Forty-seven years on since Professor Michael Russell’s famous quotation, people are still dying from tar despite smoking for nicotine, the World Health Organisation (WHO) estimates the annual death toll from smoking combustible cigarettes to be over 8 million, with the latest WHO data as of August 2023 showing that more than 7 million of those deaths result from direct tobacco use.
Public health interventions have resulted in a number of regulations being imposed to control tobacco smoking and force smokers to quit totally. Quitting smoking or smoking cessation is by far the most effective Tobacco Harm Reduction (THR) intervention, and those who succeed in quitting before age 40 can return almost all those years by reducing chances of tobacco-related death by 90 percent. Public health data shows that smoking causes more than a decade of life loss.
Quitting data on the other hand shows that approximately 70 percent of smokers want to quit, but quitting smoking is incredibly challenging because nicotine is addictive. Data from the Centre for Disease Control (CDC) shows that as few as one in ten adult cigarette smokers succeed in quitting each year. Despite being the addictive substance in tobacco, science has proven that nicotine is not the cause of the high mortality and morbidity associated with tobacco smoking. Combustion is the culprit.
Countries that have adopted alternative novel nicotine products are already enjoying the fruits of their interventions as evidenced by the reduction in tobacco-related morbidities and deaths. Sweden for example now has one the lowest cancer death rates in the world and it will very soon be declared Smoke Free in accordance with the WHO criteria. Sweden has 44 percent fewer tobacco-related deaths, 41 percent lower lung cancer rates, and 38 percent fewer cancer deaths.
Despite overwhelming data on the success of novel nicotine products in reducing the health burden tobacco poses to the healthcare sector, governments across the world continue to regulate and penalise nicotine products in the same manner they would punish combustible tobacco products.
Dr. Kgosi Letlape, president of the Africa Harm Reduction Alliance, told journalists at the 3rd Edition of the Tobacco Harm Reduction Exchange in Nairobi, Kenya that the World Health Organisation was using morals instead of science to regulate nicotine products.
“Any product that threatens combustible cigarettes faces opposition from governments, illicit traders, public health specialists, moralists, religious people and those that get taxes from combustible cigarettes. The key issue however is this, science and toxicological analysis have proven that the problem with cigarettes is with combustion. If you get your nicotine in a non-combustible manner, you are not eliminating harm but you’re greatly reducing it,” said Dr. Letlape.
He added that the problem with tobacco harm reduction comes from the World Health Organisation.
“When you look at the statement that they put out about prevention of Non-Communicable Diseases (NCDs), one of the things they talk about there is responsible alcohol use. But when it comes to tobacco use, they want to abolish tobacco use. There is no alternative or responsible nicotine use and that is the problem that the position around tobacco is different from the WHO. All they know in terms of interventions is either quit or die.”
The WHO also has a Framework Convention for Tobacco Control (FCTC) which was developed to combat the challenges presented by combustible cigarettes as well as to reduce consumption of tobacco.
“When you give people knowledge, they will make informed decisions. They don’t need to be driven by legislation. They are just driven by correct information. The latest figures we have is that the third leading cause of death in the United States today is Misinformation. That’s the same challenge that we have around Tobacco Harm Reduction. Part of the challenge that we have is that public health specialists are not people-facing. They don’t see patients; they don’t see people. What need not happen is to misinform the smokers and the people. What we cannot do is lie about the relative harm posed by nicotine products.”
Across the world, harm reduction strategies have been deployed in public health as a pragmatic and compassionate approach to address various issues, particularly in the context of substance use and other risky behaviours. Some of these strategies include Needle Exchange Programs, supervised injection sites, condom distribution, PrEP (Pre-Exposure Prophylaxis), Nicotine Replacement Therapy (NRT), vaping and e-cigarettes, and supervised consumption of medications.
According to data, around 80 percent of the world's 1.3 billion tobacco users live in low- and middle-income countries. While progress has been made, alcohol, tobacco and drug use remain major public health challenges in Africa requiring harm reduction approaches.
Dr. Mercy Korir, a medical journalist in Kenya said nicotine regulation and tobacco harm reduction should not be regulated by morality but by science.
“When it comes to harm reduction, we start talking about morality and religiosity. This becomes a totally different issue from the whole conversation of harm reduction. We need practical interventions when it comes to tobacco and other alternatives that are safer. When we talk of heroin and other drugs, you know that there are other alternatives. We have the practical interventions. Let’s use them. We also have to be pragmatic; we have to be realistic,” said Dr. Korir.
She added that banning and restrictions to vaping and other alternative nicotine products will not address the tobacco-related health crises.
“We need to be very realistic to have interventions and a way forward that reflects our current reality. We now just need to act on what will translate to safer ways of using nicotine or any other drugs for that matter.”
Meanwhile, Dr Vivian Manyeki a medical doctor, said while the progress around Tobacco Harm Reduction in Africa is slow, some countries have made important strides and progress in implementing evidence-based harm reduction services, though broader challenges persist.
“New products like e-cigarettes, heated tobacco, and oral nicotine pouches provide nicotine with significantly less risk than cigarettes have been developed. Public health organisations have launched campaigns to educate smokers about less harmful alternatives to quitting. Governments have implemented science-based regulations for reduced-harm products that protect public health. Numerous studies by independent researchers have demonstrated the reduced risk potential of non-combustible nicotine products,” said Dr Manyeki.
She however added that while harm reduction services in Africa have expanded, major gaps remain in implementation and coverage. Stigma and policy barriers must be addressed to improve access to life-saving interventions.
