If you don’t smoke, don’t start, if you smoke, quit and if you don’t quit, change; Tobacco harm reduction is a step in right direction for public health
In the global campaign to reduce and eliminate tobacco smoking — and the harm to public health that comes with it — the focus is to discourage people, especially youths from picking up the habit.
But for those who smoke, the campaign is: “If you don’t smoke, don’t start, if you smoke, quit and if you don’t quit, change” — and switch to smoke-free products as part of tobacco harm reduction, which is a step in the right direction for public health. IQOS is one such smoke-free product that one of biggest buyers of Malawi tobacco, Phillip Morris International (PMI) has invented. It is intended for people who wish to quit smoking but not for those who do not use tobacco or nicotine products at all.
In an interview with Tommaso Di Giovanni, PMI’s Vice-President of Market Activation and Support, top Bahrain media reports take cognizance of PMI’s Smoke-Free Future Vision and tobacco harm reduction strategy.
During a presentation, the company confirmed that the UK Office for Health Improvements and Disparities (formerly Public Health England) researched that e-cigarettes do 95% less harm than traditional smoking but proposes new, clearer wording to express the magnitude of harm reduction.
Di Giovanni stressed that smoke-free products are intended only for adult smokers and adult nicotine product users, who would otherwise continue to smoke, noting that studies among adult users in Japan from 2016, the largest market for ‘IQOS’ devices, showed that rates of starting or returning to smoking using IQOS are very low. Thus the appeal that ‘if you don’t smoke, don’t start, if you smoke, quit smoking and if you don’t quit, change’, the company said, noting that change will not happen quickly if world leaders, governments, regulators and NGOs are not willing to evaluate the science behind smoke-free alternatives.
Jacek Olçak, PMI’s CEO is quoted as saying: “We are committed to achieving a smoke-free world and creating a better future, a cigarette-free future”. While on his part, Di Giovanni confirmed that there are more than one billion smokers around the world — while 25 million people smoke Philip Morris products, and in some countries they reach 45%, such as Lithuania.
“Adult smokers must realize that if they don’t want to quit smoking, which naturally remains the best option for their health, they can choose better alternatives to cigarettes such as smoke-free products,” he said.
Di Giovanni pointed out that the toxic and carcinogenic substances found in tobacco smoke, not nicotine, are the primary drivers of disease and death. When one takes into consideration the fact that by 2025 an estimated one billion people will continue to smoke worldwide, it becomes important to highlight the fact that in order to reduce the harms of tobacco, smokers are encouraged to switch to less dangerous alternatives to combustible cigarettes.
Tobacco harm reduction – a step in the right direction for public health
Throughout history, civilization has marched steadily forward with the momentum of innovations. There are many scientific innovations that cigarette manufacturers are coming up with that are in the line of reducing tobacco harm. And thanks to those innovations, improvements that can help reduce harm from everyday behaviours and activities have become commonplace. It makes sense as smoking can’t be completely eliminated. For example, people are exposed to the sun’s rays, but they can slather on sunscreen with sun protection factor (SPF) to mitigate the potential harm of sunburn.
“People can’t avoid, for the most part, the need to travel from place to place via car (or bus, train, or plane), but they can buckle their seatbelts to help keep themselves safe in case of an accident. In that same vein, PMI advocates for Tobacco Harm Reduction (THR) strategies to be applied to the known risks of smoking, saying: ‘Indeed, there is growing support for this path among public health bureaus, governments, medical groups, and others.’”
The best choice for any smoker is to quit tobacco and nicotine entirely. However, for those who don’t quit, it is also clear that scientifically substantiated smoke-free alternatives (which provide nicotine and are not risk-free) now exist that represent a much better choice than continued smoking. These products and their potential to benefit public health are central to a smoke-free future. In order for THR to help effectively eliminate smoking, PMI contends that “adult smokers must be able to choose these lower risk options.”
THR should be considered a complementary strategy, and not a replacement for existing efforts to encourage those who smoke to quit and those who don’t to never start.
Those efforts must continue — but THR can be an important supplement since there are more than 1 billion smokers in the world today and that number looks unlikely to fall materially any time soon. The goal, then, is to develop smoke-free alternatives that present significantly less risk of harm than continued smoking, that are acceptable to current adult smokers who would otherwise continue to smoke cigarettes, and that are not attractive to youth, non-smokers, or former smokers.
Further, given the well-known risks of smoking, PMI maintains that “it is correct that tobacco products should be subject to strict rules and enforcement. These are necessary to help protect public health. But it is obvious that there is more to be done than relying solely on tactics like plain packaging and other traditional regulatory measures and that’s where THR, powered by innovative products and policies, have a role to play.”
“For our part, as we work to deliver a smoke-free future, we are transforming our company. The scientifically substantiated products that PMI and other companies have developed are making it possible to picture a future in which cigarettes are replaced by less harmful smoke-free alternatives that adult smokers will accept.
“We believe that role should include following the science of THR and putting in place sensible, risk-based regulations governing access to and accurate information about smoke-free products, combined with further restrictions on cigarettes.
“Public health authorities, expert organizations, and society at large are increasingly leveraging innovation to tackle the serious health consequences of smoking. For example, the United States Food and Drug Administration (FDA) has created separate pathways for innovative tobacco products that are a better choice than cigarettes and authorized the marketing of alternatives to cigarettes that they deem appropriate in the promotion of public health.
“If these better alternatives to smoking are made available and enough smokers switch to them, we can more rapidly achieve a significant milestone in global health: a world without cigarettes.”
The case of Malawi
During the Global State of Tobacco Harm Reduction-Burning Issues virtual conference in 2020, Dr Mwawi Ng’oma — Programme Manager for St John of God Hospitaller Services in Malawi, touched on challenges for fostering THR in low and medium income countries (LMICs), saying there is need to make THR more affordable, more appealing, widely available and acceptable.
She, however, said most THR products in Malawi — such as nicotine gum and nicotine patches are expensive and thus the continued combustible smoking that is extremely cheap on the market.
She said in the case of Malawi as an LMIC there is insufficient tobacco control measures to monitor sales, pricing, sale and age restrictions.
“The ban on public smoking is not being enforced and there are no provisions of smoking lobbies in public places, which is leading to cases of passive smoking,” she had said.
“Advertising on the dangers of smoking on packaging is not as aggressive as it should be.
“When communicating information on healthy living, the greatest focus is on communicable diseases such as cholera and most recently the COVID-19 pandemic, with much less mentioned on the harms caused by combustible tobacco products.”
The scientific innovations are yet to infiltrate the African market
During a panel discussion at the second Harm Reduction Exchange conference for African journalists held in Nairobi, Kenya in December 2022, it was observed that there are many scientific innovations that cigarette manufacturers are coming up with that are in line with reducing tobacco harm, but they are yet to infiltrate the African market.
Several versions of the PMI IQOS product have been made but they are mainly accessible in the developed western countries with South Africa — closest to Malawi — having them available on the market albeit at an expensive price point.
Other African countries’ leadership have altogether banned such harm reduction gadgets, as they still produce some smoke although such smoke is not as harmful as that from tobacco cigarettes.
In his presentation — entitled ‘Harm Reduction: Making a difference in Africa’ — Professor Abdoul Kasse from Senegal, one of Africa’s fiercest medical professionals who advocates for harm reduction strategy adoption, attested that harm from tobacco cigarettes is not from nicotine but from the tar.
He said there are misconceptions that people who smoke eventually suffer from various ailments, including lung cancer due to the intake of nicotine but stressed that it is not the nicotine but the carcinogens and the tar that cause illness, which are much lower in risk reduced nicotine products such as PMI’s IQOS.
Prof. Kassé — who is a world renowned and awarded oncologist and a Professor of surgery at the Cancer Institute in Senegal — emphasized that 30% of people who eventually suffer from cancer are associated with combustible tobacco cigarettes, either as smokers or from constantly being exposed to second hand smoke.
“Nicotine does not cause cancer but the tar does,” he emphasized. “People who smoke crave for the nicotine, which is very addictive as is caffeine that is also found in coffee and other medicines.
“However, addictive substances in coffee and various medicines consumed by one individual do not affect those surrounding them, while smoke from tobacco cigarettes also affects those who do not smoke.”
Prof. Kassé said this is where there was need for harm reduction: to protect those who do not smoke as well as assisting people to quit the smoking habit by using safer nicotine products. He said that “Harm Reduction is a powerful public health tool and should be at the centre of all public health development strategies”.
“Harm reduction has already benefited many people in public health and is the most viable alternative in tobacco control. It applies to areas where there is a need to reduce the harm associated with the practice or consumption of a substance that is overused in society leading to increased morbidity and mortality.
Innovative Harm Reduction initiatives will help to keep more Africans alive. Tobacco Harm Reduction initiatives, including the use of popular e-cigarettes, nicotine patches and chewing gums have continued to generate a lot of misunderstanding in both the public health community and in the media.”
“However, there is evidence that the use of potentially less harmful alternatives than cigarettes for those who are not willing or cannot give up smoking would be far better than continuous smoking. Where cessation repeatedly fails, switching to less harmful products is expected to result in benefits for many smokers,” said the Professor.
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