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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.
  • Learning From the Past

    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.
  • All Hands on Deck

    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.
  • Ramström: Tobacco Harm Reduction Works

    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.