Thursday 19th June 2025
Opening and Keynote #1
What’s so scary about tobacco harm reduction?
Paddy Costall, director, Global Forum on Nicotine Ltd, said, ‘We chose “Challenging perceptions – effective communication for tobacco harm reduction” as the theme for this year’s event because, whilst the potential of tobacco harm reduction to play a major role in combating non-communicable diseases (NCDs) is becoming more apparent, with science clearly demonstrating this, we face continued challenges from often well-resourced organisations and individuals who remain implacably opposed to it.’
‘Communication is a key issue, and the importance of honesty and accuracy cannot be overstated. Ill-informed and often misleading representations can be seriously damaging to individuals and communities at large.’
‘A balanced and informative approach, rather than a polemic, enables people to make better decisions and thus improve their health. Critical, inquisitive and responsible journalism can play a major role in public understanding and can really help create the conditions where individuals’ decisions are more informed. However, misrepresentation – whether accidental or deliberate – does not serve individual or public health.’
Mark Tyndall, a professor of medicine at the School of Population and Public Health, University of British Columbia, said, ‘I got into harm reduction, not because I took a doctoral degree in harm reduction, but because it became a big part of my work in HIV prevention. I quickly learned that with behaviours and exposures that had inherent risk, the only approach would be to offer interventions that reduce risk, because we couldn’t eliminate the risk.’
‘Most importantly, these interventions are enthusiastically supported by people who will benefit from them. This is not a nanny state type thing that we’re trying to foist on people. This is what people want and what people need. People knowing that they could get HIV are quite happy to use a condom. People injecting drugs are quite happy to use a clean needle. And people using nicotine are generally quite happy to find alternative sources.’
‘I’ve talked about harm reduction interventions as though acceptance should be a slam dunk, but it’s not. It’s not because they don’t work. It’s because of ideology.’
‘The history of harm reduction is controversial mainly because of the people it’s designed to help. Generally, people choosing risky or socially unacceptable behaviours are frowned upon in society. We discriminate against people who are the most vulnerable and most in need of our help. Imagine a scenario where 15% of the richest Canadians, Americans and Europeans were smokers, and they knew it cut 10 years off their lives and resulted in a number of chronic illnesses. Along comes something like vaping that could reverse that. Do we really think we’d be holding this conference? I don’t think so. They would demand that they got a safer product. There’s a lot of discrimination and stigma that’s attached to our responses.’
‘We’ve developed a whole medical system in some countries around smoking, […] around treating these chronic illnesses due to smoking, and nobody’s in a big hurry to change it. Tobacco control organisations aren’t in a big hurry to change things, either. They’ve had decades of working on abstinence-based programmes. I think at the very beginning, when safer products became available, they were cautious. But now, instead of starting to discuss the possibilities of how these could help people and help people’s health, they just continue to double down. And now, 10 or 15 years into it, it’s really hard for these tobacco control organisations to take a big breath and say maybe we were wrong all along.’
‘Tobacco companies are also not pushing hard for change. There’s a lot of new products. The websites of PMI and BAT are very forward-looking, and [they] want to go smokeless, but they seem to be in no hurry. […] In Canada, and I think in many countries, tobacco companies aren’t allowed to say that vaping is safer. And so that’s a huge problem as far as getting the message out there. You would think these companies would have a whole team of lawyers trying to push back on things like that, but it really hasn’t happened. The slow transition these companies will support, but they are not aggressively trying to make this change quickly.’
‘We need to find ways to speed up the transition that I think will inevitably occur. But there are things we can do right now. One is that community activism is extremely important. We need to encourage people who have started to vape to advocate for themselves and have a voice. We can also use people who can speak truth to power. I think we need to do a better job and really get to policymakers – and we need to keep on top of all the false claims and narratives. Finally, we need to use the legal justice system better. With other harm reduction, taking cases to the courts has been very successful. Supervised injection sites, needle exchanges – all have gone to Canadian courts, and they’ve ruled in favour of access to these things. It’s pretty hard from a justice perspective to say that people who want a safer product can be denied.’
‘We should be doing everything we can to increase access, and increase the acceptance of these products, to make them as easy to get as possible so we can get as many people off cigarettes as we can. But that is not what’s happening. I really believe there’s some urgency to this. I think the policies that make vaping and safer nicotine products harder to get for people who smoke is equivalent to denying people HIV treatment.’
Carolyn Beaumont, an Australian GP specialising in rural medicine, and founder of SmokerHealth national telehealth clinic, said, ‘Although we won’t easily get media or politicians on side anytime soon, we must focus on educating health professionals about tobacco harm reduction. It’s simply about offering smokers more solutions, about acknowledging that many don’t want to give up nicotine and they’re sick of being lectured to and judged by doctors. I’m not telling doctors to ignore existing replacement therapies. I’m simply telling them there’s another extremely effective tool in the toolbox.’
‘All I can say about this is three things: innovate, regulate, educate – whatever helps a smoker quit has to be considered seriously and not just dismissed as yet another tobacco industry ploy to addict the next generation. Surely we can remain open to new nicotine technologies and at the same time ensure they remain regulated and as safe as possible?’
Panel Discussion #1
Reflections on the Framework Convention on Tobacco Control at 20
Jeannie Cameron, founder and managing director of JCIC International Consultancy, said, ‘When you consider treaty success, you must look at three key things: legal, political and objective effectiveness. The FCTC has achieved much in the first two obligations… For effectiveness, however, the objectives of the FCTC treaty were to reduce the exposure to tobacco smoke and the reduction of death and disease from smoking. And you could certainly say the FCTC has failed in terms of effectiveness.’
‘The Paris Charter Against Cancer has a much more humanitarian approach than the FCTC, although the FCTC does… reference human rights. For example, it draws on Article 12 of the International Covenant on Civil and Political Rights, which outlines that the highest attainment of health is a human right, and also from 1966, the International Covenant on Economic, Social and Cultural Rights. Both have a lot of human rights aspects that are very relevant here. Both of those treaties have what is called an optional protocol. In treaty law, an optional protocol gives individuals or groups affected by their national policy the right to take their case against their government. Most governments in the world are parties to those human rights treaties. A group of individuals who want to vape, and their government stops them from vaping, could take a case as individuals only to those human rights bodies… I did write an article in FILTER magazine last year on it, and no one has yet done that. I think it’s worthwhile to think about.’
‘How do you invoke Article 1d of harm reduction? You would do that in the very same way that all the other articles in the FCTC have been invoked at each COP. For example, Article Eight on environmental smoking bans. During the COP, one country put forward an intervention to say we would like to bring this up for further elaboration and discussion and scrutiny. Another country backed it. The COP is a consensus-making body. No one objected. So hopefully at COP11, one government backed by another one, and there being no objection, could actually bring it up for further discussion, elaboration, presentation of the science and evidence, to actually bring Article 1d out in a practical way.’
Derek Yach, a member of APCO’s International Advisory Board and former executive director for noncommunicable disease at the WHO, said, ‘Success can be looked at with two outcome measures. Do we have more smokers today than we did in the past? Yes – today we have 1.3 billion users of tobacco, a huge amount, and smoking rates exceed 50% in many countries in the world. More importantly, deaths… A billion people will die prematurely this century from tobacco-related disease. Staring us in the face is the obvious way to halt it in its tracks: tobacco harm reduction.’
‘Looking at the objective for the FCTC, if you read the text, it’s very clear that governments would see the FCTC as being successful if it reduced the death and disease caused by tobacco smoke. Each word had incredible meaning. First, it meant that success wasn’t going to be measured simply in smokers no longer becoming smokers. That wasn’t good enough. It had to go all the way through to preventing cancer, cardiovascular disease and respiratory disease. Cancer, of course, was the central one, and we’ve forgotten that. Instead, the debate has moved towards everything to do with kids, forgetting that the real purpose of the FCTC is to show benefits to adults in terms of very specific health outcomes.’
Tikki Pangestu, visiting professor, Yong Loo Lin School of Medicine, National University of Singapore, said, ‘The WHO has a very strong anti-THR position. The main issue is that WHO has huge influence on policies in low and middle income countries (LMIC)… Policymakers there don’t look at research from the US or Japan, they need local research, and that is sorely missing in many of the LMICs. There’s also apathy within governments. If WHO says THR or vaping is as harmful as combustible cigarettes, they will just follow WHO guidance.’
David Khayat, professor of medicine, medical oncologist at the Clinic Bizet in Paris, said, ‘We had 1 billion smokers [in 2005]. We still have 1 billion smokers. In my country, 28 or 30% of adults are smokers. France is a very rich, developed country that put a huge amount of tax [on cigarettes]. And did it work? Not at all. Official data shows that the poorest people either buy illicit cigarettes, about 45% of the cigarettes sold in France, or more important, they spend less money on food, so they have a poorer and poorer diet, to be able to continue what is not just a pleasure, but an addiction. You cannot just say to a drug addict “stop injecting drugs”. It will continue.’
Asa Saligupta, founder and director of consumer advocacy group ENDS Cigarette Smoke Thailand (ECST), said, ‘What Bloomberg is trying to do – or at least the intention – is to reduce smoking rates. But we all know that it’s not working. And what they are also trying to do is to limit access to what we know are safer alternatives, things like vaping or snus or pouches. A lot of countries have bans on less harmful products, like in [Thailand], where it’s illegal to import vapes and it’s illegal to distribute them. But it’s not illegal to possess, it’s not illegal to vape, per se.’
Panel Discussion #2
Nicotine pouches – what’s the real story?
Anna Franzén, clinical & regulatory business development officer, Emplicure, said, ‘I wanted to highlight Sweden, where daily smoking rates have dropped below 5%. This is one of the lowest, if not the lowest, in the world, and according to the WHO meets the definition of a non-smoking country. This is a remarkable public health achievement, with the migration of smokers to Swedish snus being one of the key reasons for that.’
‘There are actually lots of long-term studies on nicotine. NRT [nicotine replacement therapy] was approved as a medicine for smoking cessation over 40 years ago, and it has been used safely for decades. So, when nicotine is separated from tobacco and combustion, the risk profile dramatically decreases.’
‘We have forgotten that 50 years ago Sweden used to have a high smoking prevalence… The Swedish government has only just started to talk about this, sharing the message that the migration of smokers away from cigarettes to Swedish snus (and later nicotine pouches) is a key reason that we have such low smoking levels. This is also the reason why Sweden has the lowest rate of lung cancer in Europe.’
‘So on this continuum of risk, I would say that nicotine pouches and NRT [nicotine replacement therapy] are exactly the same.’
Mark Oates, director of We Vape and the Snus Users Association, said, ‘The real point is that nicotine pouches can be produced very cheaply, at a rate competitive with cigarettes. This is vitally important especially when it comes to low and middle income countries, because vapes are expensive to produce and so can’t be sold to compete with cigarettes at 50 pence a pack.’
Cecilia Kindstrand-Isaksson, director at Swedish Match, then followed with this response, ‘We have published a paper* comparing smokeless tobacco, nicotine pouches, and NRT. In fact, our nicotine pouches contain slightly fewer toxicants than nicotine gum.’ *Back et al. (2023). BMC Chemistry doi: 10.1186/s13065-023-00918-1
Barnaby Page, editorial director of Tamarind Intelligence, said, ‘Looking at it logically, dependency is only a problem if you have large numbers of nicotine naive users coming in, or if you then have a gateway to combustibles. As far as we can see, we have neither. We [Tobacco Intelligence] did a survey of pouch users in the United States, and found about half switched to pouches straight from smoking. Only 5%, one in 20, were nicotine naive. The rest used a combination of smoking, vaping, other oral products and so on.’
Watch the day’s proceedings here: