On October 27th 2021, the Global State of Tobacco Harm Reduction (GSTHR) launched their latest report ‘Fighting the Last War: The WHO and International Tobacco Control' at a conference at London’s Oval Cricket Ground - with both physical attendees and a further 100 (including us!) watching online.
What the report says
With 1.1 billion smokers worldwide, 8 million annual smoking-related deaths and smoking the single biggest preventable cause of non-communicable diseases, the report examines the progress and barriers affecting global tobacco harm reduction.
The report particularly focuses on the conflict between the World Health Organisation (WHO) and the tobacco industry. This includes the potentially negative public health implications of the WHO’s anti-nicotine stance. This stance is taken despite substantial evidence supporting safer nicotine products (SNPs) and their role in harm reduction and smoking cessation.
GSTHR argues that the WHO has a ‘moral imperative’ to adopt tobacco harm reduction rather than steering tobacco smokers away from safer nicotine delivery systems - which will ultimately only mean more smokers.
The report suggests the WHO update their 2007 MPOWER initiative to include harm reduction and should be updated to EMPOWERED with the addition of:
- ENGAGE with affected communities
- ENCOURAGE smokers to switch to SNP
- DELIVER accurate information about safer alternatives
The report also discusses the failures and damaging exclusivity of the upcoming COP FCTC (WHO Framework Convention on Tobacco Control) conference.
Despite being publically funded and making decisions that affect millions, the COP FCTC conference is shrouded in secrecy - with media, the public and anyone with any connections to the tobacco industry excluded from attending.
The report also argues that the current implementation of the FCTC is a ‘global public health failure’ - with principles set out in 2005 aiming to reduce smoking-caused death and disease abandoned. In fact, the number of global smokers has been the same (1.1 billion) for the last 2 decades.
GSTHR ‘Fighting the Last War’ Launch Event Summary & Key Messages
In case you missed it, here are the key messages and takeaways from the event.
- Harry Shapiro: From hope to despair
- Dr Derek Yach: The origins and decline of the FCTC
- Tom Gleeson: Consumers – the often forgotten majority
- Ethan Nadelmann: Under the influence – the politics of international drug control
- Nataliia Toropova: The journey from TC to harm reduction advocacy
- Professor Gerry Stimson: What we have learned and what’s next for THR?
Session 1: The FCTC: past, present and future
Host Will Godfrey of Filter Magazine opened the event with the grim facts - the global smoking population of 1.1 billion has remained the same for the past 20 years and smoking-related deaths are estimated to reach 1 billion by the end of this century.
Despite a number of safer nicotine delivery systems, the WHO’s battle with big tobacco has led them to adopt a blanket anti-nicotine stance that must be reapproached.
Harry Shapiro: From hope to despair
“The battle lines have been drawn, but there should be no battle lines."
In a speech packed with war references, report author Harry Shapiro began with a simple truth:
“We all want to deal with the death and disease caused by the global epidemic of smoking.”
Shapiro points out that a 1997 report estimating a figure of 8 million tobacco-related deaths by 2030 has been reached almost a decade early. Smoking rates remain high in lower/middle income countries and global smoking rates have remained stagnant for 2 decades. He concludes that, while the WHO boasts of 5.3 billion people being protected or ‘covered’ by tobacco control policies, all of this points to them failing.
Shapiro suggests that a sensible response to this would be for the WHO to take SNPs seriously. He argues that there needs to be a tobacco harm reduction initiative relating to the evidence and ‘game changing’ potential of NRPs. After all, there is substantial evidence they are safer, offer significant smoking cessation opportunities, and pose little risk to bystanders.
He also suggests that the WHO’s ‘MPOWER’ process is lacking in its ‘O’ initiative of ‘OFFER: to help quit tobacco’. There is little evidence of concern to the plight of current smokers, families and marginalised groups. He deems MPOWER a ‘tick box exercise’ with unenforceable policies.
Shapiro states that Tobacco Control is simply out of control. Misinformation and misdirection opposes the best interest of public health, with nicotine being caught in the crossfire and Tobacco Control ending up on the “wrong side of history”.
He claims the FCTC conference has become cult-like (shrouded in secrecy, paranoia and with key stakeholders excluded). Keeping the conference private is undemocratic and totalitarian. Instead, all stakeholders, including industry and consumers, should have a seat at the table.
Dr Derek Yach: The origins and decline of the FCTC
“The chance to act remains but the results will be seen for the next 10 - 15 years.”
Dr Derek Yach - founding executive director of the foundation for a smoke free world and former WHO Cabinet Director involved in the initial development of the FCTC - discussed both the emergence and the decline of the FCTC conference.
Providing historical context, he shared that 1970 was the first time the WHO received a resolution stating that smoking kills and action is needed - based on 2 major reports from doctor-led organisations. This led to an advisory board being created. Since this, he says, there have been very few issues where so many resolutions have been put in place - including advertising laws and bans on smoking in certain areas, taxation etc. All of which led, over the next 25 years, to smoking being recognised as a serious public health issue that causes chronic diseases and was pushed to the top of the list of priorities.
Yach lists certain governments including the UK, Norway and Canada who showed leadership in this. He points out the key role of the Canadian government in establishing the FCTC by supporting the WHO.
A key mistake made in regulation was a lack of focus on low-middle income countries where enforcement was not possible or more difficult. These implementation problems were not considered by the WHO and instead put on to governments - with the assumption that they would ‘miraculously' deal with them - leading to the problems we see today.
In 1998, the WHO led negotiations by inviting tobacco industry scientists to discuss harm reduction. Due to the lack of scientific advancement, the WHO was not impressed walked away from the meeting deciding this was the last time they would listen to them. What they didn’t consider was how the scientific innovation cycle would progress.
Despite the obvious scientific advancements and with over 75,000 patents existing for safer nicotine delivery products, the word ‘patent’ is never mentioned in the framework convention. Derek says this is due to the WHO being ‘blinkered’ to the possibility of innovation and transformation of the core product that was killing people.
In 2005, when the treaty had already been adopted by 180 countries, Yach raised concerns that excitement over the treaty had subsided, bureaucracy was taking over and that it was losing focus on people and disease. Instead, ‘the vague term’ tobacco control was taking over. At the same time, harm reduction products were gaining prominence and he insisted that the WHO needed to keep an eye on and engage with these communities. Yach also insisted serious investment was needed by low-middle income countries into tobacco control… which never happened.
While the FCTC’s purpose is dealing with diseases, he argues that they are no longer talked about - with leading organisations ‘going quiet’ on the issue.
In 2015, after leaving Tobacco Control, Yach was asked to write a piece on e-cigarettes. Reviewing the evidence he was shocked that there were now millions of e-cigarettes, smoking and death rates were down, and harm reduction was about to gain dramatic prominence. This led him to take an active role in harm reduction and set up his foundation.
Now, when the benefits of e-cigarettes and the evidence of their help in reducing smokings (and therefore deaths) are clear, Yach uses the Covid-19 pandemic to illustrate the failings of Tobacco Control to act on projections.
In the pandemic, action was taken based on projections. When death rates went up we acted with masks, social distancing and lockdowns. Yet, while Tobacco Control can make more accurate projections there is still no action taken with preventable methods to reverse these trends.
Tom Gleeson: Consumers - the often forgotten majority
“We (consumers) will not be silent - this is about us.”
New Nicotine Alliance Ireland’s Tom Gleeson discussed the pivotal and often forgotten role of the consumer in the tobacco harm reduction debate.
He argues that when tobacco alternatives are discussed, the consumer isn’t heard from and ‘people’ are never mentioned. The term ‘consumer’ is used to dehumanise the real people affected and that they are used ‘as props’ to exemplify the evils of tobacco.
Yet the e-cigarette evolution has been created by ‘us’ - the users who have lived experience of quitting smoking using e-cigs and have changed and developed them to suit their needs.
The emergence of this community in setting up forums, websites, and festivals led on to shops and, eventually, advocacy groups that spread the message of e-cigarettes. Never has a smoking cessation aid been so championed by its users.
Gleeson claims that Tobacco Control’s exclusion of nicotine is ignoring data, evidence and facts and represents a missed opportunity for harm reduction. While the FCTC never thought quitting smoking was possible without full nicotine abstinence, “We are the proof that harm reduction works.”
He recommends that, for Tobacco Control to be effective, it must factor in all involved - including manufacturers, regulators and the consumer. Should policymakers engage with harm reduction to create policy “the consumer will do the rest.”
Gleeson summed up his consumer-focused speech with a fitting phrase:
“There can be nothing about us without us.”
Session 2: Challenges to making the FCTC an inclusive international framework convention
Ethan Nadelmann: Under the influence - the politics of international drug control
“Prohibition doesn’t represent control - it represents the abdication of control.”
Ethan Nadelmann, founder of the Drug Policy Alliance, has vast experience of using harm reduction strategies and policy to fight the US ‘War on Drugs’ and feels this approach can be applied to tobacco and nicotine.
Nadelmann advocates for harm reduction rather than bans concerning illicit drugs. The basic principle is an acceptance that society will never be drug free. We need to learn to live with this fact whilst ensuring they cause the least amount of harm.
He believes harm reduction is pragmatic and makes sense - intersecting both human rights and public health. Yet, despite the evidence, society, media and the government move the other way - to prohibitionist style bans. Nadelmann insists that should this be applied to tobacco and nicotine it will result in black markets and harmful adaptations - as found in the case of outright drug bans.
The objective has to be that tobacco is here to stay. The challenge is to learn to live with tobacco and nicotine in a way that causes the least amount of harm.
He points out that Tobacco Control has split into two ideologies - reduced harm and abstinence only.
Nadelmann points out that even governments of countries where there is positive evidence of harm reduction working still refuse to provide leadership on the subject. This, he says, is due to Big Tobacco advocating it while scientists who advocate harm reduction, despite showing real evidence of it working, are being slandered and discredited simply for taking money from Big Tobacco.
Regarding nicotine (‘the elephant in the room’) he says that the biggest obstacle for tobacco control is the amount of people who believe nicotine is more harmful than it is. It’s misinformation regarding nicotine which will prevent tobacco control objectives going forward.
He ends by asking the question of whether we want to continue in a world with 1 billion smokers or a world where 1 billion people are consuming nicotine - just in a safer way?
Nataliia Toropova: The journey from TC to harm reduction advocacy
“Fighting for principles means entering into wars.”
Ukrainian Natalia Toropova, from Healthy Initiatives, told of her journey from traditional tobacco control (i.e bans on tobacco and nicotine) to advocating for harm reduction.
She tells of how she began advocating for tobacco control because “If we can change it, why don’t we?”
Toropova insists she hasn’t left Tobacco Control but has instead moved to Harm Reduction to help save lives - blaming the number of deaths and the lack of smokers successfully quitting on the lack of information about safer options.
This draws on her personal experience of the smoking-related death of her own friends and the staggering statistic of 18% of deaths in Russia caused by smoking.
She believes that Tobacco Control should now be about providing information on safer options rather than stigmatising or victim-blaming smokers and expecting them to quit unaided.
She points to the ‘twisted facts’ that Tobacco Control and the WHO are presenting - with them stepping away from both science and fact, demonising harm reduction products and wrongly equating them with cigarettes.
Toropova claims that the WHO and Tobacco Control are refusing to recognise and talk about the lack of help given to help smokers quit and that, while they put their efforts in to prevent youth smoking, to tackle cancer and cardiovascular diseases, we must tackle present smokers.
Professor Gerry Stimson: What we have learned and what’s next for THR?
“ Tobacco harm reduction is here for good and is an easy fix that would have a massive impact on world health.”
When Professor Stimson came across tobacco harm reduction in 2008, he saw it as a simple solution to the world smoking problem. A solution that ticks all the boxes, has public health in mind and puts control in the hands of the people. He assumed all of his public health colleagues would think the same. Yet, while harm reduction has worked in drug reform, many of them had a different view when it comes to tobacco and safer nicotine products.
Indeed, many groups have tried to stop harm reduction. Stimson himself has been blacklisted by the WHO, has his own entry on the University of Bath’s Tobacco Tactics website and has even had friends banned from speaking to him due to his work.
Despite these setbacks and the many opposers, Stimson insists that the end of combustion is in sight - driven by new technology, consumer interest and regulation. He claims that both the public health and medical establishments are simply uncomfortable with tobacco harm reduction due to their lack of ownership and ease of control over it.
Unlike other initiatives such as the HIV/AIDS prevention initiative, tobacco harm reduction doesn’t require government expenditure as it is the manufacturers that create the products and the consumers who put their hands in their pockets to buy them. Tobacco harm reduction is simple - it just requires accessible products and regulation.
He believes that the sooner we move from harmful to safer nicotine delivery products, the sooner we will reduce smoking-related harm.
Stenson runs through some of the bans and regulations regarding SNPs imposed around the world - from the ‘bizarre’ Australian rule of prescription-only nicotine vape products to flavour bans and taxation in Europe.
In the US, he points to the WHO-driven moral panic of youth vaping in the US (“What’s the preoccupation with kids in America?”) as well as the Truth Initiative’s ‘foul’ campaign featuring fake e-cig like ‘depression stick’ products suggesting a link between nicotine and mental illness - which he described as a ‘muckraking fantasy’ that is harmful to children.
He also later suggests that this moral panic regarding youth vaping is being imported to the UK by ASH - who have reported no recommendations on e-cigarettes and have called for ‘kid-friendly’ flavour bans, despite evidence to show almost non-existent youth vaping rates.
Stenson goes as far as to say he hopes to one day see class action taken against these organisations by those driven back to smoking by this propaganda.
Prof Stimson does point out that it isn’t all bad news - with no increase in the number of countries enforcing vape bans and the recent development of the FDA filing PMTAs for snus and some other safer nicotine products.
He also points out the success of the UK in being progressive - with vaping being normalised, many vape shops, vaping being allowed in public spaces and used in NHS stop smoking campaigns - all with no moral panic ensuing.
Moving on to the FCTC - Stenson questions its banning of anyone with tobacco industry associations and looks to academics who are complicit in this by not challenging it - possibly through intimidation.
“(it) is shrouded in secrecy, apathetic to those who are now part of the solution, paranoid about the public and driven by anti THC rhetoric in conjunction with the WHO."
He insists that countries that own the FCTC must push for change and press for them to include harm reduction - as is mandated in the convention itself.
Stinson concludes with the fact that tobacco harm reduction is ‘unstoppable’ and driven by good products. “Tobacco harm reduction is here for good!”
If our round up has made you eager to hear more, you can view the full conference online here.