Session 4: 2022 Seminars

Research over the past decade has provided evidence for the potential of harm reduction from e-cigarettes, but there are considerable challenges along the path from potential to reality, of which a key component is the extent to which e-cigarettes can help smokers quit. Clinical trials have demonstrated the efficacy of e-cigarettes as a cessation aid, but ultimately, studies of the effectiveness of e-cigarettes for quitting smoking in the real world will tell us whether the potential of harm reduction is being realized. This presentation describes the conceptual model underlying the ITC Project’s longitudinal cohort studies being conducted across key countries where e-cigarettes and/or heated tobacco products hold an important presence in the tobacco/nicotine product marketplace. At the centre of the conceptual model is the individual user and his/her transitions (or lack of transitions) between products over time.  The possible causal forces that influence those transitions, among others, include those within the individual (e.g., history of smoking, dependence), those within the social environment (e.g., product use of close others, norms), product characteristics (e.g., nicotine delivery, flavours, ease of use), and policies and regulations on alternative products, and on cigarettes. The model is structurally symmetric in that policies and regulations on both cigarettes and on alternative products can have an impact on the individual and his/her transitions.  This presentation, which will review some recent ITC findings, will discuss important implications of this conceptual model for measuring and understanding the possible role of alternative nicotine products and policies on those products and on cigarettes in reducing smoking. It will also highlight important limitations in the role of policies in shaping those transitions.

Mr. Zeller will share his views on the evolution of the harm reduction debate in the United States, where for nearly 30 years he has played a central role.  He will talk about the process of achieving consensus around harm reduction and the continuum of risk in the 2005-2009 Strategic Dialogue on Tobacco Harm Reduction, which he co-led, and in the adoption of the Tobacco Control Act in 2009, which provided a mechanism for FDA review and authorization of true reduced risk products.  He will describe the current stalemate in the U.S. on issues related to tobacco harm reduction and e-cigarettes.  Finally, Mr. Zeller will close with thoughts on one potential endgame strategy focused on making combustible tobacco products minimally or nonaddictive.

Aotearoa New Zealand’s government has tabled some of the world’s most aggressive tobacco control policy with an explicit focus on smoked tobacco. Endgame legislation proposes to remove nicotine from all smoked tobacco, drastically reduce supply by 95%, and ban the sale of smoked tobacco to anyone born after January 2009. The aim being to reduce smoking rates to under 5% by 2025. The proposed smoking endgame legislation builds on recent laws regulating the sale and use of vaping products. A harm reduction approach ensures vaping is accessible to adult smokers, whilst protecting never-smokers from taking up vaping. New Zealand’s liberal approach to vaping is seen as prerequisite to highly aggressive policies that will restrict and devalue smoked tobacco. For many the smoking endgame policy represents the peak of New Zealand’s history of tobacco control leadership, for others it creates deep concerns about coercive approaches to people who smoke. This talk will outline the context for New Zealand’s endgame legislation, the role of vaping and harm reduction, and examine perspectives around what these policies might mean for public health, social justice and health equity.

The status of reduced-risk products in a smokefree society In Norway has meant that practically no one initiates cigarette smoking any longer. The prevalence of daily smoking in the age-group 16-24 years has dropped below the 2% mark. The remaining smokers are typically in their 60's. Within few decades Norway will probably be almost smokefree, thanks to previous decades of robust infrastructure for tobacco control - and to the long-time availability of a popular alternative to cigarettes; snus. Compared to cigarettes, snus is cheaper, comes in a variety of flavors, can be used indoors and correctly perceived as less risky. The majority of snus users are made up of ever-smokers and youth susceptible for smoking uptake. But as smoking declines, the reservoir of its most potential users (smokers) will shrink, and subsequently the relative share of never-smokers among snus users will increase. Faced with this prospect, the authorities have signalled that they will make snus the next target. This is the backdrop for the emerging debate on the future for low-risk nicotine products for non-therapeutic recreational use. Dr Lund will give an account of this debate - now in the process of overshadowing the debate about harm reduction (which is considered increasingly irrelevant because there will be no smoking to cure with alternative nicotine products).

The level of adolescent tobacco use ranges from around 2% to over 30% worldwide, depending on region and on the form of tobacco. As the leading cause of preventable death globally, most of the global mortality burden of tobacco use lies predominantly in ‘low to middle’ income countries (LMICs).

Overall, about a fifth of young teenagers (13–15 years) around the world are smokers. High-income countries may lower levels of adolescent tobacco use. Low and middle-income countries have contrastingly high rates of adolescent smoking, where rates in some countries can reach as high as 46% and reflect high rates of all-age smoking. Adult smoking rates generally appear to reflect adolescent smoking rates

With this fear in mind, policymakers in LMICs have made “tobacco control” a priority to mitigate effects of tobacco related morbidity and mortality, by harnessing cessation interventions techniques from high-income countries. In reality, we are only seeing an increasing number of smokers in LMIC, questioning the effectiveness of the ‘total cessation’ policy. This session reviews reasons for this failed attempt of ‘total cessation’ in LMICs, and the possible risks it possesses. One evident phenomenon is the creation of ‘hidden populations’ of smokers, who continue their smoking habit against regulations and isolate from health providers, in fear of litigation.

Is there a role for ‘tobacco harm reduction’ in the form of e-cigarettes or alternate non-combustible products over ‘total cessation’ policies? Despite evidence of its less harmful effects compared to conventional cigarettes, there has been lots of restrictions and hesitations towards ‘tobacco harm reduction’. In driving their agenda, international policies have also neglected special populations, individuals living with mental health problems, where even nicotine replacement has shown modest results.

This talk stands firm on the fundamental understand that ‘harm reduction’ initiatives respect the rights, health and safety of smokers, without compromising on ‘the right of all people to the highest standard of health’, as per WHO’s Framework Convention on Tobacco Control.

Deborah Arnott will set out how the UK government’s approach to e-cigarettes is misunderstood and overstated both by those who support and oppose the role of these products in helping bring about the end of smoking. She will make a plea for both sides to recognise that the UK government positions harm reduction in tobacco control as just one tool in the toolbox, relevant to the UK because of the phase it has reached in the tobacco epidemic. She will examine how political theory can be used to explain how the UK got to this position, and what the implications are for the future of harm reduction in other countries, regions and globally.

• Each Country has taken different approaches to fix the same problem – why is this?
• Why is harm reduction a recognised tool for many societal issues, but so controversial in tobacco control?
• We recognize and protect public health policy discussions from conflicts of interest with tobacco industry but is there a conflict of interest with extreme philanthropic funding? – should these be declared?
• Novel nicotine products come in many different forms and exist under different legislation in different countries.  Is there a case for liberalizing the nicotine market?