Tobacco harm reduction: An effectiive tobacco control strategy

According to medical experts, smoking is destructive to body organs and public health. People who smoke end up developing lung cancer, colon cancer, brain tumour, etc. Every year, there are seven million tobacco-related deaths worldwide of which 80% are among tobacco users in low- and middle- income countries (LMICs) while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.

Ghana, with a population of approximately 33 million, recorded about 4,000 smoking-related deaths in 2022. Of which sixty-six percent of this number died prematurely under age 70 from direct smoking; 18 percent represents the number of people that lost their lives to second-hand smoking.

Tobacco products are frequently vilified for the adverse effects of smoking on individual and public health. However, it is important to point out that the majority of tobacco-related deaths are caused by inhaling smoke from burning cigarettes as well as cigars.

From country to country, in efforts geared towards reducing access to combustible tobacco products, the use of, and access to, cigarettes and cigars are subject to stringent regulations to reduce high morbidity and mortality caused from consumption. However, how effective have these measures been?

By embracing the primary techniques of these established tobacco-control measures, England, like many other countries, has chosen a broad-based strategy for tobacco control. They include tobacco taxes, smoke-free zones, advertising prohibitions, standardised packaging with risk messages and warnings, quit-smoking assistance and some product controls.

But what makes this strategy unique and fascinating is the adoption of harm reduction in tobacco control and, consequently, an extremely favourable attitude towards reduced-risk products as alternatives to smoking cigarettes.

The Tobacco Control Plan published in 2017 by the Department of Health and Social Care, sought to reduce smoking overall and target this inequality in smoking rates. In doing this, its objectives included reducing smoking in adults, young people and pregnant women, ensuring a parity of esteem for those with mental health problems, and supporting evidence-based use of innovative technologies to reduce smoking, such as e-cigarettes.

In 2019, it further published a green paper, titled Advancing our Health; prevention in the 2020s where it announced an ambition for England to become smoke-free by 2030. This ambition according to the government can only be achieved when adult smoking prevalence reduces to 5% of the entire population or less.

A report published by Office for Health Improvements and Disparities in December 2022, shows a decline in smoking prevalence in adults between 2011-2021. ‘The adult (18+) smoking index for 2021 in England was 13.0%. This a reduction from 13.8% in 2020 and continues the general downward trend observed since 2011 (19.8%)’, it states.

England recognizes the priority which is- getting rid of toxicant - filled smoke produced by combustible products and reducing smoking prevalence in adults through its smoke-free ambition for England. The single most important aspect of this is the overriding focus on smoking.

This is because at the heart of tobacco control is the goal of reducing premature death and serious diseases (cancer, diabetes heart and respiratory conditions – bronchitis, asthma) which emanate from smoke inhalation. It is worthy to note that it is the process of combustion released when cigarettes are burned that causes the most risk

From this instance, this then implies that there are potential trade-offs to be made by policymakers on tobacco control. If it is then possible to reduce smoking and smoking-related harm through harm-reduction strategies, why shouldn't this goal take precedence over the goal of reducing tobacco use?

Bystanders are exposed to second-hand smoke (widely known as ‘passive smoking’) and suffer negative health effects from it. From the standpoint of public health, focus on smoking is more appropriate since smoke causes harm and thus clarifies the policy intervention.

Tobacco Harm Reduction (THR) refers to replacing the highest-risk tobacco products (cigarettes and other combusted products) with Reduced Risk Products (RRPs), such as oral nicotine pouches (a smokeless non-tobacco product), nicotine e-cigarettes (non-combusted and contains no tobacco), and Tobacco Heated Products, which heat rather than burn tobacco, for smokers who find it difficult to quit the use of cigarettes outrightly.

This relies on risk reduced technologies that supplies nicotine without smoking or burning. A sufficient or gratifying nicotine dosage can be delivered without combustion using a wide range of emerging techniques.

These techniques are a unique category that need a distinct regulatory framework because nicotine, though it can be derived from tobacco (just as vitamin C can be derived from oranges) is not the same as tobacco. While it is clear that Nicotine is not without health risks and is in fact addictive, the risk profile of nicotine is much lower than that of tobacco. Nicotine is in fact present in food staples, such as potatoes and tomatoes.

Therefore, there is no justification for regulating these items as anything other than what they are. The main challenge for governments is to find a proportionate way of regulating this technique that will take into consideration the huge public health opportunity and minimized risk to smokers and bystanders, while at the same time protecting the manufacturers of these alternatives from illegal competition, blocking valuable innovation or denying or obstructing smokers from access to much safer smoking alternatives.

These techniques are very different in terms of their potential danger to human health. In comparison to smoking, a review by Public Health England (an agency of the UK Department of Health and Social Care) on an alternative in January 2018 concluded that the new techniques are at least 90% less harmful than smoking and about 44.8% of the population do not realize that they are less harmful than smoking’.

It further adds that using these reduced risk products have been instrumental to the drop in smoking of combustible cigarettes as consumers are switching to these less harmful products.

The goal of tobacco control is to decrease and discourage the persistent use of tobacco. However, while addressing the health consequences of tobacco use, it is essential to offer an alternative that consumers find compelling enough to justify switching to. Safer alternatives exist which, though addictive, reduce the health impact on people who wish to smoke cigarette by as much as 99%.

History has shown that enforcing a complete ban on consumer products with addictive tendencies, like sugar, alcohol, coffee, marijuana is almost impossible and making it illegal, often, increases the illicit sale of such products. In the US, for example, the ban on alcohol between 1920 and 1933 did not eliminate alcohol but is widely accredited with the growth of organized crime across the US.

A much better and sustainable approach would be for governments to work hand in hand with legitimate manufacturers to regulate the production of less risky options for consumers, based on science and not sentiment.

This can be accomplished by keeping abreast of current developments in tobacco harm reduction and the scientific research behind it and observing best practices from countries like England, Sweden, Canada and Japan, which have successfully adopted and deployed similar strategies.

With this, there is a need for the relevant regulators such as national standards bodies, the food and drug authorities, ministries of health, public health professionals, among others, to explicitly acknowledge the difference between tobacco and nicotine and consequently the differences between smoking tobacco products and using reduced-risk products.

With the overall impact to the public health in mind, it is paramount to provide policies and measures to support their availability to encourage safer options to consumers and the general public by applying a harm reduction mindset to tobacco usage.