The term "ethics" is derived from the Greek word ethos, and coincidentally, the 5th Scientific Summit on Tobacco Harm Reduction: Novel products, Research & Policy, was held in the city of Athens in Greece. Over the past few years, a number of alternative Tobacco products have been developed with the aim of reducing the harm that is associated with smoking tobacco. Every year, Tobacco claims more than 7 million lives.

Tobacco use is a major risk factor for the four main non-communicable diseases: cancer, cardiovascular disease, chronic lung disease, and diabetes. In 2019 alone, tobacco use caused more than 8.67 million deaths worldwide (6.53 million in adult males, 2.14 million in adult females). Most of these deaths (7.37 million) were attributable to smoking, followed by second-hand smoke (1.30 million).

While the goal is to create a smoke free environment, it is imperative to note that at any given time, there will always be smokers due to the addictive nature on nicotine. Nicotine is highly addictive. It creates physical as well as psychological dependence, and that's why it's so hard to quit. Very few people are able to quit on the first try.

Thus, the Ethical principles in harm reduction recognise that substance use will occur regardless of healthcare provider's wishes. Healthcare providers have an ethical obligation to respect the decisions made by the person, even if these decisions may cause harm. According to the American Cancer Society, most people relapse many times before they quit smoking. That is why making people quit smoking in the absence of an alternative that is less harmful and smoke free could be detrimental.

Speaking during a panel on an Ethics and Harm Reduction perspective in Tobacco at the just ended 5th Scientific Summit on Tobacco Harm Reduction, Professor of Law at the University of Otawa, David Sweanor said if the world is to have an ethical framework on control of nicotine products, there is need to have something that identifies the health goals that are consistent with prevailing health challenges.

"You need to evaluate the effectiveness of the programmes that you are enacting. You need to identify the burdens on these programmes, what is it imposing on people. You need to try to minimise those burdens to the extent that you can. You want to have a fair distribution of the burdens like not inconvenience or disadvantage a select group of the population unnecessarily and you want to make sure that those burdens end up being fairly balanced.

If we look at this in terms of what happened in the area of nicotine and Tobacco, I think we have a clear failure on issues of ethics and if we look at that sort of framework, what's the goal? What are we trying to accomplish when we are dealing with issues of Tobacco and nicotine from a public health standpoint?

"It's not clear because some people are saying the goal should be a public health imperative, you are wanting to reduce harm to the best that you can within an ethical framework. Clearly, you can't reduce harm by threatening to shoot everyone who doesn't do what you say. That's not ethical. You have to say we have got cigarettes that are causing 8 million deaths every year, our goal is to reduce that as rapidly as we can in ways that are consistent with human rights and human respect," said Professor Sweanor.

He added that there was constant tension between those who are on a scientific pragmatic public health agenda and those who are on a moralistic one.

"This is common in public health. We see this on many issues, whether we are talking about the war on drugs, sex education, alcohol policy or nicotine. Is it a moral quest where we are fighting sin or is it a public health quest where we are trying to improve health? We have to agree on that goal. And then we look at the effectiveness.  We have to be able to evaluate our strategies to constantly check if they are working to maximum effect. What we are trying to do is do good in a better way."

While public health talks of empowering people to help them make better decisions about their own health, tobacco and nicotine control measures seem to have left both socio-economic and psychosocial burdens on the smokers through enforcing punitive taxes and exorbitant prices on cigarettes. He added that tobacco control uses a lot of cohesion rather than offering empowerment alternative pathways to better health outcomes.

Professor Panos Vardas, a Cardiologist, said tobacco cessation without alternative nicotine solutions was catastrophic.

"For us cardiologists, the holy grail is the complete smoking cessation. No doubt, smoking is totally and absolutely catastrophic. Cancer, Heart Attacks, sudden death are some of the health challenges that come as a result of smoking. However, the question is if smoking has been avoided, what about the alternative ways of the Modern developments. In my view, if we want to be ethical, we have to be based on real scientific data.  If these alternative ways of nicotine use are working, if the human beings like these alternative ways and if the clinical data is indicative of the less risky effects to human beings, then why not," said Professor Vardas.

Meanwhile, Konstantinos Farsalinos, a cardiologist and research fellow at the Onassis Cardiac Surgery Center in Athens says there is need to be realist and pragmatic about tobacco control and harm reduction.

"The use of seatbelts when driving and the wearing of helmets when riding a motorcycle is a typical example of harm reduction in our daily lives because neither the seat belt nor helmet eliminates the risk of being injured or dying in a car crash. They reduce the risk, and no one is telling you that you shouldn't drive your car unless you are doing something very urgent. We all take our cars and go for weekends with our families. We are all exposed to that risk. We take measures to reduce the risk (harm reduction) but we don't necessarily avoid the risk," said Farsalinos.

A study conducted by researchers working for the American Cancer Society analysed the changes in cigarette sales in Japan over the same period as heated-tobacco products (HTP) were launched. The results showed a significant decline in cigarette sales, beginning at the time of the introduction of PMI's IQOS HTP. During the same period, combined sales of all tobacco products continued to decline. There are also clinical studies currently underway in Japan to ascertain if switching to heated-tobacco products has had any effect on the number of hospitalisations for tobacco related ailments.