nicotine as the cause of cancer and other health risks of tobacco. Region-specific studies of doctors’ perceptions and needs are essential. I could locate only one small study. A 2019 Egyptian survey found that doctors were aware of e-cigarettes but viewed them less positively than their patients.

    Cheryl K. Olson is a California-based public health researcher who specializes in behavioral health issues and consults on tobacco product behaviors via McKinney Regulatory Science Advisors. She spent 15 years on the faculty of Harvard Medical School.

    References

    Al-Hamdani M, Hopkins DB (2023). E-cigarettes in the Middle East: The known, unknown, and what needs to be known next. Preventive Medicine Reports. https://doi.org/10.1016/j.pmedr.2022.102089

    Beaglehole R, Bonita R (2024). Harnessing tobacco harm reduction. The Lancet. https://doi.org/10.1016/S0140-6736(24)00140-5

    Fouad H, Commar A, Hamadeh RR et al. Smoking prevalence in the Eastern Mediterranean region. Eastern Mediterranean Health Journal. 2020;26:1. www.emro.who.int/emhj-volume-26-2020/volume-26-issue-1/smoking-prevalence-in-the-eastern-mediterranean-region.html

    Nasser AMA, Geng Y, Al-Wesabi SA (2020). The prevalence of smoking (cigarette and waterpipe) among university students in some Arab countries: A systematic review. Asian Pacific Journal of Cancer Prevention. https://journal.waocp.org/article_88992.html

    Samara F, Alam IA, ElSayed Y (2021). Midwakh: Assessment of levels of carcinogenic polycyclic aromatic hydrocarbons and nicotine in dokha tobacco smoke. Journal of Analytical Toxicology. https://doi.org/10.1093/jat/bkab012

    Raj AT et al (2019). Systematic reviews and meta-analyses of smokeless tobacco products should include shammah. Nicotine and Tobacco Research. https://doi.org/10.1093/ntr/nty144

  • Thoughtful Reflection

    Thoughtful Reflection

    Photo: Tobacco Reporter archive

    Speakers and panelists discussed the nicotine value chain during the InFocus virtual conference.

    TR Staff Report

    Participants in the May 22 InFocus virtual conference took a close look at the nicotine value chain, covering agriculture, synthetic nicotine products and innovation in tobacco harm reduction, among other topics. Below are some of the highlights of the event, which was sponsored by BAT, FEELM, Smoore, Alliance One International and Universal Leaf.

    Michael Strupp, professor of neurology at the Ludwig Maximilian University of Munich, addressed misconceptions about nicotine, stressing that it is not a nitrosamine and does not cause cancer. He emphasized the importance of distinguishing between the nicotine molecule and the substances produced by the combustion of tobacco. Strupp highlighted nicotine’s non-toxic nature and clarified that it is not a pesticide. He further explained that nicotine has potential therapeutic benefits, particularly in the treatment of neurodegenerative diseases such as Alzheimer’s and Parkinson’s as well as certain psychiatric disorders like schizophrenia.

    Strupp pointed out that nicotine can enhance attention and memory, improve mood by inducing euphoria and relaxation and indirectly influence body functions such as heart rate and blood pressure. Strupp discussed how nicotine’s mechanism of action has been well understood for decades, acting on nicotinic acetylcholine receptors in the brain. He explained that nicotine mimics acetylcholine, a neurotransmitter, and its interaction with these receptors can enhance learning, memory and attention.

    Concluding his keynote, Strupp emphasized the significance of understanding nicotine’s effects from a scientific perspective. He illustrated how the dopamine reward pathway is involved in nicotine addiction, with nicotine mimicking the effects of neurotransmitters like acetylcholine and dopamine.

    James Murphy, director of research and science at BAT, reflected on the remarkable transformation within the tobacco industry over his career, particularly with the development of three distinct noncombustible tobacco and nicotine product categories: heated products, vapor products and oral pouches.

    As a model for tobacco harm reduction, Murphy highlighted Sweden, where the widespread adoption of snus has led to a dramatic decline in smoking rates to just 5 percent. This shift has resulted in significantly better health outcomes compared to any other country in Europe, demonstrating the potential impact of noncombustible products on public health.

    Unfortunately, the promise of noncombustible combustible products is not reflected in consumer perceptions. Research findings indicated that a record percentage of consumers (90 percent in one survey) now believe that the risks associated with noncombustible products are equivalent to those of smoking.

    This misperception extends to medical practitioners as well, with a majority surveyed incorrectly attributing nicotine as a direct cause of cardiovascular disease, chronic obstructive pulmonary disease (COPD) and cancer. Murphy emphasized the need for education to correct these misconceptions and overcome barriers preventing adult smokers from switching to lower risk products.

    Murphy concluded by underscoring the importance of basing public health guidance on clear, rigorous science. He called for a unified commitment from all stakeholders to prioritize research and harm reduction strategies. A smokeless world, Murphy argued, is achievable through collaborative efforts focused on the well-being of millions worldwide. By dispelling myths and promoting evidence-based understanding of nicotine and noncombustible products, the industry can make significant strides in reducing smoking-related harm.

    Participants in the “Misperception of Nicotine” panel stressed the need for accurate information and education regarding nicotine, calling for global efforts to correct misconceptions and promote harm reduction strategies effectively. The panelists collectively highlighted the importance of engaging respectfully with all sides of the debate, basing policies on scientific evidence and ensuring transparency in public health communications.

    Moderator Jasjit S. Ahluwalia, professor of behavioral and social sciences and professor of medicine at the Center for Alcohol and Addiction Studies at the Brown University School of Public Health and Alpert School of Medicine, opened the panel by emphasizing the need to shift the narrative around nicotine. He pointed out that nicotine is often demonized despite scientific evidence suggesting that it is not the primary cause of smoking-related diseases.

    Ahluwalia highlighted a troubling public misconception that marijuana is safer than nicotine, which is not supported by science. He stressed that while nicotine will continue to be used, the focus should be on eliminating combustible tobacco products, which pose the greatest health risks. Ahluwalia also noted that e-cigarettes, though not without risk, are significantly safer than combustible cigarettes and do not cause cancer or COPD.

    Ahluwalia called for policies guided by science, advocating for accurate information to be provided to smokers about the benefits of switching to reduced-risk products (RRPs). Engaging with those who disagree is crucial, Ahluwalia argued, as there is much common ground and a shared purpose in harm reduction efforts. He also debunked the myth that nicotine use lowers IQs, stating that such misinformation undermines harm reduction efforts and that governments must play a role in correcting these misconceptions.

    Dave Dobbins, former chief operating officer at the American Legacy Foundation/Truth Initiative and consultant to Altria, underscored the importance of listening to all perspectives in the nicotine debate with kindness. He criticized the current tobacco control efforts, which he believes are often led by individuals who are not directly affected by nicotine use.

    Dobbins highlighted the severe health consequences of smoking, noting that cigarettes can reduce life expectancy by a decade and kill half of their users. He emphasized that nicotine delivery through RRPs is significantly safer than smoking.

    Dobbins called for clear, consistent communication with adult smokers, stressing the need to treat them with respect and provide accurate information about the benefits of vapes and pouches. He asserted that it is the duty of everyone, including cigarette companies, to disseminate accurate information about nicotine. Transparency in the origins and funding of scientific research is crucial to ensure trust and clarity in public health messaging.

    Delon Human, a specialist family physician and president of Health Diplomats, began by identifying himself as both a doctor and a consumer, emphasizing the human aspect of smokers. He expressed concern that a significant proportion of doctors (70 percent to 80 percent) incorrectly conflate smoking with nicotine consumption.

    Human criticized the World Health Organization for its inconsistent and unclear stance on nicotine, which also conflates tobacco use with nicotine use. He stressed the importance of the WHO and related agencies following scientific evidence. Human highlighted Sweden as an example of a country providing accurate information about nicotine use, resulting in significantly fewer cancer deaths due to the use of snus instead of cigarettes. He argued that scare stories about e-cigarettes need to be countered with scientific facts.

    Human pointed out that there is substantial opposition to nicotine within the WHO, which will take time to change. He also criticized Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC), which excludes the tobacco industry from discussions, arguing that this exclusion damages scientific progress and policy development and ultimately costs lives.

    Sudhanshu Patwardhan, nicotine expert and health tech entrepreneur, highlighted a study from the U.K. showing that 44 percent of doctors incorrectly believe nicotine causes cancer—a misconception common worldwide. He pointed out a significant gap between policy and medical understanding, which he said has real-world implications for smokers seeking healthier alternatives.

    Patwardhan called for a global nicotine literacy project to educate doctors and align public policies with scientific evidence. He emphasized the importance of making doctors champions of reason to communicate safer alternatives to cigarettes effectively.

    Patwardhan also stressed the need for sensible regulation that is supported by and encourages industry involvement. He concluded that educating healthcare providers around the world is key to promoting harm reduction.

    David Jones, a member of the U.K. All-Party Parliamentary Group for Responsible Vaping and deputy chair of the European Research Group, emphasized the critical role of tobacco harm reduction in public health policy, highlighting the U.K.’s pioneering “swap to stop” strategy, which provides vape starter kits to smokers to help them quit. He praised the U.K.’s evidence-based approach, which has significantly reduced smoking rates, but warned against recent proposals that could undermine these achievements.

    Jones argued against banning disposable vapes and flavored products, explaining that such measures could drive consumers to the black market and hinder smoking cessation efforts.

    Jones criticized the WHO for its opposition to RRPs, stating that its stance is not supported by scientific evidence. He called for greater accountability and transparency in international regulatory discussions, advocating for public and parliamentary scrutiny of decisions made by the FCTC.

    Highlighting the importance of flavors in vaping products for adult smokers, Jones cited research showing that nontobacco flavors are popular across all age groups. He argued that banning these flavors would be counterproductive and could lead to increased smoking rates as consumers turn to unregulated alternatives.

    Jones also addressed the potential of heat-not-burn products and nicotine pouches, urging the government to reconsider its stance on these alternatives and commission further research into their benefits. He emphasized that public health policies should provide smokers with accurate information about all nicotine products to support informed decision-making.

    In conclusion, Jones called for a continued focus on tobacco harm reduction, advocating for evidence-based regulations that support smokers in their efforts to quit. He stressed the need for the U.K. to maintain its leadership in this area and to hold international organizations accountable for their policies and decisions.

    Ramsey S. Lewis, Charles and Marilyn Stuber distinguished professor of plant breeding at North Carolina State University, delivered a detailed keynote on the complexities and challenges of developing low-nicotine tobacco varieties. He highlighted the increasing interest in these due to potential regulatory mandates that could require more than a 35-fold reduction in nicotine levels in conventional cigarettes. He emphasized that nicotine accumulation in tobacco plants results from complex interactions between environmental and genetic factors and asserted that genetic modification is the only viable method to achieve the stringent targets suggested by regulatory authorities.

    Lewis outlined the significant difficulties in achieving lower nicotine levels without negatively impacting other critical aspects of tobacco cultivation. He noted that reducing nicotine content often leads to undesirable reductions in yield, increased production costs and severe effects on leaf quality and other chemical properties of the tobacco. He warned against underestimating the complexity of biochemical pathways in living organisms, explaining that modifications in one area can lead to unexpected consequences in another.

    Furthermore, Lewis enumerated the numerous obstacles facing the development of low-nicotine tobacco. These include the feasibility of such projects, the limited availability of suitable varieties, susceptibility to diseases and insects, lower yields and higher production costs. Additionally, he highlighted the challenge of global acceptance of gene-editing techniques and the potential impact this may have on exports. Lewis underscored the need for extensive research and development to overcome these barriers and meet future regulatory requirements effectively.

    Participants in the “Nicotine – An Agricultural Approach” panel provided a comprehensive overview of the agricultural challenges and considerations associated with nicotine regulation. The discussions emphasized the need for continued research and development, thoughtful regulatory approaches and the importance of supporting both farmers and consumers in navigating these changes.

    Moderator Miranda Kinney, senior vice president of global communications and sustainability at Pyxus International, began the panel by delving into the agricultural aspects behind the tobacco products on today’s shelves, likening their personalized production journey to that of food products in supermarkets. She highlighted the importance of tobacco leaf, noting that it is the essential ingredient in most nicotine products and plays a critical role in supporting consumer satisfaction.

    Kinney emphasized that the tobacco industry supports millions of jobs globally, from farmers and processors to manufacturers, exporters, distributors and retailers, thereby enhancing livelihoods and supporting the economic viability of many developing countries.

    Kinney guided the discussion toward the intricate journey of the tobacco leaf, from the speck of a seed to a substantial industry contributor. She explained that the genetics and breeding of the seed, agricultural production practices, environmental factors and regulatory landscapes all impact the industry today and shape its future. She highlighted recent scientific advancements in genetics, cultivation practices and mechanization, noting their significant impact on farmers, particularly in developing countries where tobacco for novel nicotine products is often grown.

    Addressing regulatory challenges, Kinney pointed out that regulations, such as those proposed by the U.S. Food and Drug Administration on menthol and low-nicotine mandates, present key concerns for the industry. She discussed how potential regulations, particularly from influential regions like the EU and the U.S., could set trends globally. Kinney emphasized the importance of industry collaboration to anticipate and adapt to potential changes, ensuring that all parts of the supply chain are considered. She concluded by stressing the need for collective industry expertise to navigate the future, underlining that the agricultural aspects of tobacco production are intricately tied to the overall industry.

    George Cassels-Smith, chief executive of Tobacco Technology Inc., addressed the potential complications of mixed-crop standards, where only some plants meet lower alkaloid levels. He questioned the practicality and extensive testing required to manage such standards, particularly for plants that do not meet the set criteria.

    Cassels-Smith noted that synthetic nicotine gained a foothold in the U.S. market due to the stringent regulations on tobacco plants, although the regulations on synthetic nicotine have since been tightened. He pointed out that vaping products predominantly use synthetic nicotine, highlighting a significant shift in the industry toward these alternatives.

    He underscored the need for clear and feasible regulatory frameworks that consider the practical implications for producers and the broader industry.

    Lewis opened his remarks by clarifying that his expertise lies in plant breeding rather than addiction or behavior. He highlighted the significant challenges associated with modifying the nicotine content in tobacco plants without causing negative effects on the plants themselves.

    Lewis pointed out that if a regulatory mandate for low-nicotine tobacco were imposed today, the industry would struggle to comply due to the limited availability of viable low-nicotine varieties, which currently number around five and are associated with lower yields.

    He emphasized the complexity of biochemical pathways and the unintended consequences that can arise from genetic modifications, underscoring the need for extensive research and development to meet potential regulatory requirements.

    Carlos Pulcinelli, global project manager at Alliance One International, elaborated on the critical role of alkaloids in plant metabolism, with nicotine being the most significant alkaloid in tobacco. He asserted that it is currently impossible to control or modulate nicotine expression through agronomic practices alone, necessitating substantial investment in research and development.

    Pulcinelli stressed the increasing regulatory pressures facing the industry and the importance of developing the right plant varieties that meet the needs of farmers, regulators and consumers. He also highlighted environmental challenges such as extreme weather, droughts and floods, which complicate efforts to reduce nicotine levels.

    Despite potential changes in product formulations, he argued that the importance of plant alkaloids would remain paramount, calling for a balanced approach to meet these diverse challenges.

    Lea Scott, senior vice president of agronomy and agricultural sustainability for Universal Leaf Tobacco Co., discussed various agronomic practices, such as topping, used to manage alkaloid levels in tobacco plants. He emphasized the economic significance of tobacco farming, which generates approximately $944 million in revenue for the U.S. annually.

    Scott raised concerns about whether low-nicotine mandates might inadvertently encourage the growth of illicit trade, which already accounts for around 11 percent of the global tobacco market. He highlighted the substantial improvements in technology and the development of disease-resistant, high-yielding plant varieties. However, Scott noted that the transition to RRPs, such as heat-not-burn tobacco, would impact farmers by requiring less raw tobacco.

    He questioned whether lower nicotine levels might lead to increased consumption if consumers use more product to achieve their desired effect. Scott stressed that any shift to lower nicotine tobacco must be gradual and carefully managed, given its profound impact on farmers and communities worldwide. He also pointed out the trend of growing tobacco specifically for nicotine extraction into liquid forms, underscoring the importance of supporting both consumers and farmers.

    David Newns, entrepreneur and investor, chairperson and co-founder of Plxsur, highlighted the transformative potential of RRPs in global health outcomes. He noted that RRPs have evolved from a virtually unknown category to one now embraced by mainstream populations. This shift presents a significant opportunity to improve health outcomes worldwide by reducing the risks associated with traditional smoking. Newns emphasized that innovation cycles have been instrumental in driving the growth of the RRP category, transitioning vaping from a niche product to a globally recognized tool for harm reduction.

    Newns acknowledged the challenges associated with disposable vaping products but highlighted their crucial role in helping a large number of smokers switch to safer alternatives. These products have made it easier for smokers to incorporate vaping into their daily routines, facilitating a widespread transition from combustible tobacco. He also pointed out the collaborative efforts between academics and creatives in the vaping industry, dedicated to the mission of harm reduction. He reaffirmed that there is no one-size-fits-all solution, as different consumers have varying needs.

    Focusing on these needs, Newns explained that the universal demand from RRPs is for “more”—more convenience, flexibility, flavor, nicotine and personalization. This desire for “more” drives the continuous innovation within the industry. Looking ahead to GTNF 2024 in Athens this September, Newns expressed his enthusiasm over participating in “The Big Pitch” panel, which will invite innovators to present new and exciting nicotine products to industry leaders, fostering dialogue and shaping the future of RRPs.

  • The Forgotten Frontier

    The Forgotten Frontier

    Photo: fontriel

    Is tobacco harm reduction reaching the Global South?

    By Pieter Vorster and Sudhanshu Patwardhan

    Eighty percent of the current users of risky tobacco products live in the “Global South,” the geopolitical clubbing of low-income and middle-income countries (LMICs) that includes not only Southern Hemisphere nations such as Fiji but also nations that are firmly in the Northern Hemisphere, geographically, like China, India, Russia and Bhutan, along with countries that straddle both segments, such as Uganda.

    A world free of smoked and smokeless forms of risky tobacco products such as cigarettes, bidis, gutkha, mishri, zarda and toombak can prevent a billion premature deaths this century. This can potentially reduce the social, economic and health inequity within and between countries, thus delivering on many U.N. Sustainable Development Goals and taking a step closer to the World Health Organization’s “health for all” ambition. Do manufacturers of tobacco products, as well as businesses delivering cessation products and services, have a role in this?

    Sudhanshu Patwardhan is a medical doctor, nicotine expert and health tech entrepreneur. Pieter Vorster is managing director of Idwala Research, a consultancy aiming to accelerate global tobacco transformation and harm reduction. Both have roots in the Global South and are motivated by the goal of reducing the harms from tobacco, as seen in the Global North. Below, they discuss the challenges and opportunities related to global health equity in a freewheeling dialogue, interchangeably playing the role of interviewer, respondent, expert and devil’s advocate.

    Background

    In June 2023, at the Global Forum on Nicotine in Warsaw, Sudhanshu Patwardhan convened and chaired a workshop of international experts representing diverse stakeholder groups—tobacco control, industry and management consulting. The session was titled “Tobacco Industry Transformation—Is It Really Reaching LMICs?” The panel and the audience, including Pieter Vorster, brought deep and wide expertise in public health, consumer advocacy, regulatory affairs, nicotine supply chains and capital markets. As the first anniversary of the session approaches, it is timely to discuss the developments that have occurred since and what needs to be done going forward to achieve a world free from risky tobacco products.

    Pieter Vorster: Sud, let us summarize the session before we leap forward into what has happened since and what is next. So, in the workshop, you brought up the role of a range of stakeholders in the ecosystem: regulators, industry, consumers and healthcare professionals, to name a few. What are the regulatory challenges in the Global South that significantly impact tobacco cessation and prevention of initiation?

    Sudhanshu Patwardhan: Pieter, smoked and smokeless forms of risky tobacco products are a leading cause of noncommunicable diseases (NCDs) globally and increasingly in the Global South. However, when it comes to tobacco control, there is a serious regulatory capacity gap in the Global South. Most of these countries are still developing locally relevant systems and policies that can best meet their populations’ needs for healthier, happier and longer lives. All these countries are going through a dramatic epidemiological shift—with NCDs overtaking infectious diseases as a leading cause of disease and death. Most of these countries are signatories to the WHO’s Framework Convention on Tobacco Control [FCTC], but the implementation of the FCTC articles is still very selective. For example, most emphasis is on taxation (a proven tool for reducing demand and increasing treasury earnings), advertising restrictions, and campaigns for public awareness and prevention of initiation. Although this is having an impact, progress has been slow. The principle of harm reduction, although explicitly stated as a component of tobacco control in Article 1(d) of the FCTC, has largely been ignored by the WHO to the extent that its guidance on tobacco policy favors a prohibitionist approach toward safer nicotine alternatives and that is being adopted by many countries in the Global South that look to the WHO for leadership on health policy.

    Vorster: Please explain how that is also a regulatory issue.

    Patwardhan: This came up during our workshop. The tobacco industry is innovating into “reduced-risk products” at a breakneck speed, catching up with product innovation from outside the industry (e.g., e-cigarettes) or launching products they have developed through years of R&D (e.g., nicotine pouches and heated-but-not-burned tobacco products). Their ability to launch these products is stymied by local prohibitions in many countries globally. If regulated strictly enough and marketed only to current tobacco users, these products have the potential to reduce tobacco-related harms significantly. Evidence from the U.K., Japan and Sweden is a case in point.

    In an interlinked issue, there is hardly any capacity built for tobacco cessation in the Global South. Most of the pharmaceutical industry or health tech entrepreneurs there are equally unenthused about innovation into tobacco cessation and the massive public health opportunity. They fail to recognize the financial dividend by serving the “base of the pyramid.” So, effectively, nearly a billion people in the Global South—current tobacco users—are consigned to struggle by themselves in their attempts to quit, and most fail.

     An important aspect of “demand reduction” in tobacco control, i.e., enabling access to appealing nicotine-replacement products that can enable and sustain cessation among current adult tobacco users, is therefore not available in most of the Global South.

    Vorster: So, bans on newer “safer” nicotine alternatives in many countries are causing a strange situation: Risky forms of tobacco are still available everywhere, legally, while reduced-risk products are not? One would have thought that the science underpinning the tobacco harm reduction principle is universal. If it is clearly understood by U.K. policymakers and enshrined in the U.S. Food and Drug Administration’s “modified-risk tobacco product” authorization, why is it not accepted in the Global South?

    Patwardhan: It is important to bear in mind that sound policymaking and regulations cannot be a simple copy-paste from the Global North. Yes, global good practices can be adapted—but there is no substitute for local science to ensure relevance and sustainability. Local research capacity not only helps build the scientific evidence base but also helps society interpret it objectively. That is currently missing in most of the Global South. A glaring example is from my recent attendance at the biannual global meeting of the Society for Research in Nicotine and Tobacco, held in Edinburgh. Out of the over 1,000 delegates there, in my estimation, less than 5 percent of those attending were working on the ground in tobacco cessation and harm reduction in the Global South. The fact that these conferences happen mainly in Europe and the USA also points to systemic bias in funding and research, all skewed to the affluent Western nations. Even conventional tobacco cessation treatments are hardly, if at all, studied and available in the Global South.

    Vorster: Do you mean nicotine-replacement therapy products (NRT)?

    Patwardhan: Yes, that’s a good example. NRT are on the model essential medicines list of the WHO for tobacco dependence treatment. They have also made it to the National Essential Medicines lists of member countries. But the reality on the ground is vastly different and quite frustrating. Little or no local research data on the use of NRT for tobacco dependence treatment exist in most of the Global South. NRT gums, patches and lozenges are much costlier than the tobacco products they are meant to replace during a quit attempt. They are either available at limited points of sale or not at all, and healthcare practitioners are not equipped to advise patients on using these products.

    Vorster: You often talk about nicotine misperceptions among healthcare professionals, and you led the first published research study on this topic in 2013. More recently, the Foundation for a Smoke-Free World-funded SERMO study of over 15,000 doctors from 11 countries also showed that of those interviewed, over 70 percent believed (wrongly) that nicotine in tobacco products causes cancer. How does that impact cessation?

    Patwardhan: From personal experience interacting with numerous frontline clinicians worldwide over the years, I can see how nicotine misperceptions influence their advice to tobacco-user patients. Smoked tobacco and most smokeless tobacco products are harmful due to a wide range of chemicals, including carcinogens, either produced during combustion or added during manufacturing. Nicotine is not a carcinogen; it is, however, the dependence-causing chemical in tobacco products for sure! The misperception about nicotine regarding cancer is a likely cause of hesitance among clinicians to recommend adequate NRT treatment for long enough, alongside behavioral counseling. Cravings for nicotine and withdrawal symptoms can last from weeks to months. Not supporting the quit attempt with adequate dosing of clean forms of nicotine (e.g., NRT) for long enough is very likely to lead to a failed quit attempt or relapse. Countries such as the U.K. have strong regulatory expertise in tobacco control and expertise in nicotine science and have therefore embraced a tobacco harm reduction indication for NRT—i.e., deemed it safer for smokers to consume NRT as long as necessary, for quitting smoking altogether and to prevent relapse.

    Vorster: You make the role of regulators in tobacco cessation loud and clear. What about the industry?

    Patwardhan: The industry is not a monolith. Nor is it just the tobacco industry we are talking about here. The nicotine supply chain has never been so exciting! A significant proportion of the world’s pharmaceutical-grade nicotine comes from companies extracting nicotine from tobacco in India. Many of those companies also supply the increasing demand for nicotine for e-cigarettes and nicotine pouches. Then there is synthetic nicotine, made to pharmaceutical standards, also poised to disrupt the supply chain and potentially free up thousands of hectares of arable land to address food security issues. Some of the large multinational tobacco companies have invested in medically licensed NRT, e.g., BAT and Philip Morris International, blurring the lines between tobacco and NRT companies, potentially expanding the choices available for enabling quit attempts among current tobacco users. However, given the history of the industry, any efforts by the tobacco industry to conduct tobacco cessation training among healthcare professionals would be viewed with suspicion and likely to evoke a reaction from those in public health. There is a clear role and an unmet need for independent organizations to take the lead on this in the interest of public health. Tobacco companies can better focus their resources on conducting locally relevant tobacco cessation and harm reduction research in the Global South. That could potentially better inform regulation and an understanding of harm reduction principles among key stakeholders.

    Now, this is where I get to ask you questions! Given your deep expertise in the tobacco industry transformation process, what do you make of the tobacco companies’ innovation and launches in the context of the Global South?

    Vorster: Although there have been valuable attempts to gauge overall industry transformation, notably the Tobacco Transformation Index, no independent research has been conducted that tracks transformation progress specifically in the Global South.

    Having said that, there have been encouraging, albeit nascent, trends here. During the early years of reduced-risk tobacco product (RRP) launches, multinational tobacco companies focused on countries such as the U.S., Japan, Korea and Europe. More recently, companies like BAT have launched nicotine pouches in Kenya, Pakistan and South Africa and PMI in the Philippines, Pakistan and South Africa. Furthermore, PMI sells heated-tobacco products in a considerable number of Global South markets, including Indonesia in select cities, while BAT has a significant geographical footprint there with vaping products.

    Apart from regulatory measures that prohibit the sale of RRPs in a substantial proportion of these countries, one of the most significant barriers to harm reduction is the cost of these products relative to cigarettes, which is a function of both low cigarette prices and excise tax and relatively high production costs for RRPs. For example, the PKR120 ($0.43) per can, at which BAT and PMI sell nicotine pouches in Pakistan to compete with low-end cigarette prices, is below current production costs of about $0.50 to $0.60 per can. For RRPs to make meaningful inroads in the Global South, it is imperative that costs are reduced significantly and the price differential with all forms of risky tobacco products available locally is decreased substantially. Within this context, it is significant that BAT (followed by PMI) chose to introduce nicotine pouches in Pakistan, which has the second-highest incidence of smokeless tobacco use in the world.

    Patwardhan: Where do large national tobacco companies come into this?

    Vorster: The transformation picture is markedly different beyond the listed multinational tobacco companies. Sadly, this is also where the majority of the world’s consumers of harmful tobacco products resides.

    There exists clear potential for conflicts of interest where state monopolies control the tobacco industry, but these potential conflicts exist well beyond state ownership of tobacco companies through the tax revenues earned from tobacco products. For countries with a significant reliance on tobacco tax revenues, the WHO’s prohibitionist stance on nicotine consumer products has helped justify the banning of less risky forms of tobacco and nicotine.

    In China, the government receives the equivalent of circa 10 percent of General Government Final Consumption Expenditure from tobacco taxes in addition to the substantial revenue it earns from its ownership of the CNTC [China National Tobacco Corp.]. It was, perhaps, no surprise that, in 2022, the burgeoning independent Chinese vape industry was brought under the purview of the State Tobacco Monopoly Administration, leading to its near collapse owing to significant regulatory restraints.

    Indonesia is the second-largest cigarette market in the world after China, and whilst the tobacco industry is privately owned, the government receives some 13 percent of General Government Final Consumption Expenditure from tobacco taxes. RRPs are not banned in Indonesia, but with average cigarette prices around $1.50 per pack, they are not competitive and will likely only appeal to high-end consumers.

    Patwardhan: From the looks of it, the odds are stacked against tobacco users in the Global South: knee-jerk regulation against safer nicotine products, a local versus multinational tobacco companies’ turf war, nicotine misperceptions among healthcare professionals and a lack of locally conducted scientific research in tobacco control and harm reduction. Conducting high-quality, independent research in tobacco control and harm reduction, which can be peer-reviewed and used to inform regulatory and clinical decisions, can change this situation for the better.

    Vorster: Furthermore, despite initiatives such as the Tobacco Transformation Index that assess the overall shift in the industry, a considerable gap persists in independent research focused on monitoring transformation progress specifically in the Global South.

    Patwardhan: Agreed. There is an urgent need for industry transformation, not just in products but also in organizational attitudes toward public health, research and social responsibility in the Global South. It is quite clear to me that the industry must prioritize public health outcomes alongside business interests. It was mentioned in our panel how crucial it is for companies to engage with communities transparently to foster an environment conducive to harm reduction. This includes investing in local communities, conducting local research to global standards and responsibly supporting educational campaigns that accurately inform adult consumers about the risks of consuming tobacco and the evidence-based aids available locally for quitting tobacco use.

    Conclusion

    Eliminating harm from tobacco products is a lofty social, public health, economic and political goal. It needs to be a global goal too. The rapid pace of innovation into safer nicotine alternatives for tobacco cessation is likely to be available and affordable only to the adult tobacco consumers in wealthier “Global North” nations in a well-regulated environment, and this threatens to worsen the inequity already imposed on current tobacco users of the Global South. The industries—not just tobacco but also pharmaceutical as well as new disruptive digital and health tech companies, have much to gain commercially by innovating in the Global South. There are nearly a billion current adult tobacco consumers there waiting for just that!

    Pieter Vorster is managing director of Idwala Research, a consultancy aiming to accelerate global tobacco transformation and harm reduction.
    Sudhanshu Patwardhan is a medical doctor, nicotine expert and health tech entrepreneur from India, based in the U.K. He works on projects around the world to reduce harm from tobacco, especially among the most disadvantaged tobacco user populations.
  • Not Lost Yet

    Not Lost Yet

    Photo: JTI Poland

    While struggling with rising cost and mounting regulations, Polish tobacco companies can cheer the retreat of the illicit market.

    By Vladislav Vorotnikov

    In the next few years, Poland may lose a part of its competitive edge as a regional tobacco superpower owing to controversial European Commission policy. This will happen unless common sense prevails or the government finds the courage to stand up to Brussels, according to market players.

    Poland is one of 12 countries in the EU that grows tobacco. For eight, including Poland, this is a strategic economic sector. Poland is also the largest exporter of tobacco products in the EU, with nearly 10 percent of the country’s agricultural and food exports, 80 percent of which goes to the EU market.

    The last few years have been rough for Polish tobacco growers, primarily owing to surging operating costs in Europe, according to Lukasz Szymanski, owner of Solidus Tobacco, a trading company.

    “Unfortunately, in recent years, we have observed a systematic shrinking of the tobacco-growing sector in Poland. This was caused by systematically rising energy and labor costs, which were the main obstacle for many growers,” Szymanski said.

    Szymanski, who has been in the tobacco business since 2015, selling mostly green tobacco and tobacco in the form of strips primarily to European customers, last year moved to expand activities and open an additional branch in the port of Trieste, Italy, eyeing markets outside the EU, specifically in the Middle East.

    Weak demand in the European market might be a key rationale for Polish tobacco businesses to seek opportunities overseas.

    “For many years, market tobacco purchase prices remained at the same level, which effectively discouraged many farmers from further cultivation,” Szymanski said, adding that since he stepped into the market, he saw a gradual decline in the sales volumes, which, he calculated, nearly halved between 2016 and 2022.

    In the coming years, the lives of Polish tobacco growers could become even more challenging. Market players are increasingly concerned about the fallout of the November summit of the World Health Organization in Panama. This summit, in the opinion of some Polish tobacco businesses, has been perceived as a public declaration of war on the industry.

    “We are afraid that the Polish tobacco industry will be killed by [the] Panama [summit]. The threat of unemployment hangs over us. We do not understand why employees of legitimate businesses should fall victim to international interference in Polish affairs,” said Marcin Klimczyk, chairman of the National Section of Tobacco Industry Workers.

    Polish leaf producction has steadily declined in recent years. (Photo: Solidus Tobacco)

    Bracing for Impact

    At the end of 2023, Polish businesses, united in their concerns, appealed to the government, seeking protection. Among other things, the National Chamber of Commerce, a prominent business union, has questioned the rationale behind participating in the WHO tobacco convention, voluntarily accepting constraints on tobacco business. The organization indicated that the countries not taking part in the initiative, specifically the United States and Great Britain, are more successful in fighting tobacco addiction.

    Accepting new rules will have a heavy impact, not only in Poland but also in the entire EU, players believe.

    “I am surprised that Europe is moving in this direction,” Marek Kowalski, chairman of the Federation of Polish Entrepreneurs, told Rzech Pospolita. “There will come a time when the EU will no longer be competitive on the tobacco market with countries outside it, which will willingly fill this gap.”

    Poland is the world’s largest manufacturer of nicotine sachets, noted Zbigniew Jankowski, a spokesperson from Swedish Match.

    “We are convinced that the implementation of the WHO recommendations by the EC after Panama may lead to a ban on their sale in Europe and, in fact, to the destruction of this fledgling market. Companies will go bankrupt; people will go out of business,” Jankowski said.

    On top of that, many people who have given up cigarettes in favor of less harmful alternative products, such as nicotine sachets, will be deprived of them if the WHO recommendations are implemented. This could have a significant impact on public health and the industry’s revenue.

    Polish tobacco companies are increasingly looking for opportunities overseas.

    Flourishing Industry

    In the long run, new regulations can undermine the investment attractiveness of the Polish tobacco industry, which secures roughly 8 percent of taxes for the national budget.

    In the past few years, the general mood in the Polish tobacco industry was predominantly positive.

    Cigarette volume sales declined by less than 1 percent in 2023 while the value grew due to increased prices, Euromonitor International, a think tank, calculated.

    “In 2022, the influx of refugees from Ukraine strongly revived cigarette sales, but the impact of this factor weakened in 2023. This factor also resulted in lower volume sales of fine-cut tobacco. Meanwhile, novelty nicotine and tobacco products, such as e-vapor products, heated-tobacco products and nicotine pouches, continued to show a significant increase in demand,” said Lina Sidorenke, an analyst with Euromonitor International.

    “Closed-system disposable devices emerged as the big winner with the strongest growth in 2023. Demand for cigars remained stable; however, high demand in Asian markets and the USA has led to fewer cigars being imported to Poland. Despite regular excise duty increases, Poland still stands out in the region for low prices of tobacco products,” Sidorenke said.

    Moreover, Poland has recently achieved drastic progress in fighting against illicit trade in the tobacco market.

    In recent years, the illegal sales of cigarettes in Poland have declined dramatically, Sidorenke claimed.

    “As of 2023, the gray market comprised less than 5 percent of all cigarette volume sales. Poland has demonstrated significant success in combating illicit trade, thanks to a united effort by the police, Border Guard and National [Revenue] Administration,” Sidorenke indicated, adding that in the past, a significant portion of contraband previously originated from Belarus and Ukraine, but the imposition of sanctions on Belarus and the war in Ukraine has led to stricter border controls, resulting in a significant decrease in illegal inflows to Poland.

    JTI Poland has invested heavily in reduced risk product manufacturing.

    Emerging Niches

    The positive developments encourage international giants to pump more money into their Polish operations, primarily eyeing the segment of heated-tobacco products.

    “While sales of traditional tobacco products in Poland are relatively stable, the heated-tobacco products category has been constantly growing in the last five years, accounting for about 11 percent of the entire nicotine market in the country today,” commented Adrian Jablonski, corporate affairs and communications director of Japan Tobacco International Poland.

    “In response to these evolving consumer trends, we introduced Ploom X—JTI’s third-generation heated-tobacco product—to the Polish market in September last year. Our heated-tobacco sticks [HTS] are produced at the state-of-the-art factory in Stary Gostkow, where we have already invested over $200 million in the reduced-risk products factory,” he added.

    Jablonski added that JTI plans to continue to develop the HTS category in Poland, though the company cannot reveal details for competitive reasons.

    However, the segment may also feel the sting of the tightening regulations in the foreseeable future.

    In February 2024, Polish Health Minister Izabela Leszczyna announced that the government was considering a ban on the sale of disposable electronic cigarettes, as reported by the local newspaper Business Insider.

    Leszczyna added that she would like to pursue the fastest possible legislative path to such a measure, given that as many as 64 percent of young people in Poland had “contact” with the product.

    “Single-use e-cigarettes currently dominate the e-vapor product market in Poland. This trend has surged over the past three years. If Poland were to follow the U.K.’s lead and implement a ban on disposable e-cigarettes, it could significantly impact the entire e-vapor market,” Sidorenke said.

    Sidorenke added that while some consumers may transition to other alternatives within the sector, a decline in overall e-vapor market demand is likely.

    Heated-tobacco products in Poland currently face fewer regulatory restrictions compared to combustible cigarettes, with lower taxation and continued availability of flavored products. Despite calls from the European Commission for Poland to adhere to EU regulations prohibiting flavored heated-tobacco products, they remain on sale as of April 2024.

    “However, it’s anticipated that new regulations will be implemented rather soon. It’s worth noting that the market has historically adapted to regulatory changes, as seen after the ban on flavors in traditional cigarettes. Thus, even with a potential flavor ban, the market is expected to adjust accordingly,” Sidorenke indicated.

    In the next five years, the tobacco and nicotine market is expected to advance toward the development of next-generation novelty products, partially at the expense of traditional cigarettes and smoking tobacco, Euromonitor International analysts forecast.

    A negative or uncertain forecast is anticipated for cigars, cigarillos, snuff and pipe tobacco. Beginning May 20, 2024, all tobacco products in Poland will be subject to the track-and-trace system. Previously, the EU track-and-trace system only covered cigarettes and fine-cut tobacco. However, as of May 2024, cigars, cigarillos, snuff and pipe tobacco will also fall under this system.

    “This expansion will impose additional burdens on manufacturers and retailers due to the costs, complexity and compliance requirements. In anticipation, some distributors have already indicated plans to withdraw these items from their offerings after the system comes into effect,” Sidorenke said.