Category: Harm Reduction

Correcting The Record

Photo: Yeti Studio
Targeting tobacco risk communications
By Cheryl Olson
On August 22, the U.S. Food and Drug Administration’s Center for Tobacco Products will take live comments from the public to help develop its five-year strategic plan. One of the strategic goal areas involves improving public health via knowledge: “timely, clear and accessible health communications and education to diverse public audiences.” Along with discouraging youth initiation, the CTP wants to “encourage cessation and to inform adults who smoke about the relative risks of tobacco products.”
This is welcome news. Misinformation is killing people. For example, U.S. cigarette users who believe nicotine is harmful to health are less likely to try nicotine-replacement therapies (NRTs) or e-cigarettes to help them quit and (no surprise) are less likely to quit successfully.
“If someone believes that using reduced-risk products is just as bad as smoking, why bother switching?” says Jeffrey S. Smith, a senior fellow in harm reduction at R Street Institute in Washington, D.C.
Let’s help the CTP get rolling. What tobacco-related misconceptions deserve immediate attention? And which groups are in particularly dire need of lifesaving actionable knowledge due to persistently high smoking rates and low quit rates? I asked several colleagues for their nominations.
Dangerous Misinformation
Confusion about tobacco product relative risks is a huge concern. Clifford Douglas, who directs the Tobacco Research Network at the University of Michigan, alerted me to an article he and six distinguished experts wrote recently for the journal Addiction. It responds to the U.S. Surgeon General, who called stopping the spread of trust-destroying health misinformation “a moral and civic imperative.” The article targets two huge myths about e-cigarette risks that federal authorities unfortunately helped promote and failed to correct.
First is misinformation about e-cigarette or vaping product use-associated lung injury (EVALI), which turned out to be linked instead to vaping illicit THC products. The authors contrast the CDC’s approach to EVALI to its handling of food-related illness outbreaks. With lettuce-linked listeria, authorities are quick to share brands, dates and locations of concern, which products are probably safe and when to stop worrying. That hasn’t happened with EVALI. Not even the name has been corrected, perpetuating confusion among researchers, clinicians and the public.
The second myth is the persistent insistence that youth e-cigarette use is a gateway to smoking. Not only is evidence lacking for a causal link, but studies support the reverse: that vaping reduces youth smoking rates. This information has not been shared by health authorities.
“I’ve heard researchers tell me that we still don’t know the relative harm of e-cigarettes compared to smoking,” says Bethea (Annie) Kleykamp, assistant professor in psychiatry at the University of Maryland School of Medicine. “I’ve seen [healthcare] providers very nervous about talking about harm reduction at all. I don’t know if that’s because they’re misinformed or they’re reading information that is different from what I’m reading.”
Smith, a brain researcher with deep experience in both academia and industry, shares these concerns. “I could understand this error if it was coming from nonscientists,” he says. “But it is in the messaging from academics, policymakers and national health organizations.”
He is frustrated by the way the link between smoking and nicotine is used to tar all reduced-risk products. “If cigarettes contain nicotine, then any nicotine-containing product must be equally bad,” is how he sums up that mistaken theme.
As a neuroscientist, Smith sees an additional overlooked benefit from correcting misperceptions of nicotine. “The potential of nicotine to improve health in nonsmokers has really lagged behind due to its association to smoking,” he says. If nicotine could be destigmatized, research may lead to treatments for traumatic brain injury, Alzheimer’s disease and age-related memory loss.
The Greatest Need
“Diverse public audiences” who smoke and die at unacceptably high rates should get top priority attention from the FDA. These include people in custody and persons with serious mental illnesses.
At the University of Maryland, Kleykamp works with a long-established Baltimore addiction clinic. Smoking rates are at 70 percent or higher among people with opioid use disorder (OUD).
“A little over half of people in addiction treatment will actually die of tobacco-related disease, not other addictions,” she says. People with OUD seldom quit smoking with prescription medicines or NRTs. Preliminary evidence suggests that e-cigarettes may be a more acceptable substitute.
Kleykamp notes that addiction professionals typically focus on immediate risks: stabilizing patients and making sure they don’t overdose. And for younger patients who smoke, the biggest tobacco dangers are decades down the line. But the pattern is changing.
“A lot of patients in opioid treatment are aging,” Kleykamp notes. “In our clinic, over 50 percent are over 55 and above. So tobacco harm reduction is becoming equally urgent.”
Kleykamp’s other research focus is on longtime adult cigarette users. Among Americans over age 65 who smoke, quit rates have been stagnant since the turn of the century.
“Older adults who smoke are the least informed on relative harms and more likely to think that nicotine is a cause of cancer,” says Kleykamp. “Yet they are the most likely to get the cancer and heart disease.”
There is little research on how to change the minds and behaviors of longtime smokers. Kleykamp is working to fill that gap. She’s preparing to publish research based on the Population Assessment of Tobacco and Health study data from adults aged 55-plus who have smoked for decades. In this sample, more people had tried e-cigarettes than had tried NRT. Based on such findings, Kleykamp speculates that longtime smokers “don’t want to use these medicines. They want something that’s more the look and feel of a cigarette.”
“It seems to me that if you smoke that long and have difficulty quitting and don’t want to quit, then a product that replaces the nicotine and is pleasurable is your best hope,” she says.
Wanted: Consistency and Trust
From studies and expert opinions, one message is clear: We need consistent, clear messaging on the relative risk of smoking. Kleykamp thinks that the FDA is a trusted source of information for researchers and healthcare providers. She would like to see educational interventions geared toward providers on the basics: nicotine’s non-role in cancer, and the tobacco product continuum of risk.
For the larger public, the FDA may need to work through other avenues. Surveys suggest that many Americans, and particularly people who smoke, don’t trust information from the FDA or the Centers for Disease Control.
“Aging and tobacco use is correlated with being not white and low socioeconomic status, so you also have a correlation with historic mistrust of providers,” Kleykamp says. “An interaction with a clinician that they trust could help. Maybe in the context of a relationship that’s already been built.”
Smith also advocates one-to-one education. “I think the medical and public health community could be the source of credible information, but on the local level, not large and expensive national campaigns,” he says. “I feel that there is mistrust everywhere. And without personal connection, it will be hard to drive change.”
Smith would like to see this consistent message coming from all sources: “Combustion is the problem, not nicotine. Stop smoking—through any means, quit or switch—and your health will improve.”
Finally, he calls for more communication among researchers. “I would argue today that regardless of source—academic, regulatory or industry—the only way to solve the health problems that exist around smoking is to listen, argue, discuss, agree and disagree as a single scientific community,” says Smith. “Science is what will drive change.”
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.

August 1, 2023
Activists Dispute Gateway Findings

Photo: Wlodzimierz
Recent claims by Otago University in New Zealand that vaping is a gateway to smoking have been disputed by leading global harm reduction experts Roberto Sussman, Konstantinos Farsalinos and Gerry Stimson. These experts have highlighted the importance of harm reduction strategies in reducing the negative health impacts of smoking.
Published on June 28 in Drug and Alcohol Review, the Otago University study analyzed data related to New Zealanders’ smoking and vaping status from the 2018-2020 New Zealand Attitudes and Values survey.
Unlike other studies, Post-graduate student Andre Mason and associate professor Damian Scarf found no consistent evidence that vaping acted as a cessation pathway from smoking. Mason said vaping appeared to be another smoking-related behavior, rather than a substitute for smoking that primarily helped people quit.
“We found that there was an equal likelihood of vapers transitioning to smoking as smokers were to vapers,” Mason told Radio New Zealand.
Tobacco harm reduction advocates questioned the findings. According to Sussman, there is no evidence that vaping is a gateway to smoking. “In fact, studies have shown that vaping can be an effective tool for smoking cessation,” he said. “The vast majority of vapers are former smokers who have successfully quit smoking thanks to vaping,” added Farsalinos
Gerry Stimson, a public health expert and advocate for harm reduction, emphasizes that harm reduction strategies like vaping are essential in reducing the negative health impacts of smoking. “We need to focus on providing smokers with safer alternatives to cigarettes, rather than demonizing harm reduction strategies like vaping,” he noted.
Nancy Loucas, executive coordinator of the Coalition of Asia Pacific Tobacco Harm Reduction Advocates, who compiled these comments, also disputed the gateway claim by Otago University.
Lous cited recent data, which suggest the smoking incidence rates in New Zealand have fallen significantly over the past five to 10 years. The current smoking rate of New Zealand adults is 8 percent in 2021/2022, which has decreased from 16.5 percent in 2015 and from 27 percent in both men and women in 1993. Loucas insists that vaping has played a significant role in the reduction of smoking rates in New Zealand over the past five to 10 years. According to research published in the NZ Medical Journal, the current vaping rate in New Zealand is 8.3 percent of adults being categorized as daily e-cigarette users, up from 6.2 percent in the previous year.
“We need to focus on harm reduction strategies that work, rather than relying on outdated and inaccurate claims about vaping being a gateway to smoking,” said Loucas. “The evidence is clear: vaping can be an effective tool for smoking cessation and harm reduction.
The government of New Zealand has given NZD1.4 million ($860,411) to a large trial to help New Zealanders quit vaping. Over six months, more than 1,000 participants will test whether cytisine—a medicine that partially blocks the effects of nicotine on the brain—is more effective than a tapered reduction in nicotine, when accompanied with behavioral support.
July 6, 2023
Doctor’s Orders
Photo: Minerva Studio
Medical licensing of e-cigarettes and nicotine pouches should be an urgent priority.
By Derek Yach
The alarm about the risks of products to health is usually first sounded by physicians. That was certainly the case with tobacco and health. The 1962 Royal College of Physicians (RCP) Report on Smoking as well as the 1964 Surgeon General’s (SG) Report on the same topic were led by physicians and drew upon the best epidemiological evidence available. The reports’ statement that “smoking kills” led to rapid changes in physicians’ smoking behavior well before regulators took up the challenge. The world had to wait eight years before the World Health Organization passed its first modest resolution on smoking. Only then did modest public health policies emerge.
Internationally, the evidence is clear: No country experiences a serious decline in their smoking rates before it declines among physicians. And it takes about a decade before the population benefits start appearing. Globally, smoking rates among men approach 40 percent to 50 percent in countries as diverse as China, Bulgaria, Jordan and Bangladesh—or 50 years behind where the U.K. is today. Smoking rates among the physicians in these countries are about the same. There are few examples of physician-led reports like those of the RCP or SG from middle-income or lower middle-income countries. In such settings, we cannot expect to see substantial progress in ending smoking if we stick with the status quo.
Physician Leadership Is Crucial for the Introduction of Innovative Interventions
Innovations in healthcare are usually led by physicians armed with solid epidemiological and clinical data showing the benefits of new interventions for patients and the population. Physician leadership gives credibility to new products. The opposite is also true. Products that are not endorsed or approved by physicians rarely achieve population benefits and may face stiff regulatory approval.
Sluggish Progress on Improving Cessation Outcomes
For decades, physicians have followed a “medicalization” path to cessation, so it is not surprising that they have neglected tobacco harm reduction (THR) options. The basic advice given by physicians has changed little. Quit cold turkey, counseling, nicotine-replacement therapies (NRTs) and a few other pharmaceutical and behavioral services remain the mainstay of cessation. None have success rates that exceed 15 percent over the year, and most are associated with repeated relapses. The World Health Organization’s own reports to the World Health Assembly this year pointed to slow progress in addressing cessation. Numerous reports, such as those issued by the Foundation for a Smoke-Free World, have pointed to the failure of the pharmaceutical industry to bring better cessation tools to the market despite advances in behavioral and neuroscience that have led to new therapies for a range of diseases.
It is long overdue that physicians have access to far more efficacious and effective ways of ending smoking. We now have a full range of feasible options that have been authorized by the U.S. Food and Drug Administration as “appropriate for the protection of public health”: heated-tobacco products, e-cigarettes, snus and most recently nicotine pouches. E-cigarettes and nicotine pouches are well placed to form the basis of a new approach to cessation and harm reduction.
How Do We Engage Physicians in Scaling up Access to These Lifesaving Products?
Recent experience shows that physicians have been resistant to these products for several reasons. They fear these are a new tactic by the tobacco industry to keep the next generation addicted. They seek data on long-term benefits. They are bamboozled daily by well-funded nonprofits and WHO messages about the dangers of these products for kids, and the impact of them on cancer or heart disease. The fact that none of this is based on science has not stopped the opposition.
Could Medically Licensed Products Break Through and Reach Physicians?
I strongly believe that they could.
At a recent Keller and Heckman meeting, Ian Fearon, chief scientific officer at McKinney Scientific Advisors, described the “halo” effect of having medically licensed e-cigarettes on the market. To get medically licensed requires proof of quality, safety and efficacy. Once achieved, this could legitimize the category and open the doors to widespread physician acceptance of the products. The same could happen with nicotine pouches.
This could start to erode distrust of these products by physicians as they use them and advise their patients to use them. The predictable positive outcomes would accelerate adoptions and use.
Recall that almost 50 percent of male doctors in many low-income and middle-income countries and countries across the Middle East smoke. Helping them to switch first deserves concerted effort. And having a new medically licensed e-cigarette or nicotine pouch could well trigger the desired cascading impacts on their patients and then among the general population.
The process to obtain a medical license has been well outlined by the FDA’s Center for Drug Evaluation and Research (CDER) and the U.K.’s Medicines and Healthcare products Regulatory Agency (MHRA). Neil Benowitz et al. (see below) and Fearon have stressed that CDER requirements are particularly onerous. The MHRA process is more “encouraging.” According to them, a major benefit of the MHRA is that studies required can be conducted in any country whereas only U.S. studies are accepted by the CDER.
A unique authoring partnership between people who usually disagree about the value of THR concluded that the CDER should “reach out to companies that may be interested in developing smoking cessation products” and indicated that that could include medically approved vapes. Authors included Benowitz and Ken Warner, known supporters of THR, and Matt Myers and Joanne Cohen, who until now have opposed THR.
They commented that “the deadliest form of nicotine delivery has been subject to limited oversight whereas products marketed to help people quit face far more regulatory barriers.” The fact that agreement can be reached on the value of THR in the context of medically licensed products should be taken as a signal to how broader acceptance might happen.
Mitch Zeller, previous head of the FDA’s Center for Tobacco Products, jumped into this field recently and urged action on medical licensing when he announced that he had joined a company aiming to bring a medically licensable vape to market.
Why Has Industry Not Led the Way?
There can be little doubt that the pharmaceutical industry and leaders in the tobacco industry have long had the scientific knowledge and technical capabilities to develop medically licensed equivalents to e-cigarettes and nicotine pouches. So why has there been no progress? Are short-term commercial interests taking precedent over health needs? I suspect this is a major factor delaying progress by large companies. But thankfully, smaller entrepreneurial companies are pursuing medical licenses at considerable cost to them.
In addition to commercial interests, industry leaders and analysts have mentioned three other issues as hampering to progress:
Concern that the WHO and anti-harm reduction activists would mount campaigns against them.
Tobacco companies fear that a medically licensed product would reach a small part of the market—people with early symptoms of disease or those deeply concerned about their health. That might turn off other smokers seeking to use safer products for recreation and pleasure. They do not want to be stigmatized as being “patients.”
Any innovation or improvement to a medically licensed reduced-risk product needs costly, lengthy and comprehensive re-appraisals by the regulating body with no guarantee of consumer acceptance. For industries specializing in fast-moving consumer goods, this can be a deterrent.
What Is the Size of the Market?
Companies need to look at data on the burden of disease and at data they have showing that an extremely high percentage of e-cigarette users switched from combustibles for health reasons. Global burden of disease data shows that 8 million people die annually from tobacco use. That figure hides the fact that hundreds of millions of tobacco users have early symptoms or signs of cancers, heart and lung disease or tuberculosis. It hides the fact that over 50 percent of people with serious mental illness smoke, that about 60 percent to 70 percent of people with early chronic obstructive pulmonary disease, tuberculosis and schizophrenia smoke at the point they are diagnosed. And that figure does not change much during their treatment, suggesting physicians’ failure to help their patients end smoking.
It is not surprising that a recent Bloomberg analysis suggests that the size of the nicotine-replacement market could reach $100 billion by 2028. That should stimulate companies to invest in medically licensed options that consumers demand and enjoy in unprecedent numbers.
How Would These Products Be Marketed?
Marketing strategies would need to distinguish between products that are medically approved versus others. There are many precedents for designing marketing plans to reach two different audiences using the same basic product. The most recent being how Ozempic addresses the needs of people with diabetes while Wegovy (both made by Novo Nordisk) addresses obesity. Two brands, one set of active ingredients. In an analogous way, initially NRTs were prescription-only in most countries but were changed to “over the counter” use to improve access to “essential medicine,” and NRTs are noted as such in the WHO Model List of Essential Medicines.
I could see this developing a comparable way for e-cigarettes and nicotine pouches.
Conclusion
There is a massive untapped need to get more efficacious cessation products on the market. Medically licensed e-cigarettes and nicotine pouches could well be the key to gaining widespread and critically needed physician support for the categories. That could unblock deep opposition to THR as it has happened with so many innovations that benefit health.
A global health expert and anti-smoking advocate for more than 30 years, Derek Yach is the owner of Global Health Strategies. Previously, Yach was the director of the Foundation for a Smoke-Free World and a World Health Organization cabinet director and executive director for noncommunicable diseases and mental health. He was deeply involved with the development of the Framework Convention on Tobacco Control.
July 1, 2023
Sweden Close to Smoke-Free Status

From left to right: Julia Kril (World Vapers Alliance); MEP Johan Nissinen; Carissia During (Considerate Pouchers); MEP Charlie Weimers; Michael Landl (World Vapers’ Alliance) | Source: World Vapers’ Alliance
Sweden has almost reached smoke-free status, which is considered 5 percent of the population or less smoking, reports AP. In 2019, 6.4 percent of Swedes over the age of 15 were daily smokers. Last year, 5.6 percent of the population were smokers, according to the Public Health Agency of Sweden.
“We were early in restricting smoking in public spaces, first in school playgrounds and after school centers and later in restaurants, outdoor cafes and public places such as bus stations,” said Ulrika Arehed, secretary-general of the Swedish Cancer Society. “In parallel, taxes on cigarettes and strict restrictions on the marketing of these products have played an important role.
Members of European Parliament expressed concern with the European Union approach toward smoking cessation, noting a need for an approach following that of Sweden. Charlie Weimers and Johan Nissinen called for a more open approach toward harm reduction in the EU at a press conference in Brussels that was hosted by the World Vapers’ Alliance.
“The Swedish case presents the third and final determining pillar in the pro-harm reduction argument,” said Michael Landl, director of the World Vapers’ Alliance. “The science, the experience of the consumers and now the Swedish example are proof that harm reduction works in achieving a smoke-free society. Now we have an undeniable case that the EU-wide regulation must be risk-based and evidence-supported.”
“Policy should be evidence-based,” said Weimers. “WHO [World Health Organization] will soon classify Sweden as Europe’s first smoke-free country because of harm reduction policies and widespread use of snus. Sweden has a wide range of harm reduction products: We have snus, nicotine pouches, vaping, etc. People are given a choice!”
Nissinen said, “It is clear that smoking kills, and we need to do everything we can to prevent those unnecessary deaths. Sweden is the best example of how this is achievable, namely with a pragmatic harm reduction approach. It is the only country in the EU where snus is legal and popular, with 18 percent of the population using it. Consuming snus instead of cigarettes saved many Swedish lives. It is time that the EU Commission expects this reality and starts acting accordingly.”
“Snus has been used since the 1800s, so we have more than 200 years of a case study that proved that tobacco harm reduction works. Snus is a great way to continue consuming nicotine without harmful chemicals you take from the traditional combustible cigarettes,” said Carissa During, the director of the Considerate Pouchers. “Many countries in Europe are trying to overregulate or ban alternative nicotine products. Policymakers believe that banning something will make them disappear. We know that it is not true.”
The WHO, however, attributes Sweden’s declining smoking rate to tobacco control measures, including information campaigns, advertising bans and “cessation support” for those wishing to quit. The agency stated that Sweden’s tobacco use is at more than 20 percent when including snus and similar products.
“Switching from one harmful product to another is not a solution,” the WHO said in an email, referring to snus. “Promoting a so-called ‘harm reduction approach’ to smoking is another way the tobacco industry is trying to mislead people about the inherently dangerous nature of these products.”
June 2, 2023
Vaping Up in U.K. Prisons

Image: Tobacco Reporter archive
Vaping has surged in U.K. prisons since a smoking ban went into effect in 2017 (in England and Wales), according to Filter.
In the 2021–2022 financial year, prisoners spent close to £8 million on vapor products. Prisoners have access to vapes as well as nicotine-replacement therapy.
While the surge in vaping has been positive in terms of harm reduction, the abrupt change has had its challenges. With the prohibition of smoking in prisons came illicit cigarettes and trading/selling other personal property, including meals, in order to obtain cigarettes.
The Howard League for Penal Reform “has supported making prisons smoke-free in principle, given the health risks to both prisoners and staff,” said Andrew Neilson, director of campaigns. “But we’ve always been concerned that the ban was implemented responsibly and that prisoners were given the proper support and resources to move away from smoking.”
Neilson cited a general lack of provisions to support mental and physical health, including lack of access to fresh air. “Prisons are still struggling to deliver these kinds of open regimes after the pandemic effectively locked prisons down and saw people kept in their cells 23 hours a day.”
The smoking ban raises questions, according to Andy West, who teaches philosophy in prisons, when a prison cell is someone’s residence and when “people still want to smoke” and “prisons seem to stoke addictions.” He said that illicit cigarettes are “more dangerous” and “Prohibition always creates a bigger monster than the one it kills.”
Despite this, the number of prisoners who have turned to vaping and stuck with it is promising. “The fact that many people have access to vaping products is welcome news from a tobacco harm reduction perspective,” said Debbie Robson, senior lecturer in tobacco harm reduction at King’s College London. “Great progress has been made in creating a smoke-free prison estate despite doubting it was achievable given the high smoking rates in prison settings.”
Robson speaks with formerly incarcerated individuals while conducting research, and many have expressed that their first vaping experiences were in prison, and “some have stayed smoke-free ever since.”
“As a nurse, that makes me question why a prison setting may be the first time someone has the opportunity to use a vape,” she said. Outside the prison system, “health and social care practitioners can do more to raise awareness and reduce barriers to vaping in groups where smoking prevalence is high,” she said.
June 2, 2023
British Government Cracks Down on Kids Receiving Vapes

Image: Diego Cervo | Adobe Stock
The British government is cracking down on a loophole that allows retailers to give free vape samples to kids, reports Reuters.
“I am deeply concerned about the sharp rise in kids vaping and shocked by reports of illicit vapes containing lead getting into the hands of school children,” Prime Minister Rishi Sunak said. “The marketing and the illegal sales of vapes to children is completely unacceptable.”
“We should continue to encourage smokers to swap to vaping as the lesser risk whilst preventing the marketing and sale of vapes to children,” England’s chief medical officer, Chris Whitty, said.
The government plans to review the rules on issuing fines to shops that sell vapes to those under the age of 18 in order to more easily allow local authorities to issue on-the-spot fines and fixed penalty notices.
The U.K. Vaping Industry Association (UKVIA) expressed support for the government’s decision.
“The UKVIA fully supports the government’s actions to protect minors and urges the Prime Minister to ensure that this tough stance is followed up with equally tough action,” said John Dunne, director general of the UKVIA, in a statement. “For too long, some rogue firms have felt they had free reign to sell a product designed to help adult smokers quit to youngsters because they realized that the chances of getting caught were slim at best.
“Even if they get caught, the fines—which have been as low as just £26—are no deterrent, so we welcome the review into fines and repeat our calls that they should be up to £10,000 per instance and be backed up by a retail licensing scheme, which would include age verification requirements and robust enforcement by Trading Standards departments up and down the country.
“Sadly, many Trading Standards departments are not resourced anywhere near enough to clamp down on the illicit and illegal vape sales, and this is an issue that the government should now look at very seriously indeed.
“Data in the possession of the UKVIA shows that very few prosecutions have been made for underage or illicit sales across the country, and this must be addressed as a matter of urgency,” Dunne said. “Unless unscrupulous traders know that selling vapes to children is an endeavor that would be financially ruinous to them, then they will continue to do so.”
“We totally agree that there can be no justification in giving free vape samples to children—whether or not they contain nicotine—but any new measures the government does impose in this area must not impact on the tremendous work being done by stop smoking centers around the country.”
June 2, 2023
European Elections Could Affect Vaping

Image: Tobacco Reporter archive
Elections in several European countries could affect support of reduced-risk nicotine products like e-cigarettes, according to Tamarind Intelligence Policy Radar research.
Governments in Europe are the most likely to officially support reduced-risk products.
According to Tamarind Intelligence, forthcoming elections in Finland, Spain, Ireland and the Czech Republic as well as elections for the European Parliament could be significant in determining the future of the products.
“Our analysis of official attitudes toward e-cigarettes and other tobacco harm reduction products shows some clear global trends,” said Tamarind Intelligence Editorial Director Barnaby Page. “For example, European countries tend to have more favorable attitudes while Asian countries tend to be much more polarized.
“However, the laws in this area can change very rapidly—sometimes because government itself changes or at other times because issues such as underage vaping or the environmental impact of disposable vapes come into the spotlight.”
Researchers expect worldwide regulation of reduced-risk products to become stricter, especially in upper-middle-income and high-income countries. Flavored products are expected to receive the most attention with countries proposing bans on the products.
June 1, 2023
Changing Gear

Photo: Taco Tuinstra
How the tobacco industry can accelerate transformation
By Clive Bates
In the unlikely event that I am appointed CEO of a large tobacco firm, this is what I would do to accelerate the transformation of the business.
First, I would ask if we really do want to transform the business and, if so, why. Until the board, thousands of staff, investors and stakeholders understand our rationale, what chance is there of bringing them on the journey? This is a more vexing question than it might appear at first sight. Perhaps we would be better off as we are? After all, we make terrific margins on cigarettes; we have tremendous pricing power courtesy of the tax authorities; we are embedded in a comfortable oligopoly that knows how to make money; and, of course, it helps that the product is addictive, and the customers are loyal to our brands.
In contrast, the transformation is toward a volatile and diverse market, intense competition holding down margins, the ever-present danger of being caught flat-footed by rival innovation, fickle customers pursuing the next new thing and the potential for illicit entrants flooding the market. Why would we want that? The answer is that we don’t get to choose. Even if we could join forces with all other tobacco companies, we cannot individually or collectively hold back this transformation and restore the situation as it was before 2010. This is because consumer preferences and competition from nontobacco companies drive it. The ship has sailed. Our only viable strategy is to compete ferociously for market leadership in the new product categories. We need to deepen our explanation of the drivers of transformation and set out our transformation rationale clearly and rigorously. For inspiration, we will look to the scholars of creative destruction, diffusion of innovation and corporate strategy: a little more Harvard Business Review and a little less New England Journal of Medicine.
Second, we need to sell high-quality, compliant products that people want to buy as alternatives to cigarettes and make good money by doing it. Apologies if this is a statement of the obvious, but it is the core function of businesses undergoing a market transformation. Everything else is froth. Fortunately, the impetus for this is all too clear: competition and the threat of rivals converting our cigarette smokers to their smoke-free products and, equally, the opportunity to convert their customers to become ours. Some in public health suspect that Big Tobacco would like to hold back innovation and slow down the rate of transformation. However, Big Tobacco is an imaginary construct comprising companies that compete intensely. A company that tries to hold back innovation will not fare well at the hands of its innovative rivals. The aggregate effect of all the companies pursuing competitive advantage in new product categories will be the primary driver of transformation. Ironically, the primary drag on transformation will be legislators, regulators and tobacco control activists intervening to throttle innovation and uptake of new technologies. Yet, it would be a mistake to rely on “useful idiots” to protect the cigarette business. Their attitudes and ideas could change with as little as the stroke of a philanthropist’s pen.
Third, we should engage with the environmental, social and governance (ESG) investing community. ESG is the new language for “ethical investment.” There are really three types of ESG investing: (1) taking stakes in virtuous companies that do not trigger exclusion criteria, of which “tobacco” would always be one. This route is closed. (2) To back emerging world-changing companies, though these are difficult to spot in advance and few in number. (3) So-called “engagement investing,” where ESG investors buy into companies with a significant problematic health, social or environmental burden and pursue improvements. By reducing negative footprints, this form of investing has the potential to do more material good for society than the other two. For tobacco companies, ESG engagement would endorse a transformation strategy with external validation and accountability.
Fourth, we must master the future of nicotine and its place in society. Nicotine is a popular recreational stimulant for a reason and not just because it is “addictive.” Tobacco companies have been understandably shy about discussing nicotine and why there is a demand for it. But companies are in the consumer nicotine business—it is the reason they exist and why they have a future. As consumer nicotine products are becoming smoke-free and far less harmful, the main deterrent to nicotine use—the health risks of smoking—is becoming weaker. The decades-long controversy about tobacco is shifting its focus from severe smoking-related diseases, such as cancer and chronic obstructive pulmonary disease, to concern about nicotine use and addiction. Most people understand and accept why there is a demand for alcohol and caffeine, and many understand the demand for cannabis. But who really understands the demand function for nicotine once this is no longer conflated with smoking? People use nicotine for pleasure and stimulation, to modulate mood, stress and anxiety, and for a range of cognitive improvements. Nicotine may interact beneficially with various health conditions, including attention-deficit/hyperactivity disorder and Parkinson’s disease. As a society, we should not be recommending or endorsing nicotine use, but we should surely have a better understanding of why people use it.
Fifth, to the extent possible, we should agree with other transformation-minded businesses on the optimal regulatory and fiscal approach. We routinely state that excise and regulation should be “risk-proportionate,” but what do we mean by that in more detail? How should we approach contentious issues, such as youth uptake? We should be (and be seen to be) leading the thinking and marshalling of the evidence base for risk-proportionate regulation. This requires some careful judgements: we must avoid erecting excessive barriers to entry to smaller players, or we risk looking (and being) predatory, and our approach will be dismissed as cynical and expedient and generate opposition among potential allies. The regulatory environment may evolve over time and may contain dependencies. For example, some of the stricter measures to address cigarettes must be accompanied by readily available and well-understood pathways to smoke-free products.
Sixth, we must be more assertive scientifically. Just as the industry’s science provides high-quality insights into tobacco harm reduction and reduced-risk products, it is increasingly excluded from conventional publishing platforms and scientific fora. The exclusion is not accidental or merely a misunderstanding based on historical industry malpractice. Nor is it likely to change. It is because a significant share of the academic community rejects the strategy of harm reduction and, therefore, the science that supports it. For many, it is seen as “the nicotine maintenance survival strategy of Big Tobacco” and thus to be opposed, whatever its benefits to health and welfare. The way to address this is to fully embrace the ideas and principles of the open science* movement. The industry could produce or sponsor publicly accessible scientific resources that are category-wide, such as living reviews of biomarker or toxicology studies or informative behavioral research. We should engage credibly, respectfully and systematically to challenge poor-quality science, misleading interpretations and policy recommendations that go far beyond the science that supposedly justifies them. The lack of accountability and redress in tobacco control science has created cavalier attitudes to scientific rigour that would not be acceptable within the industry. Consistent with an open science approach, we should acquire and release all relevant market data to the independent research community and allow them to interpret it. If substitution effects are real and a transformation is proceeding, this is the best form of validation.
Seventh, we may need an organizational vehicle to advance the transformation agenda for the industry as a whole. The tobacco industry is not homogenous. Many companies, notably the state-owned monopolies, are not interested in transformation and profit mightily, at least in the short term, from the prohibitions promoted by the World Health Organization and its fellow travelers. Yet, all the tobacco multinationals generally recognize the transformation imperative and decline to be seduced by the Bootlegger and Baptist implicit bargain with tobacco control activists. This group must find its voice—not as a conventional trade association but as a cross-industry body dedicated to an idea. It would delineate the territory of common category-wide interests (e.g., greater public understanding, a common regulatory agenda, marketing standards, environmental issues, scientific engagement, etc.) from inter-company competitive interests (pricing, product launches, etc.).
Finally, something we should not do. We should resist the temptation to use regulation for short-term gain by supporting regulation that helps us and hinders our competitors. Over the longer term, our opponents will selectively adopt the restrictive and reject the permissive measures we back. What appears to help us today may harm us a couple of years from now as we develop new products or acquire new businesses. Our goal should be an enduring fiscal, regulatory and communications environment that works for smoke-free categories as a whole. That will create a rules-based context for competition between companies and an attractive alternative to illicit trade.
Clive Bates is the director of Counterfactual Consulting and the former director of Action on Smoking and Health (U.K.).

June 1, 2023
Vietnam Harm Prevention Approved

Image: Tobacco Reporter archive
Vietnam has approved the National Strategy on Tobacco Harm Prevention and Control to 2030, reports Vietnam+.
The strategy aims to reduce the rate of male tobacco use to less than 39 percent between 2023 and 2025 and to reduce the rate of female tobacco use to below 1.4 percent.
It also aims to reduce passive smoking to less than 30 percent at work, less than 75 percent at restaurants, less than 80 percent at bars and cafes and less than 60 percent at hotels.
A road map will be created to increase taxes on tobacco products, regulate the minimum selling price of tobacco products and research and evaluate the effectiveness of the plan for calculating taxes on tobacco products on the retail price in order to achieve a reduced rate of tobacco use.
The strategy also proposes promulgate regulations on the prevention of e-cigarette products, heated-tobacco, shisha and other new tobacco products and the sale of tobacco for juveniles or juveniles selling tobacco under the World Health Organization Framework Convention on Tobacco Control.
Vietnam remains one of the 15 countries with the highest smoking rate among male adults.
May 30, 2023
World Vape Day:

Photo: BAT
A new scientific study on Vuse underscores the contribution vapor products can make toward tobacco harm reduction.
By James Murphy
Almost 20 years ago, I joined BAT as a scientist motivated by the positive change that tobacco harm reduction (THR) can achieve. We have made great strides since then, and on days like World Vape Day, it is encouraging to see continued innovation in this area. This ambition to support THR is embodied by BAT’s release today of one of the largest vapor product studies ever conducted, further supporting the role that Vuse, BAT’s flagship vapor brand, can play in tobacco harm reduction.
Science and research have been fundamental to the progress that I have witnessed over almost two decades at BAT. Together, they form the cornerstone of consumer and regulatory confidence in our brands. This confidence is essential for our new-category products to be able to both support THR and provide reduced-risk*† alternatives for consumers who would otherwise smoke.
Early in my career, I had the opportunity to lead product development for BAT’s first vapor product, which would subsequently turn into Vuse: a billion-pound brand and the No. 1 global vaping brand by market share.¹ Now, in 2023, there is wide acceptance that vaping continues to grow in importance as adult smokers seek reduced-risk alternatives to continued smoking.
As director of research and science at BAT, my priority is to develop and publish science-based information needed to better understand the real-world impacts of our products.
Our latest study, published today in the peer-reviewed journal Internal and Emergency Medicine, is intended to do just that. By comparing clinical measurements from exclusive Vuse consumers with current smokers, the results of the study show that adult consumers using BAT’s vapor brand Vuse² had significantly better results for biomarkers relevant to smoking-related diseases than smokers.
For priority cigarette smoke toxicants identified by the World Health Organization, levels of exposure were significantly lower in the Vuse consumers compared to the smokers. Additionally, favorable differences between the Vuse consumers and smokers were found across all seven measured biomarkers of potential harm relevant to smoking-related diseases.
We believe these results underscore the contribution that vapor products can make toward tobacco harm reduction and how, by using a robust evidence base to substantiate the role of reduced-risk* products, we can give adult smokers who would otherwise continue to smoke access to satisfactory reduced-risk* alternatives.
While World Vape Day brings together a global community to converse and learn about tobacco harm reduction, there are significant barriers and challenges facing companies involved in the vaping industry. I believe a core component to overcoming these barriers is evidence-led and science-backed regulation and leadership. These two areas are key to ensuring that reduced-risk* products are only made available to adult consumers and that consumers feel confident about the quality and safety standards governing the development of alternatives like vapor products.
In countries where the concept of tobacco harm reduction has been embraced, we have seen accelerated declines in smoking rates as smokers migrate to noncombustible products. Sweden, for instance, is on the cusp of becoming the first European country to become officially smoke-free—with smoking rates at just 5.6 percent—a 51 percent drop in a decade. Low smoking rates have also had direct benefits for Swedish public health, with cancer rates that are 41 percent lower than the rest of Europe. However, many countries are yet to offer consumers legal access to reduced-risk* products as alternatives to widely available conventional cigarettes.
I am more convinced than ever that tobacco harm reduction has the potential to be transformative for our consumers and significantly lower currently projected smoking rates worldwide.
There is a clear opportunity to use the scientific evidence we now have available to substantiate the benefits of reduced-risk* products for those who would otherwise smoke. Looking ahead, I am increasingly confident that the quality of ongoing research from us, other manufacturers, academics and public health authorities—combined with open and honest debate with a diverse range of political, regulatory and public health stakeholders—will accelerate tobacco harm reduction.
James Murphy is the director of research and science at BAT.

* Based on the weight of evidence and assuming a complete switch from cigarette smoking. These products are not risk-free and are addictive.
† Our products as sold in the U.S., including Vuse, Velo, Grizzly, Kodiak and Camel Snus, are subject to FDA regulation, and no reduced-risk claims will be made as to these products without agency clearance.
¹ Based on Vype/Vuse estimated value share from recommended retail price in measured retail for vapor (i.e., total vapor category value in retail sales) in the U.S., Canada, France, the U.K. and Germany. These five markets cover an estimated 77 percent of global vapor closed-system net turnover, calculated in June-July 2021.
² The study focused on self-reported exclusive users of commercially available Vuse ePod or Vuse ePen3. Thus, references to “Vuse” in the context of the study means either Vuse ePod or Vuse ePen3.
May 30, 2023