The genie’s out of the bottle – embracing tobacco harm reduction could end smoking within a generation, says Knowledge Action Change. DDN reports.
Smoking causes at least 8m deaths every year – more than from HIV/AIDS, tuberculosis and malaria combined. Despite this global public health crisis, the number of smokers worldwide has remained static at 1.1bn over the past two decades.
In The right side of history, Knowledge Action Change (KAC)’s third report in a series on the global state of tobacco harm reduction, Harry Shapiro looks at past, present and future. Why have there been so many false starts to find safer ways to use nicotine? How have consumers themselves influenced the development of tobacco harm reduction? What’s been the response of public health and tobacco control organisations? What role has the tobacco industry played in all of this? And the key question: ‘Are we now going to see the opportunity to end smoking slip away – leaving the tobacco industry to continue profiting from the sale of combustible cigarettes?’
The report is a fascinating and disturbing read. It’s a story of innovation, but equally a story of ignorance, greed, corruption, neglect, inertia and privilege as we see the emergence of much safer products being regulated and dismissed to further confirm deadly combustible cigarettes as the number one choice. As we read about the burden of tobacco-related death and disease falling disproportionately on people who are poor, vulnerable and disadvantaged, we are reminded of tobacco companies’ sham promotion of ‘safer’ cigarettes (for which they were penalised in the 1990s) with a filter that was nothing more than a PR exercise. Their products remained deadly, and they knew it.
The twist in this story is that the breakthrough in tobacco harm reduction was consumer driven and not the result of public health policy dealt from on high. Individual innovators began experimenting for a safer vaping product, motivated by their desire to quit smoking. An American man came close, but China gave their candidate the backing and a new industry was born. Developing an export market quickly, China offered the world the opportunity to try vaping instead of smoking.
Harry Shapiro, the report’s author, explains how interest and excitement spread through internet forums, chat rooms and websites – ‘what’s all this e-cig stuff that I keep reading about in the newspapers? Is it going to help me? Are they safe? Where can I get them? How much do they cost?’
Politicians, regulators and law-makers were all completely caught off guard, he says. ‘They had absolutely no idea what to do with these products – is it tobacco? Should we make them medical products?’ And in the absence of knowledge, they took some bad advice from otherwise credible sources like the World Health Organization (WHO). ‘And of course, if you’re going to develop policies on the back of bad advice, what you finish up with is bad policy – and this is what has happened in many countries.’
Just as health and regulatory authorities moved towards restricting the products, consumers – the thousands who had benefited from vaping – began to advocate for their right to use them and this had a direct influence on policy.
But there was still a massive obstacle: the tobacco control establishment had spent millions of dollars over decades to fight the tobacco war – and it was a war against nicotine, not just cigarettes.
Life was much simpler before vaping arrived on the scene, explains Shapiro. ‘You had evil nasty tobacco companies over there, and their legal products were the devils. The angels were over here – the doctors, the clinicians, the public health people and so on. And there was clear blue water between them. But then the waters got extremely swirled up and muddy.’
Despite all the evidence on the efficacy and safety of the new products, many of the tobacco control organisations could not entertain the idea that safer nicotine products could play a part in reducing death and disease, and resorted to perpetuating ‘fear, uncertainty and doubt’. Perhaps rooted in moral and ideological objections, there was a complete unwillingness to consider that people could use nicotine recreationally outside the context of nicotine replacement therapies.
Their negativity had a serious impact, sowing doubt among health professionals. People coming forward looking to switch from smoking were likely to be met with ‘junk science’. Instead of being reassured that vaping was a safer option, they were more likely to be encouraged to go ‘cold turkey’ instead, which felt impossible for most. As Shapiro points out, ‘this plays straight back into the arms of the tobacco companies who are still making millions of dollars a year selling cigarettes.’
As a public health social scientist as well as KAC’s director of research and policy, Professor Gerry Stimson is extremely frustrated by the slow progress and unwillingness to act on evidence.
‘Here was an opportunity to massively reduce the burden of premature death and ill health caused by cigarettes – the potential of vaping products and snus was obvious and exciting to us,’ he says. The consumer interest and activism around vaping seemed as if it could consign a massive global health issue to the history books, and at virtually no cost to governments. ‘So we started our work on tobacco harm reduction with some cautious optimism.’ His colleagues were used to difficult issues – they worked in drugs harm reduction, HIV and AIDS, the criminal justice system, homelessness, mental health – but they hadn’t estimated the extreme challenges of working in the area of tobacco control and reduction.
Failure to lead
Realising the overnight revolution wasn’t going to happen, they prepared for a long uphill struggle. ‘My enthusiasm as a public health scientist wasn’t matched by the enthusiasm of my public health colleagues,’ says Stimson. Making matters worse, philanthropists who believed nicotine in all its forms was bad, were actually throwing money at preventing safer nicotine products from reaching their target market. It’s resulted in ‘a pretty dismal lack of progress’ over 20 years in reducing the statistic of 1.1bn smokers.
While realistic that it takes time to change consumer behaviour and patience for governments to work through regulations, he also understands the equation for tobacco companies. Why would they rush a transformation to new products while they continue to profit so handsomely from selling combustibles? His anger as a public health expert is directed at WHO and their failure to lead on this. Why are they not using their role – and the evidence – to shift people away from smoking? He says there needs to be an urgent review of WHO leadership in tobacco control.
Despite the challenges he is determined to remain optimistic about good products and consumer demand, demonstrated by an estimated 80m vapers globally. ‘This is a major disruptive force,’ he says. ‘For me it’s not whether safer nicotine products will predominate over combustibles, but when.’ DDN
Read the three reports on the global state of harm reduction, including The right side of history at: https://gsthr.org/resources/thr-reports/
A story of smoke and seduction…
The story of tobacco began with Christopher Columbus and crew encountering people putting rolled up leaves in their mouths, setting fire to them and inhaling the smoke. This was in 1492 in what is now known as The Bahamas, and as it spread throughout Europe it became used in the form of tobacco powder (snuff), chew, pipes, hookahs and cigars.
James I of England wanted to ban tobacco, but his short-lived prohibition turned into taxing it heavily instead to fund a round of expensive wars, triggering a thriving trade in tobacco smuggling.
The soldiers of the Crimean War and American Civil War took to hand-rolling cigarettes to get a quick nicotine hit. Then came three crucial developments – the development of flue-cured tobacco (milder, sweeter, with a relatively high nicotine content); production of the first safety matches; and the invention of the mechanical cigarette-rolling machine, which could turn out 70,000 cigarettes a day.
Cigarette advertising proved effective propaganda as smoking became a symbol of success, emancipation, and even robust good health, with smoking doctors appearing in adverts. By the end of the Second World War, nearly half of Americans aged 18 and over were smoking at least a pack a day.
During the 1950s evidence of the link between smoking and (previously very rare) lung cancer began to emerge, and by the mid-1960s there was strong enough evidence to show that smoking caused cancer.
(Features, August 2023): DDN visited the Global Forum on Nicotine in Warsaw to hear about the challenges of mainstreaming tobacco harm reduction.
(News, August 2023): 40 per cent of smokers in the UK think that vaping is ‘as or more risky’ compared to smoking up from 27% last year.
(News, June 2021): Health professionals can recommend e-cigarettes as tools to help stop smoking, according to new draft guidance from NICE and PHE.
Read more articles on tobacco harm reduction, vaping and smoking cessation in the DDN archive.