//Milestones in Tobacco Harm Reduction
Posted 21/09/2020 12:00am
Next Generation Products (NGPs) decouple nicotine from harmful tobacco smoke. Although not completely risk-free, ongoing scientific research suggests their considerable harm reduction potential relative to smoking cigarettes.
By delivering satisfying levels of nicotine while replicating many of the sensorial and behavioural elements of the smoking ‘ritual’, NGPs offer an attractive option to conventional cigarettes for many adult smokers.
They are a viable alternative for the 1 billion-plus smokers worldwide, potentially facilitating the public health concept of Tobacco Harm Reduction (THR): so adult smokers uninterested or unwilling to quit cigarettes can consider transitioning from combustible tobacco to less harmful sources of nicotine.
However, not everybody believes in THR, or that NGPs can play a role in it. Some critics – citing the relative novelty of NGPs and the ensuing lack of long-term scientific data – invoke the precautionary principle and play the waiting game.
This risks wasting time many adult smokers cannot afford.
It’s true even the most established NGP category – vaping – is still relatively nascent; heated tobacco and tobacco-free nicotine oral products even more so.
That said, there’s already a great deal of robust pre-clinical research to suggest these NGPs may be significantly less harmful than smoking.
Indications from short to medium term clinical and behavioural studies [1] are also promising, although we absolutely recognise more research is needed into NGPs and their long-term health effects.
We will continue to do this.
However, when it comes to regulating and facilitating NGP use, we also believe in making decisions based on the encouraging science available today.
Increasing numbers of key actors in public health regulation and policy agree. They’ve started to listen – and more importantly act on – the contemporary compelling evidence, acknowledging and endorsing the principle of THR and of NGPs as viable, scientifically-substantiated, potentially reduced harm alternatives to combustible tobacco.
In the UK, where vaping is both popular and widely endorsed by numerous public health groups – including Public Health England [2] – as a cessation tool, the smoking rate has plummeted. [3] Modelling suggests if other countries adopted this approach, the world would have 200 million fewer smokers. [4]
Now is the time to act. Public health bodies and regulators ignoring the evidence risk preventing millions of adult smokers worldwide from accessing potentially life-saving alternatives.
We urge policy advisers, media and regulators who believe in pragmatic and progressive public health policies to explore our dynamic THR timeline below and act on what the data tells us.
[1] E.g https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub3/abstract see “None of the studies found that smokers who used EC short‐ to mid‐term (for two years or less) had an increased health risk compared to smokers who did not use ECs. “
[2] Public Health England is an executive agency of the UK Department of Health and Social Care.
[3] https://ash.org.uk/media-and-news/press-releases-media-and-news/in-2019-around-half-as-many-britons-now-vape-as-smoke-and-the-majority-are-ex-smokers/
[4] https://www.betterretailing.com/products/vape-world-map/
Milestones in THR
France’s Parliamentary Office for Scientific and Technological Assessment concludes a drastic change in approach is required reduce smoking rates among its population. The report recommends a science-driven approach, offering adult smokers the opportunity to switch to potentially harm reduced alternatives like vapes. The authors also argue it’s particularly important to conduct independent studies on heated tobacco to help inform future policy.
The Philippines enacts its Vape Bill into law, regulating the importation, manufacture, sale, packaging, distribution, use and marketing of vapour and heated tobacco products. The legislation makes the Philippines one of a select few Asian countries with progressive NGP regulation underpinned by THR.
The Czech Republic plans to implement a 3-year tobacco harm reduction strategy which potentially advocates both tobacco snus and tobacco-free oral nicotine pouches alongside other NGP like vapes and heated tobacco. The Czech Ministry of Health’s Ondřej Jakob also cites the importance of flavours in adult smokers’ switching journeys, though: “they should be limited… to attract as few people as possible, especially adolescents, so… another group of nicotine addicts is not unnecessarily created.” The specific nicotine pouch decree – issued in May 2023 – can be viewed here.
The UK’s independent review into tobacco control (the Khan Review) is published. The report is largely supportive of the role vaping can potentially play in smoking cessation. Among its recommendations, the report suggests government must urgently increase the “promotion of vapes as an effective ‘swap to stop’ tool to help people quit smoking”, that illegal disposable vapes need to be combated via increased funding to Trading Standards authorities across the UK and there needs to be improved education of health professionals to combat misperceptions about the relative risk of vaping compared to smoking.
The European Parliament votes to adopt the final report of the Special Committee on Beating Cancer – which argues vaping has a potential role in smoking cessation and that any risks posed by NGP must be evaluated in terms of relative – not absolute – harm.
In September 2021, the French National Cancer Institute (INCA, Institut National du Cancer) releases a brochure on cancer prevention. In it, the INCA confirms −because vapes do not contain or burn tobacco – they have far fewer and lower levels of the many harmful chemicals present in combustible cigarette smoke. Additionally, they acknowledge vapes can help adult smokers transition away from cigarettes.
In the world’s largest heated tobacco market, the smoking rate reportedly drops to a record low of 16.7%, down 1.1% on the previous year.
Action on Smoking and Health (ASH) data shows the number of UK vapers has fallen compared to last year. The charity warns “unfounded concerns about health risks from e-cigarettes may mean thousands of smokers who could benefit from switching completely are missing the chance.”
The International Agency for Research on Cancer, part of the World Health Organisation, admits vaping: “…has the potential to reduce the enormous burden of disease and death caused by tobacco smoking if most smokers switch… and public health concerns are properly addressed.”
The UK Committee on Toxicity (COT) releases a comprehensive report evaluating the relative and absolute toxicological risks of vaping. When produced according to “appropriate manufacturing standards and used as recommended, as a replacement for [CC] smoking”, the report concludes, vapes are “likely to be associated with a reduction in overall risk of adverse health effects.”
In a new statement, the Ministry of Health reiterates its position that, based on the current evidence, vapes “carry much less risk than smoking cigarettes” and “are attracting very few people who have never smoked into regular vaping, including young people”.
In a country where vaping remains extremely popular, it’s reported the smoking rate has again fallen to 14.1%.
The first ever heated tobacco product obtains a Modified Risk Tobacco Product (MRTP) order from the Food and Drug Administration (FDA), recognising scientific evidence which suggests it “reduces the body’s exposure to harmful or potentially harmful chemicals.”
Recognising evidence that vaping is “considered to be less harmful” than smoking, the Western Australian Parliament’s Select Committee releases a report urging the government to lift the ban on vaping, replacing it with risk-proportionate regulation.
It’s found that heated tobacco’s popularity has caused cigarette sales to plummet 5 times faster than before the NGP was available.
On its blog, Public Health England (PHE) clears up some of the most commonly misunderstood topics on vaping – including EVALI (e-cigarette, or vaping, product use associated lung injury), youth-use and nicotine. It also refutes the findings of a controversial study, published – and latterly withdrawn – the previous year, which misreported data to suggest vapers had the same risk of heart disease as smokers.
Public Health England (PHE) issues guidance to National Health Service (NHS) mental health organisations, recommending “patients have access to vaping products” and that practitioners should consider “provid[ing] them proactively to patients who smoke.”
Public Health England’s annual report affirms that vaping regulated nicotine products has “a small fraction of the risk of smoking” and recommends “smokers should be encouraged to try regulated nicotine vaping products, along with smoking cessation medications.”
The Office for Product Safety & Standards launch a campaign on battery safety advice for vapes.
For the first time, the Royal Australian College of General Practitioners states in smoking cessation guidelines that vaping “may be a reasonable intervention to recommend” if first discussed with health practitioner and use of nicotine replacement therapies or other methods have failed.
Vapes containing nicotine are legalised when the country notifies the EU it’s implementing the EUTPD. In line with these regulations, vapes in Norway must first make an application to the Norwegian Directorate of Health, which reportedly evaluates “whether the product will contribute to tobacco harm reduction”
A survey of Directors of Public Health finds they support the use of vaping as an aid to move away from smoking, with 75% of respondents advocating vape use in smoking cessation services.
The British Medical Journal reports the US’s declining in smoking rate mirrors a rise in vaping, “suggesting that the two may be linked”.
Evidence “indicates that low-risk, non-combustible nicotine technologies (referencing various NGP categories) can successfully displace smoking and provide a significant dividend for public health”, ASH New Zealand and End Smoking state in their Smoke-Free 2025 report
Responding to reports of THC vaping associated lung illnesses (EVALI), Public Health England (PHE) says “we are as certain as ever that e-cigarettes are far less harmful than smoking‘ and the outbreak ‘is not a problem linked to long-term use of regulated nicotine vaping products.”
The Food and Drug Administration (FDA) authorises the first-ever Modified Risk Tobacco Product order, meaning some specific Swedish snus products can claim that they are less harmful than smoking.
The Federal Government Commissioner for Drug Issues releases the latest Drug and Addiction Report. The review finds some studies exist which show vapes may be less harmful compared to cigarette smoke due the significant reduction of toxicants in the aerosol.
Public Health England (PHE) says vaping is contributing to a falling smoking rate. In England, 14.4% of adults now smoke, down from 19.3% in 2011.
Ministry of Health launches a factual vaping website which says “vaping can help smokers quit. That’s a good thing.”
The Royal College of Midwives recognise the significant harm reduction potential of vaping. They also state that if a “pregnant woman who has been smoking chooses to use an e-cigarette [(vaping)] and it helps her to quit smoking and stay smokefree, she should be supported to do so.”
The Ministry of Commerce lifts the ban on vaping products. In the same piece of regulation, it also officially legalises heated tobacco products.
Public Health England’s (PHE) vaping report says that whilst experimentation has increased, regular use of vapes by young people who have never smoked (11-18) remains very low.
The Economic, Social and Environmental Council states vapes “with or without nicotine” can be useful helping smokers move away from smoking and should be placed “among the other smoking-cessation tools.”
Public Health England (PHE) launches its ‘Health Harms’ campaign, encouraging adult smokers to consider vaping.
Following the Select Committee inquiry, the Government says once it leaves the EU, it’s committed to exploring regulatory alternatives to ensure “the proportionate regulation of e-cigarettes”, specifically in areas such as the 20 mg/ml maximum nicotine limit and the block on advertising vaping’s relative harm-reduction potential. It also states it will continue to consider the evidence on heated tobacco, and will also consider reviewing the current ban on snus.
As vapes are officially legalised, the government says “vaping is less harmful than smoking” and “switching …will reduce a person’s exposure to many toxic and cancer-causing chemicals”. It also confirms “nicotine is not known to cause cancer”.
The Center for Disease Control (CDC) confirms that in America – the world’s largest vape market – the adult smoking rate has fallen to its lowest level in recorded history.
The Food and Drug Administration (FDA) Commissioner states “we must recognise the potential for innovative, less harmful products that can efficiently deliver satisfying levels of nicotine to adults who want them” while preventing uptake by vulnerable populations.
The Ministry of Health affirms “the evidence on vaping products indicates they carry much less risk than smoking cigarettes but are not risk free‘ and says they believe vaping products ‘could disrupt inequities and contribute to Smokefree 2025.”
An Action in Smoking and Health (ASH) UK study finds youth use of vapes is “very low” and “experimentation does not turn into regular use”.
The Royal College of General Practitioners issue a statement encouraging GPs to recommend vaping. The position says vaping is “a far safer alternative” to smoking and that the “benefits of ECs [(vapes)] in assisting cessation should not be ignored.”
The Science and Technology Select Committee advocates for a ‘shift to a more risk-proportionate regulatory environment, where regulations, advertising rules and tax duties reflect the evidence of the relative harms of the various e-cigarettes, heat-not-burn and tobacco products available.’
In a whitepaper, the American Association of Public Health Physicians (AAPHP) argues “[no one] ever imagined that there could be a product that could satisfy the urge to smoke for many, if not most smokers, and would reduce risk by 95% or more, without addicting teen non-smokers – while being easier to quit than cigarettes. There is now solid evidence e-cigarettes and related vapour products, snus, the chewing tobaccos currently on the American market, and, more likely than not, the new Heat-not-Burn products are likely to meet these specifications.”
The Food and Drug Administration (FDA) Commissioner confirms the potential for “novel forms of nicotine-delivery to provide a potentially less harmful alternative for currently addicted individual adult smokers who still want to get access to satisfying levels of nicotine, without many of the harmful effects that come with the combustion of tobacco.”
The Directorate of Health recognises the use of vapes may be contributing to smoking’s decline.
The Danish Cancer Society’s Cancer Control Project Manager for Tobacco Prevention says vapes “are undoubtedly less dangerous than cigarettes.”
The National Academies of Sciences, Engineering and Medicine says that while vapes “are not without health risks, they are likely to be far less harmful than conventional cigarettes.”
The Committee on Toxicity says “it is likely there is a reduction in risk, though not to zero, to health for smokers who switch completely to heat-not-burn tobacco products.”
The National Association for the Prevention of Alcoholism and Addiction (ANPPA) recognises vapes may provide a ‘substitution tool (for smoking cessation) among the other existing devices’.
For the first time Stoptober, the annual national cessation campaign led by Public Health England (PHE) and the National Health Service (NHS), endorses vape use.
National Health Service (NHS) Scotland declares vaping is “definitely less harmful than smoking tobacco.”
The Drug and Alcohol Nurses Association (DANA) recognise vaping is a “much safer alternative to smoking for those who are unable to quit with conventional therapies” and vapes “are not risk free, but evidence suggests they‘re around 95% safer than smoking”.
The Associate Health Minister says there are various products ‘including heat-not-burn, snus, moist snuff, dissolvables and inhaled nicotine that may be significantly less harmful than tobacco smoking’.
The government embraces vaping in its new tobacco control plan‚ “Toward a Smokefree Generation”.
The Food and Drug Administration states nicotine is delivered through products on a “continuum of risk” with combustible cigarettes being the most harmful, and nicotine replacement therapy the least.
In Sweden, where snus and other oral products have been popular for decades, it’s reported that the smoking rate has dropped to just 5% – the 2040 smoke-free target of multiple European states.
Action on Smoking and Health (ASH) reports there are now 2.9 million UK vapers and that – for the first time – there are now more ex-smokers who vape (1.5 million) than current smokers (1.3 million).
The Associate Health Minister announces vaping is legalised, even though official regulation is still being drafted, based on “general consensus that vaping is much less harmful than smoking.”
Following public consultation, the Canadian Government’s report “Seizing the Opportunity’ recognises THR. New legislation will allow people to access “vaping products, which expose them to fewer harmful chemicals than cigarettes”. This marks a significant shift from 2009 when Health Canada advised people “not to purchase or use electronic smoking products”.
Based on evidence it’s potentially less harmful than smoking, Norway announces it will lift its ban on vaping.
Public consultation is opened on a new regulatory framework for vaping products in Canada.
The Ministry of Health opens for consultation on policy for vaping, recognising the “emerging evidence that e‑cigarette use may substantially reduce the burden of disease caused by smoking”.
Action on Smoking and Health (ASH), British Lung Foundation, Cancer Research UK and multiple others agree vapes are “significantly less harmful than smoking.”
Public Health England (PHE) says employers should allow vaping in the workplace where possible.
The Royal College of Physicians (RCP) report says in the “interests of public health it’s important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as substitutes for smoking.”
The Prime Minister says it’s promising around one million people “have used e-cigarettes to help them quit or have replaced smoking with e-cigarettes completely”. “We should be making clear this is a very legitimate path for many people to improve their health,” he adds.
Public Health England’s (PHE) landmark review finds vaping “[is] 95% less harmful than smoking”, “presents about 5% of the risk” of smoking and doesn’t create a ‘gateway’ to smoking for non-smokers and young people.
The Standing Committee on Health reviews the evidence on vapes and finds that they may be “be a less harmful nicotine product, containing fewer carcinogens than combustible cigarettes”, and as such, “could help smokers reduce their health risks, and may help them quit.” It recommends the government create a new regulatory framework, legalising vaping products.
The Royal College of Physicians (RCP) says vaping could lead to significant falls in smoking prevalence.
Almost a decade since vaping arrived in the country, Action on Smoking and Health (ASH) data shows the number of vapers tripled between 2012-14 to 2.1 million. It also reports vapes are overwhelmingly used by past or current smokers.
The High Council on Public Health endorses vapes as a potential route away from smoking, whilst recognising that they should not also act as a gateway to nicotine use and combustible cigarettes for never-smokers.
The American Association of Public Health Physicians (AAPHP) endorses harm reduction and argues it should be used “as an addition to current tobacco control policies… in a way that will minimise initiation of tobacco/nicotine use, maximise quit rates and assure that dual use does not increase potential harm to the user.” They also recognise vapes and snus as THR tools.
The European Scientific Committee on Emerging and Newly Identified Health Risks review finds “smokeless tobacco products (including snus) are clearly less hazardous than cigarette smoking”.
The Royal College of Physicians (RCP) says snus demonstrates significant harm reduction potential, stating it’s “around 90% less harmful to health” than combustible cigarettes).
The Institute of Medicine’s ‘Clearing the smoke — Assessing the Scientific Basis for Tobacco Harm Reduction’ report recognises the potential of NGPs by stating tobacco and nicotine products that substantially reduce exposure to tobacco and smoke toxicants should be developed and studied to determine any reduced health risks compared to cigarette smoking.
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