Category: Harm Reduction

Smoking Decline Traced to Noncombustibles

Photo: Natalia
Sweden’s smoking rate is poised to dip below 5 percent, a share that is widely considered the hallmark of a “smoke-free” society, reports The Business Mirror.
Only 5.6 percent of Swedish adults smoked cigarettes in 2022, down from 49 percent of men in 1960, according Sweden’s public health agency. As a result, Sweden has 52 percent fewer tobacco-related male deaths than Poland and 57 percent fewer than Romania. For male lung cancer, Sweden has significantly fewer deaths than France, Germany, Italy and Poland.
A report titled “No Smoke Less Harm” by the advocacy group Smoke Free Sweden attributes this achievement to Sweden’s openness to alternative nicotine products, such as snus.
The report points out that smoking-related diseases are caused primarily by the byproducts of tobacco combustion rather than nicotine, as many mistakenly assume.

The Swedish experience demonstrates the importance of understanding public misperceptions about nicotine to develop health policies that better protect and inform consumers.
Karl Fagerström, co-author, ‘No Smoke Less Harm’
While nearly one in four Swedish adults still use nicotine daily, in line with European averages, Sweden boasts far lower rates of tobacco-related deaths (44 percent), cancer rates (41 percent) and cancer deaths (38 percent) than the rest of the European Union.
Smoke Free Sweden’s report appeals for the World Health Organization and global public health communities to acknowledge that combustible products, not nicotine, cause harm to smokers.
“While nicotine is addictive, it does not cause the serious diseases associated with smoking,” Fagerström said. “Our findings support a shift in focus from cessation to substitution with less harmful alternatives for those unable to quit completely.”
June 3, 2024
Realists and Idealists
Image: M-SUR
We should celebrate ‘realists’ and beware of ‘idealists.’ Idealists do well in the rhetorical world of goal setting, aspirations and optics while realists do better in the real world. The problem is that the idealists obstruct the realists.
By Clive Bates
On April 22, the British Medical Journal and a new investigative publication, The Examination, funded by billionaire activist Michael Bloomberg, declared a victory. Their “investigation” had shut down a new continuing medical education program in smoking, tobacco and nicotine offered by the respected medical information provider Medscape. The course had been running for a few weeks and had proved popular with participants. It had been designed to address an essential unmet educational need: the widespread confusion among healthcare practitioners about the causes of disease, the nature of nicotine use and the options available to reduce the harms. It’s hard to imagine more valuable and actionable public health and preventative insights for practitioners. So why close it down? Simple: The initiative had been funded at arms-length by a tobacco company, Phillip Morris International, which played no role in developing the content.
It’s worth pausing to examine what has been achieved here. The objection to tobacco company funding in the case is essentially aesthetic. To some activists, it just doesn’t look right. Tobacco companies involved in ending smoking? Weird! No one has presented material objections to the course content. I have no doubt that it was a sincere effort to raise the lamentable standard of medical knowledge in this area delivered by experienced professionals. The idealists were successful in burning this initiative to the ground. But here’s the point: Like arsonists, they didn’t build anything. They have left nothing where there was previously something useful. The activists have made their impassioned denunciations, expressed their righteous anger and moved on. But it’s an empty victory because the confusion and misinformation remain, and the opportunity to do better for the public and patients has been squandered.
I chose this recent example because it illustrates a more general problem with activism. The pursuit of idealistic goals is not necessarily heroic and may not be benign. It can make matters worse with real-world costs for people and the environment. Let’s take three examples from outside the nicotine field to illustrate the point, then return to nicotine.
First, the green opposition to nuclear power. In their quest for an idealist vision of a 100 percent renewable system based mainly on solar and wind power, greens have opposed a proven, reliable, low-carbon form of electricity generation. By creating fear and foreboding about nuclear risks, activists and regulators have made the technology exceedingly expensive and difficult to deploy, making fossil fuels relatively more attractive. The French experience from the 1960s shows successful large-scale nuclear deployment, but idealistic opposition has driven the costs upward since then. Finally, idealists are starting to feel the heat from the climate realists.
Second, activists with an in-principle opposition to genetic engineering recently stopped the deployment of genetically modified golden rice, which is rich in Vitamin A, in the Philippines. Vitamin A deficiency is implicated in up to 500,000 cases of blindness in young children annually in Asia and Africa each year. Maybe it would be better to lift poverty and improve nutrition more systematically, but how long would that take, and how many people would be harmed waiting for the idealists’ more prosperous and just society? Like adding fluoride to water to protect dental health, golden rice would have added Vitamin A to the food supply system, creating widespread health benefits. Now, people will suffer instead.
Third, local and international nonprofit organizations lobbied tenaciously for Sri Lanka to switch its agricultural system to become exclusively organic, backed up by a ban on the use of agrichemicals. They got their way, but it did not go well. The food supply crashed, the people went hungry and rioted, and the government fell.
In each case, a noble aspiration, an eye-catching slogan or a grand commitment has stood in the way of making more mundane but pragmatic progress at the expense of human well-being. Some further characteristics are evident:
Idealists evade the messy and distinctly realist business of trade-offs, waving away the concerns of realists as a lack of ambition or “industry talking points.”
The idealists rarely accept accountability for the unintended consequences of their positions—the fault is with others for not trying hard enough or spending enough to match the idealists’ aspirations.
The idealists often receive an easy ride in the media, especially when they evoke youth to make their case. Did anyone ever put hard questions to Greta Thunberg?
Turning now to the battle between idealists and realists in the world of tobacco and nicotine.
First, the nicotine-free society. The idealists in tobacco control would like to rid us of this relatively benign recreational drug. Sorry, but that will not happen, and there is no reason why it should. People use nicotine because it makes them feel better, for its pleasurable, functional and therapeutic attributes. However, demonizing nicotine and treating all nicotine products as if they are equally harmful will obstruct the realists’ efforts to address the significant harm caused by smoking. The idealists take each ban and blockage of any nicotine product as progress to their larger goal. How else can we explain the sustained ban on snus in the European Union?
Second, defending the purity of youth. Though all idealists have been teenagers at some point, few seem to understand them. Some young people have a propensity for risk-taking with drugs, alcohol, sex and other reckless behaviors, and yes, to use nicotine. But the idealists have adopted variants on the mantra “no teen should use nicotine.” Fine, that might be good advice. But what if they go further and try to make that a reality with various forms of prohibition, restrictions and misinformation? The trouble is that the much larger adult market will be bent out of shape by misguided efforts to protect youth. There will be more smoking, more illicit trade and more risky workarounds, including among youth. The realist goal of providing a lawful, acceptably safe, proportionally regulated nicotine market is undermined by the fervor of the idealists, with worse results for everyone.
Third, the knockout blow. Collectively known as “endgame” measures, these grandiose schemes would abolish cigarettes as we know them, close nearly all retail outlets, impose shrinking production and import quotas, or ban sales to anyone born after a specific date. They have this in common: They won’t be implemented, they won’t work as expected, or they will have little useful effect. But they will obstruct the realists because these ideas divert political, regulatory, scientific capital and creativity into unworkable schemes and away from pragmatic, if humble, measures that will work. Worse, they occupy the imaginary sunlit uplands with a fake utopia, creating a mirage where there should be an achievable destination—a stable, lawful, well-regulated market for a popular drug.
Fourth, the pursuit of paper tigers. I recently submitted evidence to an inquiry into new legislation in South Africa. The new law had been drafted as model anti-vaping legislation with extreme restrictions and penalties and tell-tale fingerprints of American activists. The contrast between the precision control, on paper, of the new law and the chaotic reality of South Africa’s giant illicit market is matched only by that of Australia’s new legislation that tries to ban vapes even harder, even though over 90 percent of the Australian vape market is already illegal. When the idealists declare a prohibition in law on paper, actual or de facto, it doesn’t make the banned products disappear. However, it does mean that more modest regulation becomes impossible because most of the market is unregulated and illicit.
Fifth, why don’t they stop making cigarettes? A common idealist theme is that if tobacco companies are serious about health, they should just stop making cigarettes. It sounds superficially plausible and inspiring. In reality, these companies have a legal duty not to destroy their shareholders’ money. If they tried, three things would happen: The management would be fired, the company would be taken over, or the productive assets and brands would be sold as a going concern. All to no effect. The realists recognize the need for a transformation, moving the market to noncombustible nicotine products and diversifying the business into non-nicotine activities in which they have an advantage, keeping their shareholders on board throughout.
Finally, conflicts of interest (COI). Idealists divide the world into independent and industry science. They see industry conflicts of interest as disqualifying from scholarly societies and journals. Yet, conflicts arise from every funding source or institution with policy preferences. An industry COI may be no more than a sign of having valuable marketable capabilities. The realists want to engage with anyone with specialized knowledge and, with due skepticism, to learn from their insights. The idealists prefer to erase them from the discourse and pursue purity at the expense of knowledge.
To summarize, the idealists will resist the realists, and everything will be worse.
Clive Bates is the director of Counterfactual Consulting and the former director of Action on Smoking and Health (U.K.).
June 1, 2024
The Forgotten Frontier

Photo: fontriel
Is tobacco harm reduction reaching the Global South?
By Pieter Vorster and Sudhanshu Patwardhan
Eighty percent of the current users of risky tobacco products live in the “Global South,” the geopolitical clubbing of low-income and middle-income countries (LMICs) that includes not only Southern Hemisphere nations such as Fiji but also nations that are firmly in the Northern Hemisphere, geographically, like China, India, Russia and Bhutan, along with countries that straddle both segments, such as Uganda.
A world free of smoked and smokeless forms of risky tobacco products such as cigarettes, bidis, gutkha, mishri, zarda and toombak can prevent a billion premature deaths this century. This can potentially reduce the social, economic and health inequity within and between countries, thus delivering on many U.N. Sustainable Development Goals and taking a step closer to the World Health Organization’s “health for all” ambition. Do manufacturers of tobacco products, as well as businesses delivering cessation products and services, have a role in this?
Sudhanshu Patwardhan is a medical doctor, nicotine expert and health tech entrepreneur. Pieter Vorster is managing director of Idwala Research, a consultancy aiming to accelerate global tobacco transformation and harm reduction. Both have roots in the Global South and are motivated by the goal of reducing the harms from tobacco, as seen in the Global North. Below, they discuss the challenges and opportunities related to global health equity in a freewheeling dialogue, interchangeably playing the role of interviewer, respondent, expert and devil’s advocate.
Background
In June 2023, at the Global Forum on Nicotine in Warsaw, Sudhanshu Patwardhan convened and chaired a workshop of international experts representing diverse stakeholder groups—tobacco control, industry and management consulting. The session was titled “Tobacco Industry Transformation—Is It Really Reaching LMICs?” The panel and the audience, including Pieter Vorster, brought deep and wide expertise in public health, consumer advocacy, regulatory affairs, nicotine supply chains and capital markets. As the first anniversary of the session approaches, it is timely to discuss the developments that have occurred since and what needs to be done going forward to achieve a world free from risky tobacco products.
Pieter Vorster: Sud, let us summarize the session before we leap forward into what has happened since and what is next. So, in the workshop, you brought up the role of a range of stakeholders in the ecosystem: regulators, industry, consumers and healthcare professionals, to name a few. What are the regulatory challenges in the Global South that significantly impact tobacco cessation and prevention of initiation?
Sudhanshu Patwardhan: Pieter, smoked and smokeless forms of risky tobacco products are a leading cause of noncommunicable diseases (NCDs) globally and increasingly in the Global South. However, when it comes to tobacco control, there is a serious regulatory capacity gap in the Global South. Most of these countries are still developing locally relevant systems and policies that can best meet their populations’ needs for healthier, happier and longer lives. All these countries are going through a dramatic epidemiological shift—with NCDs overtaking infectious diseases as a leading cause of disease and death. Most of these countries are signatories to the WHO’s Framework Convention on Tobacco Control [FCTC], but the implementation of the FCTC articles is still very selective. For example, most emphasis is on taxation (a proven tool for reducing demand and increasing treasury earnings), advertising restrictions, and campaigns for public awareness and prevention of initiation. Although this is having an impact, progress has been slow. The principle of harm reduction, although explicitly stated as a component of tobacco control in Article 1(d) of the FCTC, has largely been ignored by the WHO to the extent that its guidance on tobacco policy favors a prohibitionist approach toward safer nicotine alternatives and that is being adopted by many countries in the Global South that look to the WHO for leadership on health policy.
Vorster: Please explain how that is also a regulatory issue.
Patwardhan: This came up during our workshop. The tobacco industry is innovating into “reduced-risk products” at a breakneck speed, catching up with product innovation from outside the industry (e.g., e-cigarettes) or launching products they have developed through years of R&D (e.g., nicotine pouches and heated-but-not-burned tobacco products). Their ability to launch these products is stymied by local prohibitions in many countries globally. If regulated strictly enough and marketed only to current tobacco users, these products have the potential to reduce tobacco-related harms significantly. Evidence from the U.K., Japan and Sweden is a case in point.
In an interlinked issue, there is hardly any capacity built for tobacco cessation in the Global South. Most of the pharmaceutical industry or health tech entrepreneurs there are equally unenthused about innovation into tobacco cessation and the massive public health opportunity. They fail to recognize the financial dividend by serving the “base of the pyramid.” So, effectively, nearly a billion people in the Global South—current tobacco users—are consigned to struggle by themselves in their attempts to quit, and most fail.
An important aspect of “demand reduction” in tobacco control, i.e., enabling access to appealing nicotine-replacement products that can enable and sustain cessation among current adult tobacco users, is therefore not available in most of the Global South.
Vorster: So, bans on newer “safer” nicotine alternatives in many countries are causing a strange situation: Risky forms of tobacco are still available everywhere, legally, while reduced-risk products are not? One would have thought that the science underpinning the tobacco harm reduction principle is universal. If it is clearly understood by U.K. policymakers and enshrined in the U.S. Food and Drug Administration’s “modified-risk tobacco product” authorization, why is it not accepted in the Global South?
Patwardhan: It is important to bear in mind that sound policymaking and regulations cannot be a simple copy-paste from the Global North. Yes, global good practices can be adapted—but there is no substitute for local science to ensure relevance and sustainability. Local research capacity not only helps build the scientific evidence base but also helps society interpret it objectively. That is currently missing in most of the Global South. A glaring example is from my recent attendance at the biannual global meeting of the Society for Research in Nicotine and Tobacco, held in Edinburgh. Out of the over 1,000 delegates there, in my estimation, less than 5 percent of those attending were working on the ground in tobacco cessation and harm reduction in the Global South. The fact that these conferences happen mainly in Europe and the USA also points to systemic bias in funding and research, all skewed to the affluent Western nations. Even conventional tobacco cessation treatments are hardly, if at all, studied and available in the Global South.
Vorster: Do you mean nicotine-replacement therapy products (NRT)?
Patwardhan: Yes, that’s a good example. NRT are on the model essential medicines list of the WHO for tobacco dependence treatment. They have also made it to the National Essential Medicines lists of member countries. But the reality on the ground is vastly different and quite frustrating. Little or no local research data on the use of NRT for tobacco dependence treatment exist in most of the Global South. NRT gums, patches and lozenges are much costlier than the tobacco products they are meant to replace during a quit attempt. They are either available at limited points of sale or not at all, and healthcare practitioners are not equipped to advise patients on using these products.
Vorster: You often talk about nicotine misperceptions among healthcare professionals, and you led the first published research study on this topic in 2013. More recently, the Foundation for a Smoke-Free World-funded SERMO study of over 15,000 doctors from 11 countries also showed that of those interviewed, over 70 percent believed (wrongly) that nicotine in tobacco products causes cancer. How does that impact cessation?
Patwardhan: From personal experience interacting with numerous frontline clinicians worldwide over the years, I can see how nicotine misperceptions influence their advice to tobacco-user patients. Smoked tobacco and most smokeless tobacco products are harmful due to a wide range of chemicals, including carcinogens, either produced during combustion or added during manufacturing. Nicotine is not a carcinogen; it is, however, the dependence-causing chemical in tobacco products for sure! The misperception about nicotine regarding cancer is a likely cause of hesitance among clinicians to recommend adequate NRT treatment for long enough, alongside behavioral counseling. Cravings for nicotine and withdrawal symptoms can last from weeks to months. Not supporting the quit attempt with adequate dosing of clean forms of nicotine (e.g., NRT) for long enough is very likely to lead to a failed quit attempt or relapse. Countries such as the U.K. have strong regulatory expertise in tobacco control and expertise in nicotine science and have therefore embraced a tobacco harm reduction indication for NRT—i.e., deemed it safer for smokers to consume NRT as long as necessary, for quitting smoking altogether and to prevent relapse.
Vorster: You make the role of regulators in tobacco cessation loud and clear. What about the industry?
Patwardhan: The industry is not a monolith. Nor is it just the tobacco industry we are talking about here. The nicotine supply chain has never been so exciting! A significant proportion of the world’s pharmaceutical-grade nicotine comes from companies extracting nicotine from tobacco in India. Many of those companies also supply the increasing demand for nicotine for e-cigarettes and nicotine pouches. Then there is synthetic nicotine, made to pharmaceutical standards, also poised to disrupt the supply chain and potentially free up thousands of hectares of arable land to address food security issues. Some of the large multinational tobacco companies have invested in medically licensed NRT, e.g., BAT and Philip Morris International, blurring the lines between tobacco and NRT companies, potentially expanding the choices available for enabling quit attempts among current tobacco users. However, given the history of the industry, any efforts by the tobacco industry to conduct tobacco cessation training among healthcare professionals would be viewed with suspicion and likely to evoke a reaction from those in public health. There is a clear role and an unmet need for independent organizations to take the lead on this in the interest of public health. Tobacco companies can better focus their resources on conducting locally relevant tobacco cessation and harm reduction research in the Global South. That could potentially better inform regulation and an understanding of harm reduction principles among key stakeholders.
Now, this is where I get to ask you questions! Given your deep expertise in the tobacco industry transformation process, what do you make of the tobacco companies’ innovation and launches in the context of the Global South?
Vorster: Although there have been valuable attempts to gauge overall industry transformation, notably the Tobacco Transformation Index, no independent research has been conducted that tracks transformation progress specifically in the Global South.
Having said that, there have been encouraging, albeit nascent, trends here. During the early years of reduced-risk tobacco product (RRP) launches, multinational tobacco companies focused on countries such as the U.S., Japan, Korea and Europe. More recently, companies like BAT have launched nicotine pouches in Kenya, Pakistan and South Africa and PMI in the Philippines, Pakistan and South Africa. Furthermore, PMI sells heated-tobacco products in a considerable number of Global South markets, including Indonesia in select cities, while BAT has a significant geographical footprint there with vaping products.
Apart from regulatory measures that prohibit the sale of RRPs in a substantial proportion of these countries, one of the most significant barriers to harm reduction is the cost of these products relative to cigarettes, which is a function of both low cigarette prices and excise tax and relatively high production costs for RRPs. For example, the PKR120 ($0.43) per can, at which BAT and PMI sell nicotine pouches in Pakistan to compete with low-end cigarette prices, is below current production costs of about $0.50 to $0.60 per can. For RRPs to make meaningful inroads in the Global South, it is imperative that costs are reduced significantly and the price differential with all forms of risky tobacco products available locally is decreased substantially. Within this context, it is significant that BAT (followed by PMI) chose to introduce nicotine pouches in Pakistan, which has the second-highest incidence of smokeless tobacco use in the world.
Patwardhan: Where do large national tobacco companies come into this?
Vorster: The transformation picture is markedly different beyond the listed multinational tobacco companies. Sadly, this is also where the majority of the world’s consumers of harmful tobacco products resides.
There exists clear potential for conflicts of interest where state monopolies control the tobacco industry, but these potential conflicts exist well beyond state ownership of tobacco companies through the tax revenues earned from tobacco products. For countries with a significant reliance on tobacco tax revenues, the WHO’s prohibitionist stance on nicotine consumer products has helped justify the banning of less risky forms of tobacco and nicotine.
In China, the government receives the equivalent of circa 10 percent of General Government Final Consumption Expenditure from tobacco taxes in addition to the substantial revenue it earns from its ownership of the CNTC [China National Tobacco Corp.]. It was, perhaps, no surprise that, in 2022, the burgeoning independent Chinese vape industry was brought under the purview of the State Tobacco Monopoly Administration, leading to its near collapse owing to significant regulatory restraints.
Indonesia is the second-largest cigarette market in the world after China, and whilst the tobacco industry is privately owned, the government receives some 13 percent of General Government Final Consumption Expenditure from tobacco taxes. RRPs are not banned in Indonesia, but with average cigarette prices around $1.50 per pack, they are not competitive and will likely only appeal to high-end consumers.
Patwardhan: From the looks of it, the odds are stacked against tobacco users in the Global South: knee-jerk regulation against safer nicotine products, a local versus multinational tobacco companies’ turf war, nicotine misperceptions among healthcare professionals and a lack of locally conducted scientific research in tobacco control and harm reduction. Conducting high-quality, independent research in tobacco control and harm reduction, which can be peer-reviewed and used to inform regulatory and clinical decisions, can change this situation for the better.
Vorster: Furthermore, despite initiatives such as the Tobacco Transformation Index that assess the overall shift in the industry, a considerable gap persists in independent research focused on monitoring transformation progress specifically in the Global South.
Patwardhan: Agreed. There is an urgent need for industry transformation, not just in products but also in organizational attitudes toward public health, research and social responsibility in the Global South. It is quite clear to me that the industry must prioritize public health outcomes alongside business interests. It was mentioned in our panel how crucial it is for companies to engage with communities transparently to foster an environment conducive to harm reduction. This includes investing in local communities, conducting local research to global standards and responsibly supporting educational campaigns that accurately inform adult consumers about the risks of consuming tobacco and the evidence-based aids available locally for quitting tobacco use.
Conclusion
Eliminating harm from tobacco products is a lofty social, public health, economic and political goal. It needs to be a global goal too. The rapid pace of innovation into safer nicotine alternatives for tobacco cessation is likely to be available and affordable only to the adult tobacco consumers in wealthier “Global North” nations in a well-regulated environment, and this threatens to worsen the inequity already imposed on current tobacco users of the Global South. The industries—not just tobacco but also pharmaceutical as well as new disruptive digital and health tech companies, have much to gain commercially by innovating in the Global South. There are nearly a billion current adult tobacco consumers there waiting for just that!
Pieter Vorster is managing director of Idwala Research, a consultancy aiming to accelerate global tobacco transformation and harm reduction.

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

June 1, 2024
WVA Raises Alarm About Misperceptions

Photo: WVA
The World Vapers’ Alliance (WVA) marked World Vape Day with a protest in front of the World Health Organization’s in Geneva today. Participants in the event urged the global health body to listen to consumers and acknowledge the scientific evidence supporting vaping, nicotine pouches and similar products as valid harm reduction tools.
The consumper group says it is concerned about the rampant “misperception epidemic” surrounding tobacco harm reduction. Recent research by Ipsos for the think tank We Are Innovation shows that 74 percent of smokers worldwide wrongly believe that vaping is as harmful or more harmful than smoking. This misconception, fueled by misinformation, is preventing millions from switching to a scientifically proven less harmful alternative, according to the WVA.
“The WHO [World Health Organization] has turned World No Tobacco Day into a propaganda day,” said WVA Director Michael Landl in a statement. “Sweden is about to become smoke-free thanks to alternative nicotine products.
“The WHO needs to stop fighting alternative nicotine products and start backing them as keys to a smoke-free future. The WHO’s false claims are fueling a deadly misperception epidemic. Smokers deserve the truth: Vaping is significantly less harmful than smoking. Accurate knowledge could save millions of lives.”
May 30, 2024
A Case for Consensus

Photo: pavelkant
A global alignment on health policy is necessary to make a smokeless world a reality.
By James Murphy
With renewed attention on smoking and vaping regulation around the world, now is the time for action that will realize global smoke-free ambitions and ensure cigarettes become a thing of the past.
Achieving this vision requires a global consensus on the most effective approach to create sustained and lasting changes to consumer behavior—tobacco harm reduction (THR).
THR is one the greatest public health opportunities today, representing a pathway for hundreds of millions of smokers who would not otherwise quit to transition from combustible tobacco products to smokeless alternatives.
Countries that have recognized the opportunity THR presents, and which have adopted supportive policies, have seen striking success in reducing their smoking rates. The U.S., U.K. and Japan are all currently witnessing their lowest smoking rates on record while Sweden is on track to declare themselves smoke-free this year—defined as having less than 5 percent daily smokers in the population—16 years ahead of the 2040 EU target.
These remarkable transformations have been driven by widespread THR acceptance from policymakers, regulators, health officials and consumers in these markets, enabling and encouraging smokers to migrate from combustible tobacco products such as cigarettes to vapor, oral nicotine pouches, snus and heated-tobacco or herbal products.
The widespread accessibility of smokeless products is essential for the success of THR. However, at present, this is being hamstrung by many countries limiting access to these alternative tobacco and nicotine products. For example, 60 percent of the world’s population live in just 15 countries. Of these, only about 40 percent permit the sale of smokeless products, leaving millions who would otherwise continue to smoke without the option to switch to such alternatives.
In order to fully realize the public health potential of THR and significantly reduce the more than 8 million deaths attributed to smoking cigarettes each year, regulators around the world should embrace evidence-based science to drive positive public health outcomes. This means implementing a supportive regulatory framework that encourages adult smokers who would otherwise continue to smoke to switch while also protecting consumers with stringent safety standards and preventing underage use.
In addition, the global success of THR depends on governments and regulators correcting persistent misperceptions of smokeless products compared to cigarettes.
A University College London-led study published earlier this year highlighted that most smokers in England wrongly believe vaping is at “least as harmful as smoking,” with 57 percent of respondents saying they thought vaping was “equally” or “more harmful.” This echoes trends reported in the U.S., with research showing that perceptions of e-cigarettes as more harmful than cigarettes doubled year on year between 2018 and 2020. Not only are these misperceptions flawed, but they also have significant implications for public health by actively discouraging smokers who would otherwise continue to smoke from making the switch to smokeless products.
Greater efforts are needed to counter these misperceptions—something that BAT is trying to tackle. As the world’s largest vapor company and a leader in smokeless products, BAT is committed to producing innovative products backed by world-class science and industry-leading product safety and quality standards. BAT’s THR approach is based on the growing body of research and weight of evidence approach that substantiates its belief of the reduced-risk profile of these products compared to cigarettes, which have been accepted by many international public health bodies. BAT publishes its science research to increase understanding of THR and raise awareness with stakeholders.
Indeed, the industry developing and producing these products has a critical role to play. But to achieve the conditions required to make a success of THR, an inclusive, open and honest dialogue with all stakeholders is required. That includes policymakers, regulators and the healthcare and medical communities. Unfortunately, this is not yet the case, with the industry all too often excluded.
We have an opportunity to usher in a new smokeless world, grounded in scientific research and a firm commitment to public health. The solutions are available today. All that is required is for the relevant stakeholders to actively work together to prioritize THR and the well-being of millions of people worldwide.
James Murphy is the director of research and science at BAT.

May 30, 2024
CAPHRA Urges End to Vape Disinformation

Vapor Voice archives
The Coalition of Asia Pacific Tobacco Harm Reduction Advocates (CAPHRA) states that as it celebrates World Vape Day on May 30, 2024, the organization is urging global leaders to recognize the life-saving potential of safer nicotine products and to expose the ongoing disinformation campaign led by the World Health Organization (WHO).
“Despite overwhelming scientific evidence supporting the reduced risk of vaping compared to combustible tobacco products, the WHO continues to ignore the facts and mislead the public,” said Nancy Loucas, executive coordinator of CAPHRA. “These products, including e-cigarettes, snus, and heated tobacco products (HTPs), offer a viable alternative for millions of smokers seeking to reduce their health risks.
“The GSTHR reports have shown that these alternatives are not only effective in reducing harm but also play a significant role in public health by providing accessible and acceptable options for smokers worldwide.”
CAPHRA has criticized the WHO’s exclusionary tactics, particularly at the 10th Session of the Conference of the Parties (COP10). By excluding consumer groups and harm reduction advocates, the WHO has demonstrated a blatant disregard for the voices of those directly impacted by tobacco use, according to an emailed press release.
“One of the most egregious aspects of the WHO’s stance is its use of children as pawns to propagate the false narrative that vaping is not a tobacco harm reduction product,” said Loucas. “This disinformation campaign not only undermines the credibility of harm reduction efforts but also jeopardizes the health of millions of adult smokers who could benefit from switching to safer alternatives.”
CAPHRA is calling on all vaping industry stakeholders, including policymakers, public health officials, and the media, to recognize the truth about tobacco harm reduction. The release states that it is time to challenge the disinformation spread by the WHO and advocate for evidence-based policies that prioritize the health and well-being of smokers worldwide.
“It’s time for the WHO and FCTC to listen to consumers and integrate harm reduction into their policies. Only then can we tackle both the public health crisis of smoking and the escalating illicit tobacco trade,” said Loucas. “The WHO’s stance not only ignores the evidence supporting these strategies but also undermines the global fight against the tobacco epidemic.”
May 29, 2024
New Briefing Details THR Success in Japan

Photo: wachiwit
Knowledge Action Change (KAC) has released a briefing paper on the rapid fall in cigarette sales in Japan following the introduction of heated-tobacco products (HTP).
Titled “Cigarette Sales Halved: Heated-Tobacco Products and the Japanese Experience,” the paper explores some of the social and cultural factors that have made Japan particularly suited to HTP and provides a case study showcasing the potential of tobacco harm reduction through the adoption of safer nicotine products.
As well as referencing a number of peer-reviewed science papers, the briefing paper, available in 12 languages, also includes some new Global State of Tobacco Harm Reduction research, which compares up-to-date sales figures that emphasize the changing nature of cigarette and HTP consumption.
According to KAC, the success of HTP in Japan offers significant hope of their potential to reduce cigarette sales in other similar countries.
“The speed and scale of the change in Japan shows just how quickly things can improve when those people already consuming nicotine are given access to a safer alternative,” said KAC Director David MacKintosh in a statement.
“This is not the result of a specific government policy or initiative, yet the benefits to individuals and society are significant. There are lessons to be learnt from Japan by all those who wish to see the use of combustible tobacco consigned to the history books. Harm reduction is about giving people the opportunity to improve their own health and the health of those around them. Given the chance, most people will do just that.”
May 15, 2024
Smokers Confused About Relative Risk

Photo: auremar
Many smokers fail to understand the comparative risks presented by vapes and traditional cigarettes, according to a new Ipsos survey among 27,000 smokers in 28 countries carried out on behalf of We Are Innovation.
Currently, 74 percent of smokers worldwide mistakenly believe that vaping is either as harmful or more harmful than smoking combustible cigarettes. This misinformation challenges public health messaging about vaping as a safer alternative to traditional smoking methods.
The survey identified countries including Brazil, the Netherlands, Slovenia and Kazakhstan as having the highest proportion of smokers (over 80 percent) incorrectly perceiving vaping as equally or more harmful than smoking tobacco. On the other hand, countries such as Italy, the Czech Republic, France and the United Kingdom exhibited a more accurate understanding, although even in these nations, over half of smokers still hold false beliefs regarding the risks of vaping versus smoking.
“The consequences are grave,” said We Are Innovation CEO Federico N. Fernandez in a statement. “If smokers are under the incorrect assumption that vaping is no better than smoking, they are far less likely to explore potentially lifesaving products as a means to quit harmful combustibles. Misinformation is stifling innovation and obstructing smokers’ ability to escape the clutches of cigarettes.”
May 8, 2024
Regulators Urged to Distinguish Combustibles and Smoke-Free

Photo: Finn Bjurvoll Hansen
A study released on May 7 adds further evidence that the harm from nicotine use is determined primarily by the consumption method.
Titled No Smoke, Less Harm, the report details rates of nicotine usage in Sweden and a number of comparable countries, finding that nicotine use was not a factor in tobacco-related disease.
Karl Fagerstrom
While nicotine consumption in Sweden mirrors the European average, the country reports a 41 percent lower incidence of lung cancer and fewer than half the tobacco-related deaths of its European peers. This stark contrast is attributed to the widespread adoption of smoke-free nicotine products such as snus, nicotine pouches and electronic cigarettes.
“This distinction between smoking and the use of smokeless products is crucial,” says Karl Fagerstrom, a public health expert and contributor to the report.
“While nicotine is addictive, it does not cause the serious diseases associated with smoking. Our findings support a shift in focus from cessation to substitution with less harmful alternatives for those unable to stop completely.”
According to the authors, Sweden’s proactive measures in public health education and regulatory frameworks have encouraged a transition to these alternatives, significantly impacting public health outcomes. The report points out that embracing similar harm reduction strategies could be pivotal for other nations striving to reduce the health impacts of tobacco.
“The Swedish experience demonstrates that understanding and addressing public misperceptions about nicotine can lead to health policies that better protect and inform consumers,” said Fagerstrom.
May 8, 2024
Registry Bills Harmfully Limiting Options: Critics

Photo: Andrey Popov
Premarket tobacco product application (PMTA) registry bills in the United States are harmfully limiting options for people seeking to quit cigarettes, according to critics.
The bills, which restrict sales to products that have either been authorized by the Food and Drug Administration under the PMTA pathway or are undergoing that process, have been spreading rapidly around the nation, according to Filter.
Alabama, Louisiana and Oklahoma already have PMTA registry bills in force while laws in Kentucky, Utah and Wisconsin are set to take effect in 2025.
To date, the FDA has authorized only a handful of e-cigarettes, all of which are owned by tobacco companies. The remaining vapes on the market are sold unauthorized and often imported from China. Limited FDA enforcement has prompted many states to step in with registry bills.
Tobacco harm reduction advocates have long condemned the PMTA process as excessively onerous. They point out that it’s easier to bring new cigarettes to market than it is to gain authorization for safer vapes that can replace them.
Tobacco companies are supporting PMTA registry bills in what critics say is a bid to dominate the market at the expense of people who smoke.
“Most legislators do not understand that PMTA registries aim to ban the sale of the vast majority of vaping products used by adults in their state,” said Greg Conley, director of legislative and external affairs for the American Vapor Manufacturers trade organization. “They think they are fighting Chinese scofflaws, but really they are making life worse for their own voters.”
May 7, 2024