Monday, December 4, 2023

Research, tech advancements in tobacco and nicotine products provide harm reduction options to smokers, but who’s listening?

Major research effort delivers pragmatic real-life solutions for those willing to discuss the scientific evidence


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While an intense ideological battle continues globally led by well-funded anti-smoking NGOs, some national governments, as well as the World Health Organization (WHO), a steadily increasing amount of research, is proceeding on new harm reduction technologies for smokers. Ultimately, they have the potential to save many lives – and support public health more effectively- than coercive measures aimed at direct prohibition of smoking, which clearly remains a utopian objective. At the beginning of September, a Spanish NGO launched a petition to ban nicotine consumption in Europe for all those born after a certain year. Considering how Prohibition in the US went, we can imagine how damaging a Nicotine ban in the EU would be.

The WHO itself is projecting more than one billion smokers globally in 2025, approximately the same number as now. According to OECD data, smoking-related diseases are still one of the leading causes of death, as was the case 20 years ago. Clearly, it seems that tobacco control measures, which focused solely on prevention and cessation, have not reached their objectives.

Some encouraging signals came from the European Parliament that, during February’s plenary session, adopted the report of its Committee on Beating Cancer, including references to tobacco harm reduction. This was actually the first instance that an EU institution has accepted its relevance in an important policy-forming document.

Despite this, the Commission, which has successfully applied risk reduction-oriented regulation in alcohol, sugar, salt, including fuel, and cars, is adamant in not doing so for tobacco.

Regulation and consumer demand

Even assuming that global cigarette consumption will continue its gradual decline in some places, consumer demand for tobacco and nicotine-based products seems to be here to stay – making the battle lines between industry and EU and WHO tougher to hold on the regulators’ side.

In researching this article NE Global came across a 2016 WHO Report on Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS) produced for a global meeting promoted by the WHO every 2 years to debate and provide guidance on what’s next for Tobacco Control. This Report includes a statement on novel products, which is unquestionably simple and clear: “If the great majority of tobacco smokers who are unable or unwilling to quit would switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement. This would only be the case if the recruitment of minors and non-smokers into the nicotine-dependent population is no higher than it is for smoking, and eventually decreases to zero.” The sentences that follow this one, explain how Public Health communities were divided back then between prohibitionists and risk reduction champions.

Between 2016 and 2022, while the WHO has not commissioned any scientific research, or a review of all published science on the relative harms and benefits of new nicotine products, it has encouraged and supported a policy of countries banning non-combustibles. For example, India’s Minister for Health received a WHO award for his role in banning e-cigarettes in India. So, what are millions of Indian smokers who have failed to quit going to do after being denied access to products that pose a fraction of the risk of smoking? Continue smoking?

It appears that the Public Health debate the WHO alluded to, focusing on new products’ role in steering smokers away from cigarettes has not been won either by prohibitionists, though they appear to have a lead, nor by the risk reduction advocates.     

NE Global was invited to tour the research facilities in Neuchatel Switzerland operated by Phillip Morris International (PMI), also known as “The Cube.” This is where the bulk of PMI’s research into new reduced-risk products is conducted. The research follows standard pharma practices and focuses only on the development and assessment of alternative smoke-free products.

What is harm reduction?

“Harm reduction,” is a broad strategy that seeks to reduce the potential harm caused by a dangerous activity, for example car racing or the consumption of unhealthy foods, rather than banning the activity itself. In Tobacco, harm reduction strategies include the development of less harmful and science-based products. And these scientific advancements need to be supported by government strategies – such as differentiated taxation policies and updated regulations regarding sale and use of these products – in order to have a positive impact on consumers and society. This is very far from what is proposed in many current anti-smoking campaigns and policies. In fact, a small number of countries seem still blind to the public health potential of these products and the progress they represent. In some cases, they are even banned while the smoking rates remain stable or increase.

Following a careful scientific approach

The scientific approach to harm reduction followed by PMI is based on acknowledged research conclusions that the use of products that do not involve combustion is less harmful than cigarettes. Nowadays, a wide body of research supports the conclusions that the main cause of harm come from the chemicals generated by smoke when a cigarette is burnt. For example, the UK’s Royal College of Physicians stated, “harm reduction works by providing smokers with nicotine without the tobacco smoke that is responsible for almost all of the harm caused by smoking.”

PMI’s efforts in the smoke-free space steadily expanded in 2008 – when the company was spun off from its US owner (Altria) – and today counts approximately 930 R&D experts in various fields. Last year, the company became the 45th largest patent filer in the EU, and the only tobacco company in the EU’s top 100.

Scientific evidence’s impact on progress

In a brief discussion at The Cube with Tommaso di Giovanni, PMI’s Vice President for International Communications, NE Global was told how some stakeholders, such as international organisations, or regulators and NGOs, will require more time before they come around to the idea that people who continue to smoke are entitled to policies based on science. We should also take into account how a lot of men and women will carry on smoking despite the price, by buying cheaper illicit cigarettes.

Considering the billions that PMI has invested so far in transforming into a technological, scientific and health and wellness corporation, and how, on their corporate website they say they want to get rid of cigarettes, they must have expected a different reaction from international organizations, states, and society. PMI states that its transformation is a response to the calls from these organizations, which have spent years demanding PMI and others to come up with a safer product. These same organizations claim that a new generation of tobacco products will provide a lifeline to an ailing industry, as these products attract more consumers.

Risk reduction solutions are never accepted until they are, which is why Di Giovanni indicated that the resistance from some governments and NGOs had recently begun to decrease and that “there is movement in the right direction.”  The over 50 independent studies and government agency assessments that confirmed important elements of PMI’s research – such as the US FDA, the Dutch Health authority (RIVM), the German Risk Assessment institute (BFR) – certainly played a role in this direction.     

Inside “The Cube” in Switzerland.   PMI has invested in excess of 8 Billion Euros in Science and in R&D

Di Giovanni also noted “It is encouraging to see that a growing number of countries, including in the EU, adopted a regulation clearly differentiating nicotine and tobacco products based on their relative risks. Differentiated regulation can drive consumers to adopt better alternatives if they do not quit, and companies to invest in innovation. It is unfortunate that some countries prefer to focus on fears of potential unintended consequences of these products and neglect the clear scientific evidence showing that e-cigarettes and heated tobacco products are a much better choice than cigarettes. Smokers who don’t quit should not be left behind.”

Like all tobacco giants, Phillip Morris included, they are supposed to have advocated a few decades ago that smoking was not addictive or harmful. It is understandable why tobacco companies have spent the last few decades atoning for what they did, and that explains the way tobacco products are regulated, and perceived by the public. It was and still is not an easy task to have public and transparent conversations with scientists and other organizations leading tobacco policy debates. Di Giovanni prefers to focus on the present and future stressing how PMI is prepared to speak with everyone, stating it is time that opponents to pragmatic solutions start to see and understand the growing evidence that is out there.”

As scientific evidence accumulates, safer products will dominate

In a discussion with University of Ottawa Adjunct Law Professor David Sweanor, NE Global was told that as the scientific evidence is generated and released, public health priorities will unquestionably change. But there is a long way to go.

Sweanor explained “it is beyond question that there are nicotine products that are massively less hazardous than cigarettes. There remains a need for evidence to show that people who would otherwise smoke cigarettes will move to these alternatives in sufficient numbers to make it a public health priority. To date, this data is held back by what appears to be a classic “bootleggers and Baptists” problem in that cigarette companies have the best insights on substitution effects but refuse to cooperate on releasing such data, and much of the anti-tobacco movement is too wedded to an abstinence-only ideology on nicotine use to be willing to fund independent work.”

Sweanor noted that changes in nicotine product usage is happening already. “But we are seeing substitution effects in any event. Countries like Japan (heated tobacco) and Norway (snus) are great examples. As more data becomes available, and especially if a major tobacco company truly pivoted to a position of seeking to speed the global transformation away from cigarettes as rapidly as possible, the evidence will be impossible to ignore. Abstinence-only campaigns will then take the same path to embarrassed oblivion as has happened to so many similar campaigns on other products and behaviors. “

Sweanor believes that we are only at the beginning of a major product substitution cycle away from cigarettes. He explained “to date product substitution effects that have dramatically reduced cigarette sales have been based on only a narrow range of alternative products being available, little public information on relative risks and no coordinated policy measures to encourage switching. Indeed, safer products have been strongly opposed by many health bodies. As data accumulates and countries compete to lower smoking rates, we can anticipate efforts to facilitate a wide range of low-risk alternatives with marketing and tax/price advantages over cigarettes and active efforts to empower people to make informed decisions. The decline in cigarette smoking could be truly dramatic, on par with past public health revolutions such as the move to sanitary food and water.”

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Co-founder and Executive Director for Global Economics and Southeast Europe at NE Global Media.  Former US diplomat with previous assignments in Eastern Europe, the UN, SE Asia, Greece, across the Balkans, as well as Washington DC.


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