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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
Learning From the Past

Photo: Lukas
This year’s GFN looked at past successes and continuing challenges for tobacco harm reduction.
By Stefanie Rossel
“Tobacco harm reduction—the next decade” was the theme of this year’s Global Forum on Nicotine (GFN), which took place in Warsaw June 21–24, 2023. For the first time, the presentations stretched over four full days. Some 220 delegates from 40 countries attended the event, which also marked the 10th anniversary of the conference—a good time for a look back not only on the progress of and the opportunities but also on the challenges facing tobacco harm reduction (THR).
The picture of THR currently is highly fragmented, as became clear during a workshop on global regulation. Regulatory treatment of safer nicotine products varies widely among countries. There’s Australia, where vape products are available on prescription only and just 5 percent of doctors can prescribe nicotine. By contrast, the Philippines, after a 10-year debate, last year introduced a law that treats vapes differently than tobacco products, offering nicotine users easier access to less hazardous products.
In the European Union, there is a double layer of regulation, which relates to the harmonization of the 27 member states and the national adoption of the Tobacco Products Directive (TPD2). Trends influencing legislation include polarizing views of member states, so countries are advocating for more regulatory freedom within the EU. Mexico has banned the sale and production, but not the use, of reduced-risk products (RRPs). Kenya’s RRP taxes are so high that they constitute a de facto ban.
For many countries, tobacco control is a relatively low priority, and smokers have been left behind in the discussion.
GFN participants cited Australia as an example of how not to regulate vaping. Nicotine can be legally bought from pharmacies only with a prescription. This has led to a flourishing unregulated market. Ninety-two percent of Australian vapers source their e-cigarettes from the black market. To curb illicit trade, Australia plans to ban the import of all nonprescription vaping products, including those that don’t contain nicotine. Colors, flavors, volumes and nicotine content of prescription e‑cigarettes will be restricted, and packaging must be pharmaceutical-like.
Consumers trying to get a prescription in Australia face many barriers, many of which are due to the country’s geography. Doctors have an inadequate understanding of smoking and nicotine addiction, and they must be registered as an authorized nicotine prescriber. Once they have the prescription, consumers must convince a pharmacist, who usually has limited stock, to get nicotine. While several Australian states have legalized possession of drugs, vape products are becoming an illicit product. In a survey, 81 percent of Australian vapers said that they would return to smoking if they had no access to vaping.
Tobacco Control: A Substitute Religion
The stigmatization of THR bears a strong resemblance to religion, according to participants in the panel discussion on science, regulation and morality. Bans are about social engineering, and the regulatory wording reveals an ideology of people who want to control others. As an example, panelists cited the imagery used to scare people off vaping (“vaping causes brain worms”).
There is still a lot of disinformation, misinformation and misleading science, and knowledge of THR in the wider harm reduction community remains limited. And although certain debates, such as the cause of e-cigarette or vaping product use-associated lung injury (EVALI), have been settled by science, they remain a topic of discussion, a phenomenon that panelists found very frustrating.
A panel evaluating the past 10 years of science reminded the audience that first attempts at safer products date back 30 years to 40 years, when the first heated-tobacco products (HTPs), Eclipse and Accord, hit the market. The introduction of modern HTPs in 2014 changed the landscape. Snus in Sweden has an even longer history. If this type of oral nicotine was accepted in the rest of Europe, 3 million smoking-related deaths could be avoided, the panelists pointed out.
Thanks to advances in technology, the new generation of e-cigarettes provides safer nicotine delivery than its predecessors. As years go by, data on vaping accumulates. Recently, the Oxford Foundation confirmed there was strong evidence that e-cigarettes help people quit.
Tobacco control advocates apply double standards to nicotine, however: In their minds, the benign nicotine in medical smoking cessation products becomes a lethal, toxic substance as soon as it leaves the pharmacy. This leads to some grotesque situations. In Austria, for example, nicotine-replacement therapies are flavored and can be sold to children from the age of 12.
While in the 1980s and 1990s, tobacco control was about the “endgame” against cigarettes, the war has now turned against nicotine, according to GFN panelists. Countries such as Finland, for example, discuss nicotine ceilings in nicotine pouches. To convince tobacco control that their science is reliable, panelists agreed that the industry must change its communication strategies and talk about science outside of the usual places. Real-data science, which is already available, will make a big difference in the next decade, one speaker predicted. It could help drive the policy debate and improve the reputation of the tobacco industry. Industry science should be based on geographies and sales of RRPs, according to the speaker.
Getting the Message Out
Scientific publishing is important as it creates transparency and builds trust. According to a panel on the politics of such publishing, more than 2 million peer-reviewed articles were published in 2021. Good journals have at least two referee reports; three tend to improve the quality of the article. Rejection rates are high. Most journals have little expertise with the tobacco and nicotine industries. Scientific publishing is a massive, $28 billion-a-year industry built on the backs of volunteers. Despite the barriers to publication, the two largest tobacco companies have published more than 350 manuscripts on RRPs.
Next to the established publications are open access journals. Their selection criteria are purely financial, as each accepted manuscript attracts a fee. While they are looking to publish as much sound science as possible, the downside is that the hurdle to becoming a publisher has dropped, and industry scientists should beware of untrustworthy, predatory journals.
One of the critical issues regarding tobacco industry transformation is the question of whether it is reaching low-income and middle-income countries (LMICs), where around 80 percent of smokers live. Currently, RRPs barely feature in the 137 LMICs, partly due to regulatory restrictions. Twenty-six LMICs, including major markets such as Brazil, India and Argentina, ban RRPs. Many consumers are unaware of reduced-risk options, with some even believing they are more harmful than smoking. If available, RRPs are expensive and difficult to access in LMICs.
While lumped together into a single category, LMICs in fact comprise a collection of very different countries with greatly varying consumer preferences. The World Health Organization, a declared opponent of THR, tends to enjoy considerable credibility in these regions. Other hurdles to RRPs in LMICs include the tendency of regulators to view the terms “tobacco” and “nicotine” as interchangeable and the low awareness in the medical community about the role of nicotine.
BAT’s introduction of modern oral nicotine in Kenya and Pakistan is an example of a promising first step and shows that products need to be designed from the point of view of the consumer.
The Pros of Nicotine
Tobacco control has turned its war on cigarettes into a war on nicotine, but the supposedly evil substance has a vast pharmacological potential, according to one presenter. The positive effect of nicotine in the treatment of Parkinson’s disease or schizophrenia is already known. A more recent studies revealed nicotine to be an efficient therapy for mild cognitive impairment as well.
Other conditions, such as late life depression, also benefit from nicotine stimulation. Nicotine can help modulate aggressive behavior in autistic patients, and scientists are currently examining its efficiency in combating the loss of hearing. In the next six months, researchers will also start investigating whether nicotine could help treat the cognitive syndrome (“brain fog”) that sometimes accompanies Long Covid.
Unfortunately, the progress of THR over the past decade, with more than 100 million people using RRPs today, has also had a less welcome effect in the form of electronic waste. The growing popularity of disposable vapes in particular has led to an increasing number of batteries and other components ending up in landfills and causing fires.
To solve the problem, manufacturers should consider standardizing the materials in their products, looking at biodegradable components for tanks and making the batteries removable, according to GFN panelists. Retailers should offer to take back used products for recycling, and consumers, too, must take their responsibility. One panelist said he wanted to set up a study to find out what motivates people to bring back their devices and to what extent such behavior could be spurred by financial incentives.
Stigmatize, Exclude, Silence
So who has a stake in the THR game? Certainly, the industry should have one, one panelist argued, as it has the will and the money, which unlocks science in toxicology, behavioral research or postmarket surveillance surveys. The industry also knows how to make consumers switch quickly, and it has the scale of manufacturing and distribution to deliver these products to the biggest possible audience in a short time.
Vulnerable communities, which represent a large percentage of smokers, appear to have no such stake, however—an equity issue that needs to be addressed. While article 5.3 of the Framework Convention on Tobacco Control, which aims to protect tobacco control policies against tobacco industry influence—does target smokers, this group remains conspicuously absent from discussions about the tobacco control process.
Medicinal licensing of vape products was not considered a solution by panelists since many smokers don’t view their habit as a medical problem. Besides, such an approach stifles innovation, as the authorization of medicinal products takes a long time, and the resulting products are not necessarily the ones consumers want.
Children, too, should be seen as stakeholders in the debate, according to one panelist. If they lose their parents to smoking-related death, they are traumatized, and this will influence their later relationships. That means THR is a child welfare issue, the speaker claimed, quoting a 2013 study that found that if all tobacco control policies were implemented, there would still be 523 million smokers in the world.
A plenary discussion focused on “the tobacco control playbook” revealed the methods that tobacco control activists have been using since RRP started gaining traction years ago. Measures include attempts to delegitimize, stigmatize, silence and exclude THR proponents and people with ties to the tobacco industry, however tenuous, from smoking cessation conferences.
Academic journals have silenced authors with research funding, however indirect, from tobacco companies. The University of Bath, which on its TobaccoTactics website keeps a running tab of people linked to the industry, has planted stories with journalists, including those it funded.
There have been attempts at making journal editors reject papers published by grantees of the Foundation for a Smoke-Free World (FSFW), which receives funding from Philip Morris International. While in many areas of health, governments consult with consumer groups, vapers are viewed with suspicion and suspected of being on Big Tobacco’s payroll. Academics have suggested links between vapers and tobacco companies where there aren’t any.
Those in tobacco control who think differently but don’t speak up against these methods become accomplices, according to one panelist. Tobacco control, he observed, needs people to blame. In the future, every opportunity should be taken to raise objections—for instance, to university ethics committees who fail to protect people, to journal editors and editorial boards that publish inaccurate articles and to academic institutions that receive funding for activist tobacco control work. Finding enemies is now so embedded in the tobacco control psyche that these activists have no interest in finding common ground. Nevertheless, optimism prevailed in the panel. The question, they argued, is not if but when THR will succeed.
Achievements and Obstacles
For THR to make progress in the future, a look at the past may be useful. In 2012, massive protest by vapers helped avert a ban on vaping in the EU. In 2014–2015, Public Health England acknowledged the relative safety of e-cigarettes, opening many eyes to the promise of vaping as a smoking cessation tool. One year later, Kenya became the first country to regulate vape products. Around this time, the split between pro-vaping and anti-vaping advocates occurred.
In 2016, the U.S. Food and Drug Administration started regulating all nicotine products as tobacco products. This had a domino effect around the world.
Founded in 2017, the FSFW faced strong opposition. In 2018, consumers joined a legal challenge to the EU snus ban. One year later, the Indian government banned vaping while in the U.S., misinformation about EVALI created a panic.
New Zealand embraced vaping in 2021, and in 2022, the EU endorsed vapes as part of its Beating Cancer Plan. Around the same time, the Philippines introduced reasonable vaping regulations. In all three cases, consumer advocates played a vital role.
This year, Quebec introduced a vape flavor ban, Australia announced a crackdown on vaping, and the U.K. launched its “swap to stop” scheme to encourage smokers to switch to e-cigarettes.
The developments in the past decade, panelists concluded, were driven by instinct and moral concern on the policy side, which leads to prohibition. Indifference to different products is a risk. Youth use is heavily emphasized by health activists, and silence has become subordinate to the political agenda. Consumer advocacy, however, has been working in favor of THR. On a global scale, vaping is rising.
GFN 2023 closed with an outlook on THR in the next decade. Participants in the final plenary discussion were confident that THR will happen one day—simply because things always change, RRPs are there, and there’s no going back. Education of the general public is vital to drive the debate. Children’s uptake needs to be solved, and THR proponents should remember that the debate is about more than vaping.
More attention must be paid to THR in LMICs, particularly those that have dictatorships in which criticism means rebellion and informing consumers is impossible.
To free themselves from their guilt from the past and be taken seriously in their claim to create a smoke-free world, tobacco companies should eventually divest their cigarette units.
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, 2023
All Hands on Deck

Photo: The Global Forum on Nicotine
Tobacco harm reduction is gaining momentum but continues to face many hurdles.
By Stefanie Rossel
“Tobacco harm reduction: Here for good“ was the theme of this year’s Global Forum on Nicotine (GFN) conference, which took place in Warsaw June 16–18, 2022. Around 50 speakers and panelists discussed the issues that will determine the future of safer nicotine use and tobacco harm reduction (THR). The meeting was preceded by a day of satellite events and once again featured the International Symposium on Nicotine Technology, which highlighted the latest technological advances in the rapidly changing nicotine delivery landscape.
Two hundred years after the first snus brand was launched in Sweden and almost 20 years after the Chinese pharmacist Hon Lik invented the modern electronic cigarette, THR continues to face challenges. While THR is making good progress in high-income countries, low-income and middle-income countries (LMICs), where about 80 percent of global tobacco users live, are mostly excluded. In India, for example, where smokers of bidi cigarettes and consumers of hazardous oral tobaccos such as gutka represent 85 percent to 90 percent of tobacco users, bidi packs do not even carry health warnings. While gutka is officially banned, prohibition is not enforced. Instead, health authorities focus on the harms of vaping. Although vape products are banned in the country, they are readily available on the black market.
Thailand legalized the cultivation and consumption in food and beverages of cannabis in early June but continues to prohibit vaping under strict penalties. Vapers risk a jail sentence of up to 10 years. An observational study in South African hospitals not only demonstrated that inpatients had a lack of knowledge of nicotine-replacement therapy (NRT) but also that doctors in LMICs are often not trained to explain to patients how to use NRTs. Research comparing THR in Russia, China, Indonesia and India found that once smokers have understood that combustible cigarettes are harmful, the key challenge is changing behavior. In Russia and China, consumers are generally aware of reduced-risk products (RRPs) whereas in India and Indonesia, nicotine is considered the most harmful constituent, and few people know that RRPs exist.

Uncontrolled Influence
Most LMICs have ratified the World Health Organization’s Framework Convention on Tobacco Control (FCTC), which takes a dim view of vaping. This position is backed by one of its largest donors, billionaire and former New York City mayor Michael Bloomberg. In his keynote presentation, journalist Marc Gunther demonstrated that philanthropy is an excise of power that requires scrutiny.
By pumping millions of dollars into nonprofits and anti-vaping groups worldwide while funding university researchers, a media initiative and a nonprofit health consultancy through the Bloomberg Philanthropies foundation has created an effective global anti-vaping campaign that is not driven by science, according to Gunther. For example, The Union a Bloomberg-backed nongovernmental organization headquartered in Paris, recently published a paper calling for a ban on all e-cigarettes in LMICs. Most damaging, Gunther said, was the relationship between Bloomberg and the WHO, which the billionaire has generously funded with many millions of dollars for a variety of projects, including $5 million for its tobacco work in 2019.
While few countries ban RRPs outright, the products often face prohibition by stealth. This month, Germany started applying a tax to e-cigarettes, which came on top of the previously applied value tax. With e-liquids now being taxed by volume, their price has almost doubled, which prevents smokers from switching as it conveys the impression that a product taxed so high must be equally as harmful as combustible cigarettes.
In the U.S., the Food and Drug Administration picks the winners and losers through its tobacco product authorization process with little regard for consumers. The agency’s requirement for comprehensive scientific documentation of a product’s contribution to the protection of public health represents a hurdle that only the largest and most amply funded nicotine companies can manage.
Prohibiting elements that make vapor products appeal to smokers, such as nontobacco flavors, are also a kind of stealth prohibition that has no effect on overall smoking or vaping prevalence. U.S. states that ban flavors miss out on tax revenues and Master Settlement Agreement money while the number of smokers stays the same and vapers buy their products in neighboring states. Prohibition by stealth, panelists agreed, stifles innovation and, given the discrimination against vape products compared to combustibles, may be potentially illegal in trade law terms.

Academic Freedom Under Threat
Misinformation about RRPs and the question of who can be trusted remains one of the biggest issues in tobacco harm reduction. While the trust in science has generally increased through Covid-19, countless flawed studies on less hazardous nicotine products continue to circulate, contributing to misperceptions among consumers. Google Scholar ranks studies according to popularity rather than quality, so even two years after e-cigarette or vaping use associated lung injury (EVALI), studies attributing the outbreak to nicotine vapes rather than illicit THC products still feature prominently in search results. But even research professionals are often interested only in the title, abstract and conclusion of a study and thus fail to detect flawed methodologies.
A recent example of misinformation is the claim by several emission studies that the aerosol of vape products is polluted with heavy metals. By providing a concise explanation of the ingredients of e-liquids and the complex chemical processes that take place in a device during vaping, Miroslaw Dworniczak, a Polish chemist and author, refuted this assumption, concluding that despite the presence of some potentially dangerous compounds, e-cigarettes were far less risky than regular cigarettes. Mexican physicist Roberto Sussman, who examined 12 studies on metals in e-cigarette emissions, found that all of them were methodologically flawed.
Having become ideological rather than evidence-based, the health debate about vaping is full of contradictions. Mark Tyndall, an infectious disease specialist from Canada, compared his experience working with HIV with the experience in vaping. It took 40 years for HIV to lose its association with fear, blame and stigma—issues that smokers and vapers are facing too. Medical treatment of AIDS was the greatest breakthrough—vaping, he claimed, could be a similarly efficient weapon to treat smoking.
Stigma is also present in the academic world, and it goes far beyond suspicion of tobacco-funded studies. Scientists detected “the ghost of Senator Joseph R. McCarthy,” the paranoid U.S. communist hunter of the 1950s, as they often confronted hostility from fellow academics and institutions. Experiences of suppressed academic freedom ranged from a lack of institutional support for THR research to “mobbing” and exclusion from faculties.

Here for Good, but …
So, is tobacco industry transformation a myth or a reality? Sharing her view from the corporate side, Flora Okereke, head of global regulatory insights and foresights at BAT, said that her company’s efforts to help smokers switch to less risky products—and therefore doing something for society—had given employees a sense of pride. Peter Stanbury, a political economist, evaluator and management consultant, pointed out that companies such as British Petroleum are also in the process of transformation, driven internally by people who realize that change is required and externally by regulation.
In advancing tobacco harm reduction, regional networks in THR consumer advocacy play a vital role. Nancy Loucas, founder and executive coordinator for the Coalition of Asia Pacific Tobacco Harm Reduction Advocates, related how her organization, faced with challenges such as government interests in tobacco growing and manufacturing, notably in China and Indonesia, and foreign philanthropist influence in the development of policy, achieved a paradigm shift in several countries by working with an expert advisory group.
Tobacco harm reduction, panelists agreed, is here to stay; consumers have a right to it. But accessibility of THR will remain a problem, and more restrictions are on the horizon.
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.

July 1, 2022
Ramström: Tobacco Harm Reduction Works

Photo: Finn Bjurvoll Hansen
A new study launched at the ninth annual Global Forum on Nicotine in Warsaw shows implementation of the World Health Organization’s tobacco control measures known as MPOWER has no clear association with low-levels of tobacco-related mortality in Europe.
Instead, the independent research, conducted by Lars M. Ramström, shows that switching from smoking to Swedish-style snus, a safer nicotine product, is a more effective strategy to reduce the harms caused by tobacco.
In 2007, the WHO launched MPOWER, a process and monitoring mechanism to implement the Framework Convention on Tobacco Control. Comprising six measures, it aims to reduce the demand for tobacco. But, despite 15 years of MPOWER, there are still 1.1 billion smokers worldwide, a total unchanged since 2000, and 8 million annual tobacco-related deaths, according to researchers.
To assess MPOWER’s effectiveness, Ramström compared the extent of implementation of these tobacco control measures with tobacco-related death rates across Europe by using figures provided by the Tobacco Control Scale (TSC), a tool that grades every European country’s level of MPOWER application, and data on tobacco-related mortality from The Global Burden of Disease.
After analyzing his results, Ramström found no correlation between tobacco-related mortality and a country’s level of implementation of MPOWER measures for Europe’s women, and a very weak correlation for the continent’s men.
Crucially, though, the two countries with the lowest tobacco-related mortality for men were Sweden and Norway. In both nations a large proportion of male smokers have switched from cigarettes to Swedish-style snus, a product that is freely available in both, but banned from sale in the EU except Sweden. Despite Sweden’s TCS score being below average, it has achieved a lower rate of tobacco-related mortality than all the countries that have higher levels of MPOWER implementation except Norway, providing further evidence in support of tobacco harm reduction.
June 17, 2022
The Way Forward

Photos: Jon Derricott
The Global Forum on Nicotine debates harm reduction in Liverpool and online.
By George Gay
If you’ve ever been involved in organizing a conference, one of the issues you will have run into will almost certainly have concerned how long people are given to speak. Among the organizing committee, there will have been those who thought 40 minutes was a reasonable slot while others would have tended toward 10 minutes. I have always leaned to the view that 10 minutes is too long to listen to one person speaking, so I was delighted to find that this year, for the first time, the Global Forum on Nicotine (GFN) included a series of five-minute videos.
That’s the good news. The bad news, if you’re short of time, is that, at last count, there were about 75 of these videos, or GFN5s. That’s more than six hours in total. I have to confess to having watched only about half of them by the time I sat down to write this piece.
There is little lost and much to gain in keeping presentations short and watching them as videos. Unlike in the case of live presentations, at your convenience and depending on your mood, you can watch a video or not depending on your interest in the subject under discussion. You can pause it and go back if you need to check something. And, if your interest is such that you want further information, most of the video makers provide details of how to go about finding it or making contact. Importantly, you can yell at the screen.
The GFN5s formed part of the 8th Global Forum on Nicotine held June 17–18 at the Crowne Plaza Hotel in Liverpool, U.K., and virtually under the theme: “The future for nicotine.” The program comprised three keynote presentations: Science and Politics: An Often Fractious Relationship; Investments in Nicotine Innovation: Risks and Rewards for Public Health; and Why Has the WHO FCTC [Framework Convention on Tobacco Control] Failed to Reduce Adult Smoking and Its Health Impact? There were, in addition, four panel discussions: Science: Orthodoxy, Challenges and Dissent; Who Uses Nicotine and Why?; Obstacles to Tobacco Harm Reduction in LMICs [lower-income and middle-income countries]; and Safer Product Regulation: Supporting or Undermining the End of Smoking? The keynote and panel presentations were interspersed with the streaming of GFN5s and analyses by a commentary team, and toward the end of the event, there was a consumer voices panel.
This was the first hybrid GFN, but conferencing with at least an element of virtual interaction has got to be the way ahead. There is little point, it seems to me, in constructing long-term strategies for reducing the harm caused by smoking tobacco if it means hundreds of people flying around the world, adding to a climate emergency that will “kill” us all anyway. I don’t know whether it was intentional, but there was a neat reference to such matters in one of the pre-panel-discussion videos, which were longer than the GFN5s. As one of the panelists delivered her presentation about the FCTC and tobacco harm reduction, hanging on the wall in the background was a print of London’s former Battersea power station belching out what looked like smoke. Having grown up in London with nonsmoking parents, my health would have been negatively affected more by the Battersea smoke and the general pollution of what was then a highly polluted city than by tobacco smoke.

Fiona Patten MP
Expanded Reach
Virtual events clearly work. The effects of the Covid-19 pandemic meant that the GFN conference organizer, KAC Communications, was forced to move the 2020 conference online; but even though this had to be done at short notice, GFN20 reached a bigger audience than ever before. Two thousand people registered from more than 100 countries, a number that included many consumers from around the world who were able to join the event for the first time. Compare this with the 1,100 from 87 countries who registered for the 2021 event.
There is, of course, considerable pressure building up among those who find virtual events unsatisfying and those with an interest in flying people around the world and putting them up in hotels. And KAC recognized this point in a pre-2021-event press release that, in part, said more than a year of online meetings had “taken their toll.” But, the organizer, which has a history of introducing innovative ideas to its conferences, reacted to this situation by aiming “to reenergize the digital format.” “A new GFN TV online platform will stream broadcast-quality footage of the conference free to viewers around the world, with a new commentary team offering their insights,” the press note said. This format worked well, in my estimation.
Again, this must surely be the way ahead. It would be a tragic waste in my view if, after having been forced by the Covid-19 pandemic to look more closely at virtual or hybrid conferences, we abandoned them at the first opportunity. It will take time for people to adjust to the new virtuality, but they will do so, especially if the way is eased by using innovative techniques. How can THR advocates preach to tobacco smokers about the health benefits of moving to “virtual smoking” with electronic cigarettes if they are not willing for the sake of the climate—for the sake of everyone’s health—to move to virtual meetings?
One of the great advantages of the GFN5s is that, while they offer the opportunity for the old lags to have another say, they also allow those watching to see and hear from people who they would not normally come across giving presentations at conferences—to learn things they probably wouldn’t have learned otherwise. What better reason to “attend” a conference? Having said that, I should point out that the GFN has always been an inclusive event. I attended the first GFN and learned a lot from a group of attendees whose main—and considerable—claim to expertise was that they were vapers and vaper advocates.
Another advantage is that the videos, which aren’t all five minutes in length, cover a range of styles and levels of professionalism that help hold the attention—watch out for the duck in one of them—better than does the usual, largely unchanging backdrop of traditional conferences, which are often held in windowless hotel bunkers where natural light rarely penetrates—with, I would suggest, the inevitable consequences.

Clive Bates, Robyn Gougelet and Michelle Minton
The Heart of the Matter
I would recommend that anybody interested in questions surrounding tobacco harm reduction take a look at these videos, but I shall draw attention to just two. I am not saying that these are the best of the bunch; I have, after all, listened to and watched fewer than half of them. But these two videos contained significant messages in my view. One, by John Oyston, a retired anesthesiologist, sought to answer the question of why many people working in the medical profession have not fully embraced the idea of tobacco harm reduction using electronic cigarettes, and made suggestions about how they might be brought on board in the future. It wasn’t that Oyston said anything new, but he brought to his presentation the insights and authority of a retired medical professional who had boiled down the salient points into a five-minute talk that, unlike some of the more data-filled presentations, got to the heart of the matter in a way that could be understood and appreciated by anybody. It deserves a wide audience.
There was something a little disturbing about Oyston’s presentation, however. This was the eighth annual GFN, and we are still apparently in a position where we are casting about for ways to get medical professionals on board. Indeed, we are still trying to get many health professionals to understand that nicotine doesn’t cause cancer. And we still seem to be in the situation where we leave each annual conference with the same words ringing in our ears—we need to refute the bad science being put about so that the messaging changes and a large majority of people accept the idea that nicotine is not the problem and can be delivered in ways that are far safer than is the case with tobacco smoking. In fact, one of the messages that came across a number of times was that science was losing out to politics and ideology, with the result that nicotine was being shoehorned into the evil empire where tobacco dwells.
This has to raise the question: do we need a plan B? Given that the object of the exercise is to encourage smokers to quit their habit, not necessarily the promotion of alternative nicotine-delivery systems, do we need to look at things again? At what point do we have to accept that, however wrong they might be, the people at the WHO and others opposed to THR have won?
One of the disheartening aspects of the conference was to see on one of the panels an unusually subdued Konstantinos Farsalinos, a physician and senior researcher at the University of Patras and the University of West Attica’s National School of Public Health in Greece. Farsalinos’ work in demonstrating the validity or otherwise of THR science has been invaluable for the nonscientists among us. But in a recent piece on Qeios, he explains how a report by journalists in the BMJ had confused his work on an aspect of Covid-19 with unconnected THR research, and had wrongly accused him of the nondeclaration of interests. But worst of all for Farsalinos, I think, was the fact that he was not allowed a right of reply in the same journal.
The next question that inevitably pops up, I guess, is outside the scope of the likes of GFN conferences. It concerns how it might be possible to encourage smokers to quit their habit without the use of nicotine alternatives. And here I mean “encourage.” What passes for “encouragement” among much of the tobacco control community is, to my way of thinking, “bullying.” It is largely about raising taxes to levels that render poorer the already financially impoverished. And in this respect, I was gladdened to hear one panelist point out that piling taxes and stigma on smokers is not ethical; indeed, it is reprehensible.
And there was some encouragement here from my other choice of videos. This one, narrated by Kevin McGirr, concerned an observational study targeting tobacco-using individuals with substance use or mental health disorders—people who make up a disproportionate amount of smoking populations. What I particularly liked about this study was its humanity—the way it has been constructed to allow the researchers to work with smokers, not work on them. Participants, who have to have shown some interest in altering their smoking habits, might not have abstinence as their final goal, which they set themselves. The researchers do not even use the term cessation.

Conference founder Gerry Stimson
A Breath of Fresh Air
Meanwhile, the conference allowed participants also to access in advance of the panel discussions videos made by some of the panelists. Again, these were worth watching, but I will draw attention to just two, which addressed, in part, an issue that many people within THR find almost incomprehensible—at least in a rational world. Why, when apparently most people are desperate to reduce toward zero the health problems caused by tobacco smoking and after more than 10 years of the cause of THR being supported by less risky products that some smokers find can substitute for cigarettes, has the idea of THR not gained more traction? Brad Rodu clearly demonstrated in his presentation how part of the reason in the U.S. is down to the way that most scientific research funding is made. In the other presentation, Michelle Minton explained how government policies in the U.S. are driven by the fears and wishes of the majority population, made up of the suburban, white middle classes. This is why tobacco smoking, a habit mainly of the financially less well-off, has been largely tolerated, while vaping, the subject of scare stories about an epidemic among the children of the middle class, has launched a moral panic.
Interestingly, given that THR has failed to gain the traction that logic suggests it should have, we were told during the conference that the FCTC was fit for purpose. I should point out that this statement was made in respect of the treaty’s text and the way it provided for parties to the treaty to embrace THR. It was not a comment about whether or how effectively THR principles had been applied. But given what has happened, it does raise a question about what is this “purpose” that it is fit for? After all, the nations of the world didn’t have to rely on the establishment of the treaty to embrace THR. It has always been my view that creating an international treaty around a legal consumer product was simply an extravagant and bizarre exercise in bureaucracy whose purpose was the creation of an endless series of environment-destroying conferences. Indeed, this sense of endlessness was suggested in a comment by one of the people associated with the FCTC when he prefaced a comment with: “If we are to finally end the use of combustible cigarettes …” There is a sense that we are content to drift from conference to conference, chewing over the same ideas and getting almost nowhere: in fact, in many places stagnating or even going backward.
So it was good that the Australian MP, Fiona Patten, a Member for the Northern Metropolitan Region in the Victorian Parliament’s Legislative Council and leader of the Reason Party, who gave the first—remote—keynote presentation, brought a breath of fresh air into the proceedings. Patten was clearly frustrated at the irrationality of Australia’s politicians who for a long time ignored the science about the dangers of tobacco smoking and today are arguing that there is not enough science to sanction alternative nicotine products. She was funny and feisty and clearly determined to get her way in respect of THR. And perhaps she will. As she, and others at the GFN pointed out, if the Covid-19 pandemic has delivered one positive, it is that politicians have been forced to listen to scientists.
Being a man and not a scientist, I wasn’t able to follow the complex reasoning through which Patten compared the clitoris with vaping devices, but the images conjured up did remind me briefly of a till-then long-forgotten Billy Connelly story about changing batteries in small electrical devices. And I would like to conclude by saying that it is surely time to give much more attention at THR conferences to considering the relative environmental impacts of tobacco and nicotine products. If we did end up converting 1.1 billion smokers worldwide to vaping, that would be an awful lot of batteries.
The organizer will be making GFN presentations available as individual sessions shortly, but for the time being, Day 1 presentations are available here.
The GFN is due to return to its live format and its “home” in Warsaw, Poland, next year on June 16–18.

George Gay is Tobacco Reporter’s European editor, but his territory spans the globe. Based in London, George has covered the tobacco industry since 1982, initially for a U.K.-based publication and since 2004 for Tobacco Reporter. George’s understanding of industry issues, combined with his keen sense of observation and dry wit, have earned him a loyal following among Tobacco Reporter’s readers.

June 22, 2021
Nicotine Forum Focuses on Harm Reduction

Photo: alpegor
Policymakers in public health and tobacco control need to listen to both the science on tobacco harm reduction and the experiences of consumers who are benefiting from it every day. Ideology must be set aside to prioritize progress toward the common goal of ending smoking. Those were some of the messages conveyed during the Global Forum on Nicotine (GFN), which took place June 16–18 in Liverpool, U.K.
Gerry Stimson, Emeritus Professor at Imperial College London and a founder of the GFN, said that much of what she has seen and heard during the event was encouraging.
“It feels as though we’re on the right trajectory,” he said. “Consumers all over the world are becoming aware of the opportunities offered by safer nicotine products, and innovations in the market will, I believe, lead to the eventual obsolescence of combustible cigarettes,” she said. “The question is how to speed up the process and scale up so that tobacco harm reduction reaches all smokers, everywhere, as quickly as possible.”
Multiple panel discussions took in subjects ranging from safer nicotine product regulation, tobacco harm reduction in low-income to middle-income countries and orthodoxy and dissent in science. Speakers’ prerecorded presentations for the panel sessions will remain available online at the conference website.
Three keynotes were delivered to honor Michael Russell, a psychiatrist, research scientist and pioneer in the study of tobacco dependence and the development of treatments to help smokers quit. Russell’s observation in the British Medical Journal in 1976 that “people smoke for nicotine, but they die from the tar” remains highly influential within the field.
The speeches honoring Russel focused on harm reduction and were given by Fiona Patten, leader of Australia’s Reason Party; Jon Fell, founder of investment company Ash Park; and Derek Yach, president of the Foundation for a Smoke-Free World.
“In Australia, governments have consistently stated that drug use must be treated as a health issue not a criminal one. But when it comes to nicotine, they are actively making criminals out of users,” Patton said. “For decades, they ignored the science about the dangers of smoking, but today, they argue that there is not enough science to sanction alternative nicotine products.”
GFN does not receive any sponsorship from manufacturers, distributors or retailers of nicotine products, including pharmaceutical, electronic cigarette and tobacco companies. Participants include consumers, policymakers, academics, scientists and public health experts alongside representatives from manufacturers and distributors of safer nicotine products.
The event organizers believe that dialogue and strategic engagement of all stakeholders involved in tobacco and nicotine use, control and production are the only way to effect true, sustainable change—both to industry practices and the public health outcomes related to smoking.
June 21, 2021
Experts Call For Global Access to Safer Nicotine

Photo: Aleksej
International public health specialists, scientists, doctors, tobacco control experts and consumers are convening for the Global Forum on Nicotine 2021 June 17 and 18 in Liverpool, U.K., and streaming free online, to highlight the vital role of safer nicotine products in the fight to reduce global smoking-related death and disease.
Experts at the forum will discuss tobacco harm reduction, a concept that calls for encouraging adult smokers who cannot quit nicotine to switch from dangerous combustible or oral products to safer nicotine products, including e-cigarettes, pasteurized snus, nontobacco nicotine pouches and heated-tobacco devices.
“Up to 98 million consumers worldwide have already made the switch to safer nicotine products,” said GFN director Gerry Stimson, emeritus professor at Imperial College London, in a statement.

Public health will not be served nor lives saved by a war on nicotine, as doomed to failure as the war on drugs. The WHO must refocus its efforts on supporting 1.1 billion adult smokers to quit by all available means.
Gerry Stimson, Imperial College London
“In England, health authorities support vaping to quit smoking, and vapes are now the most popular quit aid. Tobacco-related mortality in Sweden, where snus has almost replaced smoking, is the lowest in Europe. And in Japan, cigarette sales have dropped by a third since heated-tobacco products came to market. Manufacturers must now ensure safer alternatives are affordable to people in LMIC [low- to middle-income countries], not just consumers in high income nations,” he said.
“Worryingly, international tobacco control leaders are doggedly pursuing an irresponsible prohibitionist approach to tobacco and nicotine, while the WHO actively perpetuates misinformation on new nicotine products. Public health will not be served nor lives saved by a war on nicotine, as doomed to failure as the war on drugs. The WHO must refocus its efforts on supporting 1.1 billion adult smokers to quit by all available means.”
June 16, 2021
Forum on Nicotine to Convene in Liverpool

Photo: alpegor
KAC Communications will be hosting the Eighth Global Forum on Nicotine (GFN) from June 17–18 at the Crowne Plaza Hotel in Liverpool, U.K. With its theme “The future for nicotine,” the GFN tackles the challenges and controversies, as well as the significant potential, of safer nicotine products. Participants can choose whether to attend in person or online. In-person registration costs £60 ($84.23) for two days, and online registration is free.
A new GFN∙TV online platform will stream broadcast footage of the conference free to viewers around the world, with a new commentary team offering their insights.
The GFN will feature more than 30 speakers from diverse backgrounds, including consumers, advocates, policy experts, public health specialists and medical professionals. All sessions will be live, with speaker presentations available on the GFN website before the event.
“It’s a fallacy that tobacco control and harm reduction are irreconcilable as many believe—they’re complementary,” said Paddy Costall of KAC Communications. “While tobacco control has reduced smoking rates in many places, it’s got its limits. In the U.K. and elsewhere, it’s been shown that access to appropriately regulated safer nicotine products helps people stop smoking.
“At GFN, we offer an inclusive platform to discuss all aspects of nicotine use, and we believe it’s important that no one is excluded from the debate. With one billion smoking-related deaths predicted by the end of this century, it’s time for ideology to make way for pragmatism.”
For more information, visit https://gfn.events.
May 13, 2021
The Global Forum on Nicotine 2020 Moves Online

Photo: Rudy and Peter Skitterians from Pixabay
The Global Forum on Nicotine (GFN) will take place online June 11-12, 2020, following the cancellation of the face-to-face event in Warsaw due to Covid-19.
The conference is free of charge and open to everyone with an interest in nicotine science and policy.
During the conference, experts will discuss advances in nicotine science, the ethical arguments in favor of tobacco harm reduction and the human rights issues for all those who advocate for the right to health will be explored.
“As always, and perhaps even more so in this critical year, GFN is open to everyone with an interest in nicotine science and policy,” said Paddy Costall, co-director of the conference.
“It is open to everyone who wants to reduce the toll of tobacco-related death and disease worldwide. And it is open to everyone who recognizes that global tobacco control will fail without the strategic addition of tobacco harm reduction, in the form of widespread access to safer nicotine products. We look forward to welcoming you on the 11 and 12 June—and hope to see many of you in Warsaw, where we plan to meet again in June 2021.”
Participants can register now.
May 29, 2020
Gathering steam
Tobacco harm reduction took center stage at the recent Global Forum on Nicotine in Poland.
By Stefanie Rossel

The fourth annual Global Forum on Nicotine (GFN) took place in Warsaw, Poland, June 15–17. Under the theme “reducing harm, saving lives,” this year’s conference attracted 350 delegates from 54 countries. Attendees not only had the opportunity to listen to almost 50 lectures, but they could also study a variety of posters explaining the most recent research in the field of reduced-risk products.
The GFN is funded exclusively by registration fees, and it attracts a broad base of stakeholders involved with new and potentially safer nicotine products. Participants include academics, public health experts and parliamentarians, along with manufacturers and distributors. Consumers and consumer advocacy groups are involved as well.
The conference was preceded by ISoNTech, an international symposium on nicotine technology, which made its debut this year. Opened by Hon Lik, widely regarded as the inventor of the modern e-cigarette, it gave tobacco companies an opportunity to present research related to their nicotine delivery devices. Tobacco-heating products (THPs) featured prominently this year. Studies conducted by manufacturers suggest these devices deliver significantly lower levels of toxins than do combustible cigarettes.
The GNF was opened by Ethan Nadelmann, former director of the Drug Policy Alliance (DPA) in the United States. The DPA is a nonprofit organization that seeks to decriminalize responsible drug use and promotes harm reduction. In an emotional lecture, Nadelmann urged governments to learn from the mistakes in America’s war on drugs and cautioned against prohibitionist policies for smoke-free nicotine-delivery devices. The illegal market, he warned, would flourish.
Changing roles
The main part of the conference, divided into two tracks with partly parallel sessions, explored the changing roles of public health and manufacturers of reduced-risk products (RRPs) and looked at the conditions under which the interests of tobacco companies and public health might coincide. It also raised the question of whether the rules of engagement, regarding, for example, Article 5.3 of the World Health Organization’s Framework Convention on Tobacco Control, which bans the tobacco industry from participating in tobacco control policy negotiations, needed to be changed now that tobacco companies have products that could benefit public health.
The question about the credibility of tobacco companies’ new research, given their past misuse of science, was partly answered in a presentation on the rapidly developing science on nicotine use. Comparing e-cigarettes, THPs and conventional cigarettes, Konstantinos Farsalinos, a cardiologist at the University of Patras in Greece, reached conclusions similar to those of Philip Morris International (PMI). In Farsalinos’ study, PMI’s iQOS delivered higher levels of nicotine to the aerosol than do e-cigarettes but lower levels than do conventional cigarettes.
The definition of combustion was hotly debated at the conference. A combustible cigarette burns at between 600 degrees and 950 degrees Celsius, according to Thomas McGrath, manager of RRPs at PMI. During the exothermic reaction that takes place inside the cigarette, the tobacco is burned to ash and generates smoke that contains more than 7,000 chemicals. THPs, by contrast, operate at considerably lower temperatures. According to McGrath, the temperature of the tobacco next to the heating element in iQOS reaches a maximum of approximately 300 Celsius—well below the temperature required for combustion, which exceeds 400 Celsius—while most of the tobacco is significantly below 250 Celsius. Contrary to combustible cigarettes, the temperature in iQOS decreases when air is being drawn through the device.
By now, several THPs are available on the market, but there is no standard way yet of assessing whether a product is heating rather than burning tobacco. To comprehensively assess this aspect, a team of British American Tobacco scientists has developed a five-step approach, which they introduced during the poster presentations.
The complex phenomenon of dual use of vaping products and combustible products was another focal point of the GFN. As dual use is a highly individual issue, existing data provide only limited insight. Tom Kirchner, clinical associate professor of public health, medicine and urban science at New York University, described a new model that shows the number of combustible cigarettes displaced by e-cigarettes and essentially is a categorizing or classifying approach.
Nicotine: just another culprit?
The conference demonstrated that the role nicotine plays in tobacco harm reduction for the time being will remain a matter of discussion. Neal Benowitz, professor at the University of California in San Francisco, acknowledged that his concerns about nicotine kept changing as new studies were released. Focusing on the question of whether physicians should recommend nicotine uptake in vaping, he stressed the pharmacological effects of nicotine, which he said include cardiovascular disease, reproductive toxicity, cancer and chronic obstructive pulmonary disease. He concluded that short-term nicotine use posed little cardiovascular risk, whereas long-term use might be harmful.
While the focus currently is on delivering nicotine more safely, Eric C. Donny, from the department of psychology at the University of Pittsburgh, argued that people should be pushed to positive behavior change by reducing nicotine in combustible smokes. While acknowledging that nicotine was not the direct cause of harm, he claimed that it sustained the use of a “vehicle” that was deadly. The availability of alternative nicotine-delivery devices might not be enough to rapidly reduce smoking, he noted; therefore policies were needed that minimized the appeal of cigarettes relative to RRPs. Reducing nicotine in combustibles and enabling the growth of RRPs, Donny said, might be synergistic, complementary approaches to ending smoking.
Snus ban challenged
The second track of the GFN dealt with policy, advocacy and practice. The EU’s longstanding ban on snus featured prominently in this session. Although snus gives a similar nicotine dose as does a combustible cigarette without presenting the same risks for cancer, the product is banned in all EU countries bar Sweden. Looking at 50 years of increasing snus use in Sweden, Lars Ramstrom of the Institute for Tobacco Studies in Sweden stated that patterns of dual use of combustible cigarettes had changed considerably over this period, with snus use gradually replacing smoking. Today, Sweden has a prevalence of daily smokers of 5 percent, by far the lowest in the EU, as well as the lowest tobacco-related mortality rate. If the EU allowed the sale and use of snus, 320,000 smoking-related deaths could be prevented each year, he calculated.
In July 2016, Swedish Match filed a legal challenge to overturn the EU snus ban. Even though its previous challenge, in 2003, failed, experts are optimistic about the outcome of the current case, given that there is now significantly more scientific evidence available to support snus’s harm reduction potential. In addition, because it has so far not been available on the EU market, snus could be claimed to be a novel tobacco product, for which the revised Tobacco Products Directive (TPD2) contains a regulatory path to market.
Unlike snus, e-cigarettes are available in a large number of markets. Nevertheless, electronic nicotine-delivery devices face many challenges as lawmakers struggle to decide the new technology’s place in society, as snapshots of various countries during the conference proved. E-cigarettes are technically illegal in Australia, where nicotine is classed as poison. In spite of restrictions, people are embracing vaping, and the sector has been growing. It remains legal in Australia to import nicotine liquids for personal use. In February 2017, the medicines regulator rejected an application to legalize nicotine-containing e-cigarettes, which leaves combustible cigarettes more accessible than a safer alternative.
New Zealand, which has similar legislation on vaping products, in March shifted its policy. Reflecting the general consensus that vaping is safer than smoking, the government plans to legalize e-cigarettes to help the country become smoke-free by 2025. While sales would be restricted to adults and vaping would be banned in nonsmoking areas, the vapor products would not be subject to tobacco taxation and plain packaging laws.
In Europe, the TPD2, which came into force in May 2016, has significantly changed the business environment for the vapor industry. In countries such as Poland and the U.K., researchers have witnessed the effects on public perception of negative coverage of the vapor industry in the mass media, which is often based on poorly designed and misleading studies.
Other issues tackled at the GFN included the availability of less hazardous tobacco products for certain groups in society, such as people with mental disorders, individuals with addiction issues and poor people (groups that tend to have high rates of smoking prevalence). As far as future regulation of novel nicotine products was concerned, conference speakers said that legislators should promote innovation, set standards on product safety, and give the tobacco and vapor industries appropriate marketing freedom to build new brands. Consumers, on the other hand, should get appropriate freedom to use those products, while they needed to be informed about the risk.
July 1, 2017