Category: Harm Reduction

Study: HTPs Increase Likelihood of Quitting

Photo: Nikita
Switching to heated tobacco products (HTPs) can significantly increase the likelihood of smokers quitting smoking entirely, reports the Inquirer, citing a study conducted by South Korean researchers.
Conducted by experts at the Korea Institute for Industrial Economics and Trade, the study also found no evidence to support concerns that HTPs serve as a gateway to smoking.
Using data from the Korea National Health and Nutrition Examination Survey, the researchers observed that 99.4 percent of HTP users either switched from traditional cigarettes or are dual users, with only 0.6 percent being new smokers.
Anton Israel, president of the Nicotine Consumers Union of the Philippines, said the Korean study demonstrates how technology can mitigate the risks associated with nicotine consumption. “Nicotine isn’t the problem,” he was quoted as saying. “It’s the way it’s delivered through combustion. Smoke-free products like HTPs eliminate the harm from smoke.”
The Korean study, which surveyed 4,514 adults, also concluded that adolescents are more likely to start smoking with traditional cigarettes rather than HTPs. Among the study’s participants, 2,356 were nonsmokers, 1,316 were traditional cigarette smokers, and 842 were HTP users.
Heated tobacco products accounted for 12 percent of South Korean tobacco sales in 2021, up from 2.2 percent in 2017.
September 4, 2024
New Zealand and Sweden Lauded for THR
We Are Innovation (WAI) released a video about Sweden and New Zealand reducing smoking rates through the consistent use of innovative alternatives. Titled “Smoke-Free Success: Sweden and New Zealand’s Experiences,” it highlights the role of safer nicotine products in decreasing smoking-related deaths and diseases.
As WAI explains on its website, Sweden’s pragmatic approach to smoking reduction has been heralded as a global model. Historically, Sweden has had a significant population using snus, a smokeless tobacco product. This cultural acceptance of the product laid the groundwork for the introduction of oral nicotine pouches, providing smokers with safer alternatives to cigarettes.
According to Anders Milton, former chair of the World Medical Association, 17 percent of Swedish men use snus daily while only 5.6 percent of Swedish men—the lowest rate globally—smoke. Sweden also boasts the lowest incidence of lung cancer in the European Union.
In New Zealand, the legalization of vaping has led to a significant decline in smoking rates, dropping from 16 percent to 6.8 percent over eight years, according to WAI. This progress, the group says, positions New Zealand to achieve its smoke-free target by 2025.
Marewa Glover, a behavioral scientist with over 31 years of experience in public health, believes that vaping has been transformative. According to her, it offers smokers a less harmful option and substantially reduces smoking rates.
WAI contrasts the approach of Sweden and New Zealand to that of Australia, where restrictive policies on vaping have hindered anti-smoking efforts, according to the organization. Critics point out that ideological objections and vested interests have slowed progress toward harm reduction, with some groups favoring an abstinence-only approach rather than adopting alternative solutions like vaping. The abstinence-only approach does not work for everyone, and since cigarettes bring in a lot of tax, there are vested interests that benefit from that, according to WAI.
August 13, 2024
Role for Social Workers in Harm Reduction

Photo: pressmaster
Social workers should be given the tools to promote tobacco harm reduction as a means to reverse the high smoking rates found in many of the populations with whom they interact, according to a new briefing paper by Knowledge Action Change (KAC)
In 2021, according to the World Health Organization, two-thirds of people with severe mental health conditions were people who smoked and in those experiencing schizophrenia rates can reach as high as 70-80 percent. People who use illicit drugs are also three times more likely to smoke cigarettes compared to non-users. One study in California found that smoking-related conditions comprised around 40 percent of total deaths among people hospitalized with cocaine, opioid and methamphetamine disorders.
The KAC briefing paper explores how, in countries where they are affordable and available, switching from smoking to the use of safer nicotine products could have dramatic positive effects for those supported by social workers.
“Social workers around the world regularly work with individuals who are more likely than the general population to smoke, for example people experiencing mental health and substance use issues,” said KAC Director David Mackintosh in a statement.
“However, few countries train social workers to support those who want to quit smoking. This is a missed opportunity for both individuals in need and the public health system. Equipping social workers with the tools to provide trusted information and advice on tobacco harm reduction options would benefit their clients, as well as their families and communities. It would save lives. The potential is massive, especially in countries where smoking cessation services are rare, non-existent or expensive to access.”
August 5, 2024
No Shortcuts

The effort to correct nicotine risk misperceptions will be a marathon rather than a sprint.
By Stefanie Rossel
“Nicotine contained in tobacco is highly addictive, and tobacco use is a major risk factor for cardiovascular and respiratory diseases, over 20 different types or subtypes of cancer and many other debilitating health conditions.” With phrases like this, the World Health Organization links the undisputed harms of burning and inhaling plant tissue with the ingredient smokers seek in a cigarette.
Regardless of its form of delivery, such statements suggest, nicotine is the devil incarnate. In spreading this message, it appears, the WHO has done a good job. In a 2021 study funded by the National Cancer Institute, 83.2 percent of surveyed U.S. physicians “strongly agreed” that nicotine directly contributes to the development of cardiovascular disease. Nearly 81 percent thought it contributes to chronic obstructive pulmonary disease (COPD), and 80.5 percent associated nicotine with cancer.
While recognizing that nicotine is responsible for the addictive nature of tobacco products, the study authors pointed out that the strongest evidence for direct causality for nicotine is for birth defects (neurodevelopment), with only limited evidence supporting causal links to cancer and cardiovascular disease and scarce data for COPD. The misperception that nicotine is responsible for smoking-related health risks, they observed, is not only common among the public but also among other healthcare professionals.
“Correcting misperceptions should be a priority given that in 2017, the FDA [U.S. Food and Drug Administration] proposed a nicotine-centered framework that includes reducing nicotine content in cigarettes to nonaddictive levels while encouraging safer forms of nicotine use for either harm reduction (e.g., smokeless tobacco) or cessation (pharmacologic NRT [nicotine-replacement therapy]),” the study concluded.
In product use, risk perceptions play a critical role; they can influence smokers’ decisions on whether to switch to products with lower risk profiles. The messaging is an essential part of changing misperceptions. Studies on nicotine corrective messaging have shown that it was effective in decreasing misperceptions of nicotine harm, but repeated exposure to such messaging was necessary to reduce false beliefs about nicotine and tobacco products.
With physicians and other healthcare professionals often being the first point of call for people seeking to quit smoking, it is obvious that their misperceptions should be corrected first so that they can educate their patients and accurately convey nicotine’s relative and absolute risks.
Carolyn Beaumont
Carolyn Beaumont, a general practitioner (GP) from Victoria, Australia, has taken on the challenging task of educating her colleagues. Since July 1, 2024, all nicotine vapes in Australia have been regulated as therapeutic goods, which means they are available only at pharmacies to help people quit smoking or manage nicotine dependence. Currently, all buyers of nicotine vapes require a prescription from a doctor or a nurse practitioner.
Starting Oct. 1, the rules will be somewhat relaxed. From that date, people 18 years or over will be able to purchase therapeutic vapes directly from a pharmacy without a prescription. People under 18 will still need a prescription to access vapes, where state and territory laws allow it, to ensure they get appropriate medical advice and supervision.
The concentration of nicotine in vapes sold in pharmacies without a prescription will be limited to 20 mg per milliliter; people who require vapes with a higher concentration of nicotine will still require a prescription.
The law requires pharmacists to consult customers of both prescription and nonprescription vapes before allowing them to make a purchase.
Following the announcement of the new rules, several major pharmacy chains in Australia stated that they will no longer stock vapes. Beaumont is not surprised: “They simply don’t have the time, product knowledge or resources to advise customers on appropriate products and use. It is greatly complicated because any pharmacist-only product must be an approved medical product, yet there are no approved vapes in Australia. They are listed but not approved. Fortunately, there are some online pharmacies who specialize in vapes, and these will continue to operate but likely will require a script to avoid the ‘nonapproved’ issue.”
“There is no official doctor education in Australia that adequately presents the fuller context of smoking, vaping and nicotine.”
Enjoyment Doesn’t Feature
Despite the hostile environment for nicotine, Beaumont says she has found that her colleagues are quite interested in the field of tobacco harm reduction (THR). “Yet, to communicate THR on a larger scale, typically via continuing medical education (CME) courses or webinars, is difficult. These generally require support from the Royal Australian College of General Practitioners (RACGP), and to date, there is no official doctor education in Australia that adequately presents the fuller context of smoking, vaping and nicotine,” she says.
“In medical school and as a trainee GP, we were taught of the many smoking-related health and social issues. But a more nuanced understanding of working with smokers wasn’t appreciated. We all knew the ‘three A’s’ approach—ask, advise, assist—the measure of nicotine dependence—time to first cigarette—and the first line NRTs. Yet it stopped there as though magically, smokers would be motivated to quit, and this would happen within six months. If not, repeat the process ad nauseum.”
According to Beaumont, doctors aren’t taught that some smokers like nicotine and simply want a less harmful alternative. “Enjoyment doesn’t feature in medical education,” she says. “Doctor support can truly help some people reduce their use. But it’s not enough for many heavy smokers, and they often become disengaged with the same messaging they keep hearing from doctors.”
Beaumont is encouraged, though, that Australia’s GP College recently revised its smoking cessation guidelines and increased the recommendation of vaping from “low” to “moderate.” “I hope this will have a reasonable impact on doctors’ willingness to prescribe, or at least be open to the conversation,” she says. “I also hope this signals a greater willingness by the RACGP to support vape-related CME that is broader in scope and includes input from ‘progressives’ such as myself.”
Beaumont first became aware of vaping as a cessation tool in 2020 when Australia was on the verge of making vapes prescription-only. “My approach was simply this: I listened to the needs of smokers and vapers,” she says. “It didn’t take long before I was convinced of [the] merits [of vaping], and also, I developed a deeper understanding of nicotine use and addiction. Compassion and health improvements were, and still are, the underlying reasons why I’ve remained involved in this field.”
Beaumont aims to help disadvantaged groups, which are among the most affected by smoking-related death and disease. “It is simply unjust that smokers are also affected by nicotine myths, and it is getting to the point where people think that smoking is better than vaping.”
“Like so many areas where science is contested, adherents of contrarian positions are rarely persuaded by more science or data.”
Open Dialogue Required
Derek Yach
While some believe that science will correct misperceptions of nicotine, others are skeptical, pointing, for example, to the WHO’s proposal to define aerosols as smoke. Derek Yach, a global health expert originally from South Africa who played a key role in crafting the WHO’s Framework Convention on Tobacco Control, says that while some topics require more research, these gaps should not delay WHO support for THR, noting that they have not prevented the U.S. Food and Drug Administration and other government agencies from authorizing a range of reduced-risk products.
“Like so many areas where science is contested, including vaccine benefits, climate change or even beliefs that the earth is flat, adherents of contrarian positions are rarely persuaded by more science or data,” says Yach. “Their views deeply reflect emotional, ideological and sometimes cultural views based on their life experiences. A mother whose child gets autism after a vaccine is easily convinced that vaccines are dangerous. A tobacco control advocate who experienced tobacco industry subversion of public policies keeps that view and doubts anything new coming from industry.”
Having worked on all sides of the issue and having spoken with a wide variety of stakeholders, Yach says that there is no shortcut to finding safe spaces to not only talk honestly about the science but also examine the reasons behind the mutual suspicion. “I saw this bear fruit in the declining years of apartheid when talks about talks led to a peaceful transition of power,” says Yach. “It is possible in that setting; it must be possible in our world.”
The Morven Dialogues, a series of meetings between U.S. public health officials and tobacco industry representatives first held in 2012, have been a modest example of what is needed, according to Yach.
“They recently reported on their March 2024 meeting, which brought together industry with some public health leaders in the U.S.,” says Yach. “Further, I see signs of hope in a recent article by authors from public health I have long respected. They argue for dialogue between scientists in the public sector and industry—as I have—and not for boycotts and bans.”
Without agreement on the basic scientific issues and progress on correcting disinformation, sound policies are unlikely. “A study of how change happens in public health shows that it always starts with physician acceptance of the evidence,” says Yach. “They apply that evidence to themselves, to their patients and through organized efforts to public policy. Recall that no country has ever seen a reduction in their smoking rate before it goes down in physicians. I suspect that is true regarding uptake of THR products. And that starts with doing more to have disagreeing groups talk.”
It’s going to be an uphill struggle, though: In mid-June, the WHO in a press release expressed “grave concern over the tobacco industry’s manipulative tactics aimed at influencing healthcare providers through continuing medical education programs and thereby advancing the interests of the tobacco industry.”
Stefanie Rossel is Tobacco Reporter’s editorial contributor. An experienced trade journalist, she combines sharp reporting skills with in-depth knowledge of the tobacco and vapor industries. Prior to joining Tobacco Reporter, Stefanie was editor-in-chief at Tobacco Journal International, where she worked for a decade. Fluent in English, German and French, Stefanie covers tobacco news around the world. She is based in Germany.

August 1, 2024
Something to Smile About
The CoEHAR is studying the impact of reduced-risk products on oral health.

Photo: Andrei
By Stefanie Rossel
Polosa and his team anticipate observing better gingival/gum conditions, improved tooth color and reduced dental plaque accumulation in smokers who stop smoking after switching to alternative tar-free nicotine products. | Photo: Chris Frenzi
In the context of smoking-related issues, oral health has long been neglected. According to Riccardo Polosa, founder of the Center of Excellence for the acceleration of Harm Reduction (CoEHAR) in Italy, this can be explained by several factors. “Smoking is primarily linked to fatal systemic conditions such as cancer, heart disease and respiratory problems, which tend to overshadow its effects on oral health,” he says.
In addition, until recently, dentists were less aware of the detrimental impact of smoking on oral health, particularly in managing gum disease, tooth loss and dental implant procedures. What’s more, because oral health is influenced by multiple factors, including diet, oral hygiene practices and genetic predispositions, it is difficult to isolate smoking as a culprit.
“Dentists have historically been hesitant to invest their professional efforts in helping clients quit smoking,” Polosa says. “However, there is now an increasing recognition among dental professionals of the significant benefits of smoking cessation in improving treatment outcomes, and more and more dentists are increasingly promoting smoking cessation strategies and advocating for the use of tar-free nicotine products.”
To investigate changes in oral health parameters and dental aesthetics in smokers who switch to tar-free nicotine products, the CoEHAR earlier this year launched the SMILE study with funding from the Foundation for a Smoke-Free World (FSFW), which recently rebranded as Global Action to End Smoking. Polosa says the study is the first and only of its kind, as it aims to measure risk reduction, harm reversal and smoking cessation combined, which sets it apart from other trials that focus solely on cessation.
Geographically Diverse Approach
The international, randomized controlled trial involves 474 participants in four countries—153 in Catania (Italy), 45 in Warsaw (Poland), 168 in Chisinau (Moldova) and 108 in Bandung (Indonesia). The decision to focus on these countries was based on strategic and practical considerations, Polosa explains. “Mandated by the FSFW’s mission, the selection of low[-income] and middle-income countries was crucial to facilitate the dissemination of high-quality tobacco harm reduction [THR] science through collaborative partnerships and knowledge exchange,” he says. “Additionally, factors such as low operational costs and strong interest in participating in the study were significant in their inclusion. Italy was specifically chosen to take a leadership role in training and coordination within the study.”
All four countries have high smoking rates, providing a substantial pool of participants for studying smoking cessation and switching behaviors. “The selection of these countries enables the SMILE study to capture a broad spectrum of socioeconomic, healthcare and cultural factors that influence smoking behavior and the adoption of THR,” says Polosa. Each country represents a distinct healthcare system, ranging from well-established systems in Italy and Poland to less developed systems in Moldova and Indonesia. This diversity enhances the study’s relevance and generalizability on a global scale.”
Indonesia presents a unique case due to its widespread use of clove cigarettes, which account for nearly 90 percent of the Indonesian cigarette market. “Studying THR in a context where very popular traditional tobacco products dominate can offer valuable insights into cultural attitudes toward smoking cessation and alternative nicotine-delivery systems,” says Polosa. “Smoke from clove cigarettes contains high particulate matter and toxicants, making them as harmful as conventional tobacco cigarettes. Therefore, THR is strongly needed in Indonesia, with advocacy and education being key to successful implementation.”

Dentists increasingly recognize the significant benefits of smoking cessation in improving treatment outcomes. | Photo: RomanR
State-of-the-Art Technologies
For their study, the SMILE researchers recruited cigarette smokers interested in switching to alternative products. The participants were randomly allocated to receive either standard care, including cessation counseling (i.e., “very brief advice”), or the nicotine product of their choice plus very brief advice. The trial also includes a reference group of individuals who had never smoked. The researchers then recorded participants’ cigarette consumption and tar-free nicotine product at every visit. Additionally, participants were asked to return all empty, partly used and unused consumables. Throughout the study, the researchers monitored smoking and tar-free nicotine product use via a tracker app.
“The SMILE tracker app is an integral component of the SMILE study, designed to monitor participants’ behaviors and lifestyle choices. Through daily prompts, the app assists in tracking cigarette consumption, the use of nicotine products, and regular oral hygiene practices such as brushing, flossing and mouthwash use. Although personal oral hygiene practices were carefully tracked, there was no emphasis on oral hygiene education or management of dietary patterns,” says Polosa.
“A standardized approach was implemented to mitigate the effect of these potential confounders on both primary and secondary study endpoints,” he continues. “Participants were explicitly advised to continue their established oral hygiene practices for the entire duration of the study. Furthermore, adherence to specific restriction criteria before each scheduled study visit was emphasized to prevent any confounding of the collected data.”
To prevent confounding factors, oral hygienists removed plaque, calculus and stain from the study participants’ teeth 14 days prior to baseline measurements. “This critical element is absent in most clinical trials,” says Polosa.
Chronic periodontal disease is common in smokers that is unlikely to improve with cessation alone, according to Polosa. “Therefore, participants with periodontitis have been excluded, and only participants with mild to moderate gingivitis have been recruited, as they are more likely to maximize the impact of the intervention.”
The researchers use state-of-the-art technologies, such as spectrophotometers and quantitative light-induced fluorescence scanners, to quantify tooth discoloration and the amount of dental plaque.
“These study endpoints measure important patient factors that may drive behavior change,” says Polosa. “This is particularly persuasive for young adults, for whom a cardiovascular-cancer-respiratory risk-based narrative is either ineffective or counterproductive and for whom concern about bad breath and poor dental aesthetics due to enamel discoloration and ‘tar’ stains may be a much more significant reason to stop smoking.”
The Importance of Aesthetics
The SMILE study allows volunteers to choose their own type of tar-free nicotine product, says Polosa. “This personalized choice is likely to enhance adherence, retention, and optimize compliance, thus maximizing cessation of tobacco cigarettes,” he explains. “This unique approach also generates results that are not product-specific and therefore more generalizable and realistic for implementing such a strategy in the real world.”
According to Polosa, the researchers enroll only those who would not otherwise commit to a smoking cessation counseling program but are prepared to choose from smoking alternatives such as e-cigarettes and tobacco-heating products. The study has been designed to allow participants to tailor their own “nicotine experience” by selecting the tar-free nicotine product that aligns most with their preferences, thereby maximizing the transition away from tobacco smoking and reducing the likelihood of relapse.
The study is not designed to coerce participants to avoid tobacco smoking completely, he says. Dual use is not prevented; therefore, the sample size has been oversampled to ensure that enough exclusive users of tar-free nicotine products by the end of the study are included.
“The SMILE study also provides a unique opportunity to evaluate the impact on oral health and dental aesthetics among individuals who simultaneously smoke conventional cigarettes and use tar-free nicotine products,” says Polosa. “Different dual-use patterns exist—e.g., strong switchers versus light switchers—and are likely to have varying impacts on overall oral health. We expect to observe progressive changes with different patterns of dual use.”
Perhaps the most interesting aspect of the SMILE study is its inclusion of aesthetics. Polosa says that stained teeth and tobacco odors are a growing concern, especially among young smokers, who demand not only healthy mouths but good-looking smiles.
“Everyone wants to have a perfect dentition, as it helps in interpersonal contacts and raises value in the job market,” he says. “In our social media-driven age, vanity plays a significant role in influencing behavior. The desire for an attractive appearance, including a bright smile, is often a powerful motivator, especially among younger demographics who are highly engaged with social media platforms.”
Evidence from literature demonstrates that using images of damaged and tar-riddled lungs does not act as an effective deterrent to smoking, he says. “This is partly because people do not respond well to negative messaging and because they do not identify such images with their own bodies. The focus on aesthetics—rather than vanity—is important because we are conveying a positive outcome message for smoking cessation, leveraging the explosion in social media posts of happy, healthy people with bright smiles.”
Appealing to individuals’ desire to present themselves well and feel confident not only acknowledges the importance of aesthetics but also offers practical solutions for oral healthcare practitioners, such as aesthetic-enhancing alternative nicotine products for those who may struggle to quit smoking, according to Polosa. “The goal here is to harness today’s emphasis on appearance to encourage healthier behavior,” he says. “I predict that the argument for better aesthetics and oral health will become a more prominent and effective tool in smoking cessation efforts.”
The study’s results are expected in 2025. Polosa and his team anticipate observing better gingival/gum conditions, improved tooth color and reduced dental plaque accumulation in smokers who stop smoking after switching to alternative tar-free nicotine products.
Stefanie Rossel is Tobacco Reporter’s editorial contributor. An experienced trade journalist, she combines sharp reporting skills with in-depth knowledge of the tobacco and vapor industries. Prior to joining Tobacco Reporter, Stefanie was editor-in-chief at Tobacco Journal International, where she worked for a decade. Fluent in English, German and French, Stefanie covers tobacco news around the world. She is based in Germany.

August 1, 2024
A Missed Opportunity

Photo: luciano
E-cigarettes and older smokers
Neil McKeganey, Gabe Barnard and Andrea Patton
Amid the intense media focus and regulatory action directed toward youth vaping in the U.S., there is another population demographic whose e-cigarette use is worthy of attention—though in this case, more as a result of their relative lack of use of these devices. There are an estimated 17 million adults in the U.S. aged over 45 who are smoking every day or some days. With research showing that quitting smoking by age 50 is associated with a gain of around six years in life expectancy, the question of how best to boost smoking cessation efforts among older smokers is of increasing importance.
Although e-cigarettes have become hugely popular as a means of quitting smoking, research undertaken by the Centre for Substance Use Research (CSUR) shows that the use of these devices by older smokers in the U.S. is only a fraction of what it is among younger smokers. According to the CSUR’s Tobacco Product Prevalence Study, while 11 percent of adult smokers aged 25 to 44 years report currently using e-cigarettes, that figure drops to 5.2 percent in the case of those aged over 45.
The CSUR research also shows that the likelihood of older female smokers using e-cigarettes is even less than is the case for older male smokers. Even in the face of the overall low levels of e-cigarette use, it was evident that some brands were more successful than others in attracting older smokers, with Vuse, Smok and Voopoo reported as being used more widely than other brands.
But why might there be a disparity in overall levels of current e-cigarette use between older and young smokers? We know from research that smoking quit attempts are influenced by the level of nicotine dependence and smoking duration. It may be that for these combined reasons, older smokers are less drawn to e-cigarettes as a route out of smoking.
Equally, many older smokers might perceive e-cigarettes as devices that are more often associated with young adult lifestyles and for that reason alone may be seen as something that is not for them. Whatever the reasoning behind the lower levels of e-cigarette use among older smokers, there is much to be gained from identifying how that disparity might be tackled. To do this, it will be necessary to find out much more about why e-cigarettes appeal to some groups more than others and for e-cigarette manufacturers to explore ways of developing products that are specifically designed to appeal to the older smoker.
There is a further reason why the vaping industry might be wise to give greater attention to the older smoker, which has to do with the importance of tackling youth vaping. If e-cigarette manufacturers succeed in developing a vaping product that appeals to the older smoker, there is a strong possibility that their success in this regard will result in a product that has low youth appeal.
The likelihood of young people wanting to use a product that is associated with the older smoker is almost certainly less than the likelihood of an older smoker being drawn to a product they see as being associated with youth use. Vaping products developed specifically for the older smoker may have an increased chance of securing a marketing authorization from the U.S. Food and Drug Administration under its premarket tobacco product application process, securing access to a large market of potential new consumers. It’s worth remembering too that the market of smokers aged 45 and over within the U.S. may be in excess of 17 million, underlining the potential gain for the companies who succeed in winning that market.
Neil McKeganey is director of the Center for Substance Use Research in Glasgow, Scotland.

Gabriel Barnard is a director of the Center for Substance Use Research in Glasgow, Scotland.

Andrea Patton, is a behavioral epidemiologist and head of prevalence research within the Centre for Substance Use Research, Glasgow, U.K. Patton has over 15 years of experience working in public health for academia, regulatory bodies and industry leaders in Europe and the United States.

July 19, 2024
The Way Forward

Kgosi Letlape
How prioritizing evidence-based harm reduction strategies for smoking can improve healthcare
By Kgosi Letlape
Evidence-based harm reduction strategies, known for mitigating the adverse effects of persistent unhealthy behaviors and substances, focus on reducing health risks while acknowledging the difficulty of achieving complete abstinence.
Since the mid-1900s to late 1900s, efforts such as syringe exchange programs, safer injection facilities, overdose prevention programs and policies, and opioid substitution treatment have been implemented to reduce the adverse health, social and economic consequences of illicit drug use. These approaches have been proven to reduce transmission of HIV and other infections, increase users’ access to other medical and social services, and increase enrollment in detoxification treatment, without increasing social disorder in the community. Other examples include health education and provision of free condoms to help reduce HIV and other sexually transmitted infections and unwanted pregnancy, especially among the youth.
Likewise, these behaviors that are difficult to cut down on or eradicate should equally be extended and applied to tobacco. A formal tobacco harm reduction strategy is urgently needed for smokers, which would provide them with safer noncombustible alternatives to traditional cigarettes.
More than 1.1 billion people across the world smoke tobacco, consuming nearly 5 trillion cigarettes a year. Around 37 billion of those are smoked by South Africans. South Africa has an extremely high number of smokers; approximately two out of every five men and one in 10 women over the age of 15 smoke.
The impact on personal health and the healthcare system, and the economic implications are massive. Smokers are three times to five times more likely than nonsmokers to die prematurely, such that more than 25,000 South Africans over the age of 35 die each year from smoking-related diseases. That means one in 10 deaths are related to smoking. In our hospitals, nearly 139,000 admissions and just under 3 million outpatient visits every year are attributable to smoking. Add to that the more than 621,000 workdays lost due to illness from smoking, and the annual cost to the economy works out to about ZAR42 billion ($2.3 billion).
Examples of harm reduction strategies for smokers include nicotine-replacement products, such as gum or patches, and noncombustible e-cigarettes and heated-tobacco systems (HTSes). These, in addition to improving cessation rates and better access to diagnostics and treatment, have the potential to save 320,000 lives in South Africa over the next four decades.
Of course, ideally, smokers should be encouraged and assisted to quit. In fact, research shows that at least two-thirds of adult smokers want to quit or have thought about it, and almost half have actually tried in the past year. The problem is, even with assistance, quitting is very difficult—the vast majority of attempts at quitting will be unsuccessful. Furthermore, there are many smokers who just don’t want to quit. So, offering harm reduction strategies for these people makes sense. But there are oppositional voices to this.
That’s not uncommon. Despite the evident success of harm reduction strategies, there is frequently opposition to adopting them, especially where they are aimed at behaviors judged by some to be morally indefensible. Critics claimed that strategies aimed at drug “abuse” would enable “addicts,” encouraging continued drug use and causing greater harm to the community. Provision of condoms and free contraception, it was claimed, would promote sexual activity and promiscuity among young people who should be encouraged to remain abstinent until they are older.
In the same way, there are calls for access to e-cigarettes and HTSes to be restricted. It is claimed that promoting them for smoking cessation ignores the health risks associated with them and will increase vaping among children and teenagers. Vaping is seen as a gateway to combustible cigarette smoking.
There are most definitely health risks associated with e-cigarettes and HTSes. No one is denying that. Nevertheless, there is general agreement among researchers and authorities that most tobacco-related harms come from exposure to the products of combustion and that noncombustible tobacco consumption is associated with relatively fewer health risks. Furthermore, studies show that smokers who transition to e-cigarettes or HTSes are more likely to remain abstinent from combustible cigarettes.
Arguments that noncombustible products should not be available because they might be used by young people who are then more likely to become addicted to nicotine or start smoking also do not carry weight. Protecting young people from harm is obviously imperative, but that is a completely separate issue that must be dealt with in a specific manner. We cannot turn our backs on millions of adult smokers for whom a safer alternative is available that could save their lives. The message is simple: If you don’t use tobacco or nicotine-containing products, don’t start. If you do, quit. But if you can’t quit smoking or don’t want to, then switch to an alternative that carries fewer health risks. The problem is that most people, including many healthcare professionals, are unaware of alternatives to combustible cigarettes and the science showing the health benefits of switching.
If we want harm reduction to work, be it to promote healthier nutrition or physical exercise, safe sex, better hygiene and sanitation, safe housing or smoking cessation, then it has to be embedded in public health education, and people must have easy access to the elements that will make it possible. And it has to be embedded in the training of every healthcare worker so that it becomes a standard part of South African healthcare service delivery.
It’s a logical step that should seriously be considered.
Kgosi Letlape is president of the Africa Harm Reduction Alliance.

July 10, 2024
WHO Releases Guideline for Cessation

Image: Tobacco Reporter archive
The World Health Organization has released a comprehensive set of tobacco cessation interventions, including behavioral support delivered by healthcare providers, digital cessation interventions and pharmacological treatments, in its first guideline on tobacco cessation.
The guideline focuses on helping tobacco users who want to quit all forms of tobacco. The recommendations are relevant for all adults seeking to quit various tobacco products, including cigarettes, water pipes, smokeless tobacco products, cigars, roll-your-own tobacco and heated-tobacco products.
“This guideline marks a crucial milestone in our global battle against these dangerous products,” said Tedros Adhanom Ghebreyesus, WHO director-general. “It empowers countries with the essential tools to effectively support individuals in quitting tobacco and alleviate the global burden of tobacco-related diseases.”
“The immense struggle that people face when trying to quit smoking cannot be overstated,” said Ruediger Krech, director of health promotion at the WHO. “We need to deeply appreciate the strength it takes and the suffering endured by individuals and their loved ones to overcome this addiction. These guidelines are designed to help communities and governments provide the best possible support and assistance for those on this challenging journey.”
July 2, 2024
NGO Debates Smoking Cessation

Photo: Global Action to End Smoking
Healthy Initiatives, a nongovernmental organization, convened an international forum and luncheon in Warsaw, Poland, this week to discuss past successes in smoking cessation and how they may inform future challenges. Participants included policy experts from Georgia and Ukraine.
“We must learn to meet individuals who smoke where they are on their cessation journeys and to understand why they are unable to quit with the tools at their disposal,” said Cliff Douglas, president and CEO of Global Action to End Smoking. “If we continue to push the same approach from two decades ago, we will fail to serve those who continue to smoke and whose lives are being disrupted by war,” he said, referring to the war in Ukraine.
“Tobacco control regulations and restrictions in low-[income] and middle-income countries should follow a risk-proportionate approach so that those smokers who are not able to quit smoking combustible cigarettes will have access to objective and scientifically proven information,” said Andre Urushadze, a health policy expert and former minister of health of Georgia. “It is important to ensure the possibility of proper communication as opposed to the informational chaos and many misleading facts.”
“We should always strive for saving more lives and helping people to succeed in making healthier choices, especially now when the region is torn by the war and humanitarian crisis, the largest since WWII, and people’s priorities have changed,” said Nataliya Toropova, founder of Healthy Initiatives. “It is our task to keep up the health issues high up on the agenda and tackle smoking as a No. 1 risk factor for noncommunicable diseases. With the help of effective smoking cessation programs and education campaigns, we hope to help people who smoke quit, ultimately making the region smoke-free.”
June 19, 2024
Regulators Urged to Embrace THR

More than 1.8 million lives could be saved within the next 40 years by replacing World Health Organization-directed tobacco control efforts with products like vapes and e-cigarettes, snus and nicotine pouches, a new study has found. Urgent action is required to tackle continuing prevalence of smoking as global efforts to end smoking have stalled and current approaches to tobacco control have proven insufficient, the researchers said.
Instead of current measures, researchers found that tobacco harm reduction (THR) products that replace smoking with nicotine alternatives promise to make a significant improvement in health outcomes in the Middle East and save millions of lives.
The researchers studied the impact of tobacco use in seven countries in the Middle East including Pakistan, Egypt, Lebanon, Jordan, Kuwait, Saudi Arabia and the UAE, and determined that more than 384,000 die prematurely annually due to tobacco use. Tobacco use contributes to several major causes of death in these countries including lung and oral cancer, COPD, heart disease, and stroke, which are all set to increase in prevalence over the next few decades.
The ideal means of reducing this burden is through THR products which use nicotine without the deadly byproducts that cause disease. THR products like e-cigarettes/vapes, heated tobacco products, snus, nicotine pouches and charcoal free shisha are rapidly gaining traction among consumers in the Middle East and are considerably safer than smoking. However, these innovations have not yet been embraced by physicians and governments as means of cutting premature deaths.

Embracing THR, cessation, and improved lung cancer treatment represents a major opportunity for the Middle East to dramatically improve the health of its populations.
Derek Yach, lead author
The report comes as the quality of evidence on the benefits of smoking cessation and THR has strengthened. Stopping tobacco use at any age is associated with longer survival, and switching to THR products is almost twice as effective for cessation as nicotine replacement therapies. While long-term studies on the health benefits of switching to THR are still needed, results of studies using biomarkers of future diseases are promising.
The report comes at a critical time as many Middle East countries’ reverse bans on some THR products and liberalize their approach to tobacco alternatives. Meanwhile, new and innovative THR products are being developed for the Middle East signaling the growing acceptance of the value of THR and the demand for them by consumers.
To benefit from the promise of these products the authors recommend educating physicians to communicate the benefits of THR to patients in all clinical encounters, countering disinformation about nicotine and the value of THR, and developing a regional equivalent of the Royal College of Physicians report on THR and vapes. The authors also recommend that policymakers revise regulations to improve access to THR products and invest in national science and research to replace tobacco with THR and establishing independent science-based consumer groups to advocate for their needs. The authors encourage religious leaders to guide their communities to quit smoking and support tobacco harm reduction.
“Embracing THR, cessation, and improved lung cancer treatment represents a major opportunity for the Middle East to dramatically improve the health of its populations,” said Derek Yach, lead author of the report, global health consultant and former senior WHO official. “The prevalence of smoking is projected to only decrease by less than 2 percentage, from 33.3 percent in 2020 to 31 percent in 2025. This preventable disaster should engender outrage and immediate action. This report aims to provide an alternative vision of what is possible.”
Figure: Projected deaths from tobacco in 2060

This figure shows the number of tobacco deaths expected to occur in 2060 using three scenarios: WHO projections using FCTC and MPOWER measures; WHO projections adding THR products; and WHO projection adding THR, smoking cessation and, lung cancer innovations.
June 12, 2024