Africa: Tobacco Harm Reduction: Are Policies and Regulations on Tobacco Working Against the Final Consumer?

A tobacco pack open with cigarette.
7 October 2020

On September 24th and 25th the third Scientific Summit on tobacco harm reduction was held, also referred to as the "No Smoke Summit". This scientific meeting on tobacco harm reduction is usually organized in Greece but due to the COVID-19 pandemic it was held virtually. 50 speakers were invited and 10 sessions organized.

One of the sessions entitled - "Public health policy & regulation and what is expected in the future?" - allowed the participation of prominent experts in smoking control strategies who shared their insights on this topic. Chaired by Professor Panos Vardas - Head of the Cardiology Department at Heraklion University Hospital in Greece - the scientists discussed recent data and regulatory, medical and scientific information related to tobacco harm reduction.

Professor Karl Fagerstrom is a Swedish clinical psychologist and a founding member of the Society for Research on Nicotine and Tobacco in Sweden, and currently a deputy editor of Nicotine & Tobacco Research. He is also the former Director of Scientific Information for Nicotine Replacement Products in Sweden. He laid out the situation with regards to harm reduction in Nordic countries, Japan and in the United Kingdom.

He pointed out that in Norway and Sweden, tobacco use has drastically declined. Both countries sell a moist powder smokeless tobacco product from Sweden named Snus considered as an alternative to cigarette smoking: "In Norway, smoking traditional cigarettes started to decrease dramatically while the using of snus started to increase. Is it a causal effect? We don't know but they do coincide very well. Also, the Swedish men are using as much nicotine as other men in most of other countries in the European Union. If it was the nicotine that causes cardiovascular disease why would Sweden be the lowest of all countries?"  In fact, he presented a report from World Health Organization (WHO) published in 2004 showing that the death rates attributable to tobacco were much lower in Sweden than in European countries.

He also reminded that the same organization stated in 2012 that "among the smokeless tobacco products on the market, products with low levels of nitrosamines (toxic substance), such as Swedish snus, are considerably less hazardous than cigarettes". He then added that "Snus was been accepted as the first reduced harm product by the FDA. Smokers, now more than ever, have the opportunity to choose the best product according to their needs when they want to stop smoking."

Professor Fagerstrom went on with his presentation pointing out that, in Japan, the increase in sales of heated tobacco products coincided with an unprecedented fall in traditional cigarettes sales between 2015 and 2019. The same phenomenon seemed to have occurred in the United Kingdom: "UK cigarette smoking prevalence reached a historic low of 15, 1% in 2017, with an accelerated annual rate of decline from about 2009. The advent of e-cigarettes has been associated with faster decline of cigarette smoking in the UK."

Nevertheless, despite science-based evidence, international tobacco control strategies such as those of the WHO Framework Convention on Tobacco Control, do not adopt the concept of harm reduction in developing coordinated regulations and policies. Dr Toumbis is a pulmonologist in the General hospital of chest diseases in Athens, Greece and President of the Cyprus Institute of Respiratory Diseases.

He presented the recent tobacco control data and progress. Although WHO's framework provides a comprehensive strategy to combat the tobacco epidemic and sets out a wide range of evidence-based measures to reduce tobacco demand and supply, it does not adopt harm reduction strategy except the Nicotine Replacement Therapy such as nicotine pouches and gums.

Thus, Dr. Toumbis deplored that policies and regulations weren't aligned on the basis of proportionate harm of the nicotine products: "Harm reduction is an evidence-based approach to tobacco control, which, along with other proven tobacco control interventions, can simultaneously prevent youth from starting to smoke and help current smokers stop, saving many lives more quickly than would otherwise be possible".

Africa is not out of the question. It is actually quite the opposite since around 1.1 billion people smoke, with 80% living in low and middle-income countries where the health policies and infrastructure are fragile and authorities rather conservative when it comes to tobacco innovative alternatives. In Africa, 44 countries have ratified or acceded to the WHO

Framework Convention on Tobacco Control

According to the WHO, countries in the African Region are experiencing an increasing rate of tobacco use. The fast growth of the population in Sub-Saharan Africa and an increase in consumer purchasing power is leading to larger and more accessible markets in Africa. Moreover, there are intensive efforts by the tobacco industry to expand African markets. However, prevention is, for the UN organization, the most cost-effective measure, not the use of tobacco harm reduction products.

Should nicotine be accepted as a cultural drug?

All experts advocated for a more realistic, pragmatic and consumer oriented approach that takes into consideration every person's will and capacity, but is still based on science. For them, the current rate of progress in tobacco control is not fast enough and it is crucial to find additional means to accelerate the decline of smoking.

Clive Bates, an expert in Public health, former Director of Action on Smoking and Health in the United Kingdom said that the misconceptions and conflations around smoking, electronic cigarettes and heated tobacco products are partly responsible for the slow decline of cigarette use. For him, the battle for public health is certainly a communication battle:

"National Cancer Institute in the UK published a survey that showed that only 12.5% of participants believed that some smokeless tobacco products, such as chewing tobacco and snuff, are less harmful than tobacco smoking and only 3.6% believed that electronic cigarettes are much less harmful compared to smoking cigarettes. Additionally, 56.5% of participants strongly agreed that the nicotine in cigarettes is the substance that causes most of the cancer caused by smoking."

Yet, a countless number of studies have shown that it is the combustion of tobacco that causes diseases, and not nicotine: He cited IQOS - the marketed name of tobacco manufacturer Philip Morris International (PMI) heated tobacco product. IQOS has recently been authorized by the Food and Drug Administration of the United States to be marketed as a modified risk tobacco product. Yet, it took many years and numerous corporate and independent studies for the company to finally get this authorization:

"Unfortunately, in the name of uncertainty, we are over-regulating these products. These products have an acceptable risk, not zero risk, they are not risk-free, but we know for sure that they cause less harm compared to combustible cigarettes."

He then insisted: "We don't encourage smoking culture… But whether we like it or not, we are a drug using society. One of the concerns about tobacco harm reduction and these reduced risk products is that they would have re-normalised smoking and that hasn't happened. It has done more to de-normalise it because they have created a clear visible consumer alternative to smoking.  What they are doing is normalizing stopping smoking by switching to vaping, snus, or heated tobacco products.

So the role modeling effect that they have is beneficial. When people see friends, relatives people in the streets using these products that should be what help the diffusion of the technology into the smoking population.  It starts to be considered as a normal thing. It's anti-smoking technology.  The more people feel that the more quickly they will move away from smoking".

Dr Fagerstrom finally stated that the final battle for harm reduction is not so much on how safe harm reduction products are but if nicotine can be eradicated or will be accepted as a cultural drug?   The best way for a smoker who wants to stop smoking is to not use any nicotine and any tobacco at all.  But many find that too difficult and want to have a more step wise journey out of the traditional cigarette. "The easiest way, I think, would be using heat not burn products as a stepping stone," Dr Fagerstrom added.

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