The topic of tobacco and more specifically tobacco harm reduction is highly volatile and considering recent studies on this matter, it may not calm down soon.
There are those who affirm that cessation - thanks to Nicotine Replacement Therapy (NRT) (approved by the World Health Organization with products such as patches) - is the only way out for smokers. Others believe that NRT is not efficient and that intermediary and more effective alternatives exist to help smokers to quit. Among those alternatives are heated tobacco, electronic cigarettes and snus (a moist oral tobacco originated in Sweden and mainly used in Nordic countries). These are also called smoke-free products but, throughout the African continent, they are only available in South Africa.
Kgosi Letlape is South-African. He is a physician and current president of the Africa Medical Association and President of Association of Medical Councils of Africa. He was also President of the World Medical Association (WMA), the global representative body for physicians. At the Africa Harm Reduction Forum held in Nairobi in February 2022, he made a point about the Swedish case where the prevalence of smoking is the lowest in Europe:
"One of the biggest examples that we have of reduction of harm through non-combustion is what has happened in Sweden. Interestingly enough snus was banned in Europe on recommendation of the World Health Organization. However Sweden - being the major producer of snus and having it as an integral part of their lifestyle that has been there for 200 years - got an exemption. Now snus has displaced cigarette smoking in Sweden. They now have one of the lowest prevalence of smoking in Europe. But more importantly, they have the lowest incidence of smoking-related disease in Europe all because of snus."
Still in Europe, in 2015, a United Kingdom study published by Public Health England (an agency of the UK department of Health) said that electronic cigarettes (e-cigarettes) are 95% less harmful than traditional cigarettes. They refer to them as "reduced-risk products" and affirmed that they should be used as a tool to help smokers quit:
"The comprehensive review of the evidence finds that almost all of the 2.6 million adults using e-cigarettes in Great Britain are current or ex-smokers, most of whom are using the devices to help them quit smoking or to prevent them going back to cigarettes. It also provides reassurance that very few adults and young people who have never smoked are becoming regular e-cigarette users (less than 1% in each group)."
Japan has also seen a major drop in conventional cigarettes use in the last few years. A Study published in May 2020 by the International Journal of Environmental Research and Public Health registered a 34.2% drop between 2015 and 2019 at a time when the sales of heated tobacco have increased from 5.1 billion sticks to 37.1 billion sticks. So this decrease coincides with the introduction of non-combustible alternatives in 2014:
"Domestic cigarette sales in Japan appear to have declined at an accelerated pace since 2016 following the introduction of HTPs (Heated Tobacco Products) into the Japanese national marketplace".
Heated tobacco products heat the tobacco without burning it. They contain lower levels of harmful chemicals than cigarette smoke according to various studies. The combustion in conventional cigarette creates high levels of chemicals which lead to tobacco-related diseases, such as cancer since tar and monoxide are the most harmful elements in tobacco smoke. Many scientists, experts and consumers consider these non-combustible products as an aid to stop smoking even if they are not risk free:
"Knowledge is power. One of the major problems in Africa is lack of knowledge and the abundance of misinformation. The major problem in tobacco is the combustion of tobacco. There are vast amounts of scientific evidence that shows that it is the combustion that is the problem not the nicotine… So, when I say knowledge is power it is about re-educating the public. It's about creating space for truthful information to be available so people can make informed decisions.", added Dr Kgosi Letlape.
Organizations such as the WHO say that those alternatives to cigarettes are as harmful as cigarettes, especially for the young people. They say that teenagers who have tried those nicotine devices are more likely to move on to smoking cigarettes.
"Both tobacco products and ENDS (Electronic Nicotine Delivery Systems) pose risks to health. The safest approach is not to use either…Toxicity is not the only factor in considering risk to an individual or a population from exposure to ENDS emissions. These factors may include the potential for abusing or manipulating the product, use by children and adolescents who otherwise would not have used cigarettes, simultaneous use with other tobacco products (dual or poly use) and children and adolescents going on to use smoked products following experimentation with ENDS."
For Joseph Magero, who is the chairman of Campaign for Safer Alternatives, a pan African organization that advocates for the adoption of tobacco harm reduction policies in Africa, the WHO is doing more harm than good to consumers, especially African consumers. On a Nigerian newspaper in EnviroNews Nigeria on July 2021 titled: "WHO doing untold harm to Africa's desperate smokers", he said:
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"Despite growing evidence that e-cigarettes are the most effective stop-smoking method available and are nearly harmless, the WHO's latest report doubles down on its opposition. It is a betrayal of the WHO's duty to improve public health. Its latest attack on alternative nicotine products is unscientific, dogmatic and an effective death sentence for millions of smokers who are trying to quit cigarettes, particularly those in less affluent nations like ours".
Taking the example of Kenya, he made a point about the legislation in the continent being ludicrous:
"Already this year, 4,200 Kenyans have died as a result of cigarette smoking. Yet lawmakers in Kenya, and Africa as a whole, take their cue from the WHO in regulating and taxing e-cigarettes and nicotine pouches. Pouches, which would appear to be a pertinent solution for our continent, where there is a tradition of using oral stimulants, were even suspended from sale in Kenya. Instead of providing reliable and trustworthy information about these lifesaving products and making them readily available, authorities treat them as if they are just as dangerous as traditional combustible cigarettes."
There more than 1 billion smokers in the world according to the WHO and over 80% live in Low and Middle-Income countries. In Sub-Saharan Africa, smoker prevalence goes from 4% in Benin to 18% in Lesotho.
