DDN visited the Global Forum on Nicotine in Warsaw to hear about the challenges of mainstreaming tobacco harm reduction. Earlier this year we looked at tobacco harm reduction and observed that smoking still causes 8m deaths a year. Why had there been so many false starts on finding safer ways to use nicotine? Despite brilliant innovations and the launch of safer products – thanks to consumer-driven breakthroughs in tobacco harm reduction (THR) – we learned about inertia in public health, varying resistance through global politics, conflicts within the tobacco industry, and confusion surrounding tobacco control organisations, who resisted the notion that safer nicotine products could be used recreationally (DDN, February 2023). Event co-founder Paddy Costall So when DDN was invited to the tenth Global Forum on Nicotine (GFN), it seemed like an interesting opportunity to see key players in active debate. As the event’s co-founder Paddy Costall said, ‘Ours is the only conference in the smoking, tobacco and nicotine arena that welcomes all the players involved in tobacco harm reduction – consumers, regulators, parliamentarians, manufacturers and scientists – with no bans on who can attend or who can speak.’ A Sense of Optimism 'The event was born from a sense of optimism', said co-founder Prof Gerry Stimson The event was born from a sense of optimism, said co-founder Prof Gerry Stimson. ‘We thought we were on the cusp of a breakthrough, and that with safer nicotine products, millions of premature deaths from smoking could be avoided. If played right, we felt sure that harm reduction for tobacco could be a huge individual and public health success.’ The last ten years had been a challenge, with regulators, parliamentarians and legislators changing the pace of progress. But he still remained confident that ‘it’s not a matter of whether tobacco harm reduction will happen, but when’. Fifty ‘thought leaders’ from the field were invited to speak. They looked at the milestones of the last ten years, assessed a complex political, regulatory and scientific environment, and debated the challenges of the future. The flavour of the event was energetic and respectful, and characterised by a willingness to listen. Despite the great divide between countries that were being constrained by poor policy and regulatory obstacles and those buoyed by a wave of progress and consumer interest, there was a sense that sharing the science could translate into helpful take-home messages. There were bound to be more questions than answers. A session called ‘The Big THR Conversation’, chaired by UK public health expert Clive Bates, asked: How can the last decade influence and inform the next?’ What are the dynamics? What causes success or failure? Why does the World Health Organization (WHO) do what it does? Why is the science a mess? Why is there such indifference to that? What role should the industry play? How do we see the world of nicotine in 15-20 years? Entrenched Positions As delegates from different countries gave their thoughts, we heard about narratives changing – or positions becoming more entrenched. In some countries there were very active communities of users, linked by social media; in others, vaping was still new to politicians accompanied by ‘a lag in public health awareness and understanding’. Snus - a smokeless tobacco pouch, placed under the top lip Comments from a Swedish delegate illustrated this. He had been in the Court of Justice when consumers challenged a ban on snus and said, ‘What happened in court made me decide the ban on snus was 100 per cent political. A hundred pages of scientific evidence were ignored.’ There was discussion about the reasons for banning THR products. Bans made good headlines (delegate from the US); bans make politicians look like they have potency (Clive Bates, session chair); prohibition and a ban is a much easier sell to the public (Fiona Patten, former politician from Australia). There were different routes to prohibition, from changing the law to making the products as unappealing as possible. The Tobacco Industry The involvement of the tobacco industry in THR, primarily vaping, had been a double-edged sword. Alongside their innovations, they ‘brought their reputational baggage into the room’, which hardened attitudes towards vaping products. The Foundation for a Smoke Free World, set up to ‘end smoking within a generation’, belonged to Phillip Morris and was launched at a tobacco industry event. No wonder there was cynicism. But in this forum, the industry was a welcome contributor to the debate – a partner in driving up product standards and keeping illicit (and possibly dangerous) products outside of the marketplace. New products to emerge included nicotine vapes, Swedish-style snus, and nicotine pouches – none of which burned tobacco, and all of which had been shown to be significantly safer than combustible cigarettes. An estimated 112m people used these products worldwide. Success Stories In some countries, ‘amazing progress’ had translated into public health success stories; for instance in New Zealand Maori smoking had plummeted after introducing vaping. The Philippines had ‘got over the line’ with vaping because of consumer advocacy, and a turning of the tide meant it would soon be legal to vape in Malaysia and Thailand. For others, progress was being frustrated. Last year Mexico banned vapes on World No Tobacco Day – a decision that was ‘science-free and a political gesture’, according to Bates – while in South Africa a new tax on vaping was likely to push people back to cheaper tobacco and Australia was also cracking down on vaping. In England there were positive signs of free vaping kits being distributed – but also a media-driven narrative about young people becoming addicted. The WHO continued to oppose safer nicotine products for smoking cessation and to publicly deride tobacco harm reduction. All eyes were on the WHO Framework Convention on Tobacco Control Tenth Conference of the Parties (COP10) in Panama this November, which GFN feared could have ‘grave implications for global public health’. We needed to be mindful that ‘science has become subordinate to the political argument,’ said Bates. But the endgame was that the THR debate was very useful – it could solve COPD, cardiovascular disease and cancer while involving a stimulant that people enjoyed using. For many, the debate served to re-energise efforts to take THR to the next level. ‘We need to keep kicking those doors,’ commented a delegate. ‘It’s easy to be negative, but we’ve done incredible work.’ ‘Nicotine doesn’t cause cancer and when we make people realise this then we can discuss lower levels of harm of the products,’ said another. ‘There is not one single golden bullet.’ DDN Headline Ruse Don't believe everything badged as research, said Roberto Sussman. 'I understood indoor smoking bans’ - that people needed to be protected from my smoke. But not outside bans. Bullshit alert!' Dr Roberto A Sussman waved his arms around theatrically and the audience responded to his lively presentation. A full-time senior researcher and lecturer at the Institute of Nuclear Sciences at the National University of Mexico, Sussman had nipped across from the world of cosmology to write peer-reviewed research on e-cigarette aerosols. There's a nasty short circuit in tobacco science that would never have happened in physics,' he said. 'Outdoor smoking bans are social engineering, and their goal is not health driven. It's about eradication of conduct.' The question was - could this be justified for vaping? Are we going to allow denormalising of vaping as was done on smoking?' Tobacco harm reduction was seen as a Trojan Horse of the tobacco industry, he said, a way of bringing in young people, young addicts.' There was a toxic academic environment in which technically sloppy papers were published to support policy. 'Research ignores that most usage is experimental,' he said. 'Frequent vapers tend to be those who have tried tobacco and/ or smoking. The vaping youth epidemic is a political construct. Dr. Roberto A Sussman is a lecturer at the Institute of Nuclear Sciences, National Autonomous University of Mexico. He is also the director of the non-profit association Pro Vapeo Mexico. Related articles (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. (Features, February 2023): The genie’s out of the bottle – embracing tobacco harm reduction could end smoking within a generation, says Knowledge Action Change. Read more articles on tobacco harm reduction, vaping and smoking cessation in the DDN archive.