Session 2: 2021 Seminars

In some countries, like Norway and Sweden, the level of smoking has reached a minimum – in particular among young adults below the age of 25 where the prevalence of smoking is approximately 2%. Availability to snus in combination with a robust infrastructure for tobacco control are the main reasons. In these markets snus has displaced cigarettes and ever-smokers has made up the majority among snus users. When smoking is about to be eradicated, the largest reservoir of potential snus users – the smokers - will decrease. As a consequence, the future prevalence of snus users will probably decline. However, the decimation of smokers will subsequently also change the user configuration of snus. Never smokers will eventually make up the majority, and – if large enough - tip the net effect on public health effect from positive to negative. In such a situation, the harm reduction function of snus - and e-cigarettes – will be reduced. Still, availability to these products may deter tobacco prone youth in future generations from taking up cigarettes – provided that hunger for nicotine will exist in future generations. I will present the recent trends on tobacco use in Norway and discuss how the new situation will challenge the narrative of THR.

The prevalence of tobacco smoking in Germany is still at a very high level (nearly 30%), and the use of alternative nicotine delivery systems (ANDS) has been increasing in the population. The World Health Organisation (WHO) recommends monitoring the use of tobacco and ANDS on a national level to support implementation of the WHO Framework Convention on Tobacco Control and reduce tobacco-related harm. The DEBRA study (German Study on Tobacco Use) addresses this recommendation by tracking key variables of patterns and trends in the use of tobacco and ANDS in Germany. Furthermore, the study collects data on relevant associated factors, such as socioeconomic background, alcohol consumption, and mental health.  This session will explore attitudes towards e-cigarettes by medical/public health organisations and the evidence- and consensus-based view towards harm reduction according to the recently updated German clinical guidelines for treating tobacco. It will provide contextual data on the use of tobacco and ANDS and provide a future outlook, including the strategy for a smoke-free Germany 2040.

Definitions of THR have evolved since the late 70s and more recently includes targeting people who cannot or don’t want to quit nicotine. Those who cannot or do not want to quit nicotine tends to be people with mental health and substance use problems, but also those in routine and manual occupations, those living in social housing and in certain geographical locations.  There are several challenges and opportunities relating to THR and this presentation will highlight a few of these, such as the need to reconsider how we measure THR, how we incorporate and prioritise what outcomes matter most to people who smoke or vape. The discourse around THR needs to evolve and expand rather than be constricted or silenced.

Australia is one of the only English-speaking, high-income countries that has banned the sale of e-cigarettes as consumer products. Until 1 October 2021, smokers could legally import nicotine for personal use with prescription. Most smokers imported nicotine illegally because very few doctors were prepared to prescribe nicotine. The use of e-cigarettes increased among Australian smokers and adolescents despite the sales ban prompting a tougher enforcement of the sales ban. Since 1 October 2021 smokers who import nicotine without a script may face up to a $200,000 fine and imprisonment. This policy has been justified by giving an absolute priority to protecting youth from a ‘vaping epidemic’ that has supposedly occurred. I make some predictions about how the policy may work and what its likely effects will be on Australian vapers and smokers who want to use e-cigarettes to quit smoking.

What hostile and supportive forces are bearing on the transitions to low-risk alternatives to smoking? Are we about to squander the opportunity to avoid millions of premature deaths and cases of disease through a dogmatic refusal to embrace innovation and harm reduction? Or will the fundamentals of risk and personal agency and autonomy ultimately prevail?  An epic battle is underway between the Public Health establishment and the public's health. How will it play out?

Does tobacco harm reduction (THR) compliment or undermine core tobacco control principles?