Tobacco harm reduction: the best hope for averting deaths from smoking in the developing world

1. Tobacco harm reduction: the best hope for averting deaths from smoking in the developing world Carl V. Phillips, MPP, PhD Karyn Heavner, PhD the TobaccoHarmReduction.org project University of Alberta School of Public Health

2. Overview • Tobacco harm reduction (THR) – encouraging smokers to substitute low-risk nicotine products for smoking – is the most promising strategy for further reducing the health costs from smoking in the West. • It is an even clearer choice in the developing world, where it is far more promising and affordable than other choices.

3. Overview • THR reduces the risks from nicotine use by about 99%, so the benefits are the same as eliminating all use. • But no medical service, muscular policy apparatus, or imposition on individual liberty is necessary. • Unfortunately, Western activists strongly resist this right-sized measure, demanding replication of expensive and ineffective Western practices.

4. As years of potential life lost from smoking decreases in the West, (more due to improving treatment and screening than decreasing exposure) it is increasing in poor countries. (due to increasing life expectancy and disposable income) Specific quantitative estimates for the toll from smoking in the developing world are junk science, but the trend (increasing) and at-risk population (several billion people) are clear.

5.  Prohibition is not a reasonable option Nicotine (the relatively harmless drug that is the primary reason people smoke) is very beneficial for many people and an everyman pleasure for many others. Tobacco is easy to produce as a small-scale cash crop in most fertile climates. Thus, demand and supply are inevitable.

6. Even so, health costs of smoking-caused diseases are not currently expensive or socially devastating like other diseases, (does not kill the young; most diseases so expensive they are free) Thus, substantial expenditure and effort at the expense of pressing needs is inappropriate. But can do better than to just let smoking become well-established. 

7. Only two methods have ever substantially reduced smoking prevalence • Simply informing a health-conscious and long-lived public about the risks reduced smoking in the West by about half to "only" 25-30% of adults presumably the same will happen elsewhere

8. Only two methods have ever substantially reduced smoking prevalence  2. Harm reduction by substituting smokeless tobacco (ST) for smoking reduced smoking by more than half again among Swedish men, causing expected health improvements (Heavner et al. 2009), (and increasingly among Swedish women and Norwegians)

9. Only two methods have ever substantially reduced smoking prevalence All other methods combined (cessation programs, taxation, media campaigns, advertising restrictions, etc.) have had very small effects (roughly another 5 percentage points all totaled) Moreover, they are impractical outside of rich health-conscious countries

10. Tobacco Harm Reduction (THR) Low risk alternatives: smokeless tobacco "electronic cigarettes” pharmaceutical nicotine products cause about 1% of the mortality risk of smoking (in Western populations). So, switching from smoking is effectively the same as quitting nicotine entirely.

11. Tobacco Harm Reduction (THR) The harms from smoking tobacco are caused by the smoking part, not the tobacco. Nicotine and unburned tobacco are basically like drinking coffee.

12. Tobacco Harm Reduction (THR) Proven for ST effective in Sweden with ST ("snus", but other snuff or chewing tobacco would be similar) estimated 99% reduction based on direct evidence (e.g., Phillips et al., 2006) (Note: oral cancer worries are largely a myth, though it would be best to encourage Western-style products) Extrapolated to e-cigs (increasingly popular) and risk from pharmaceutical products (but never very promising)

13. Tobacco Harm Reduction (THR) Surprised? Blame the massive effective anti-ST and anti-THR disinformation campaign.

14. Tobacco Harm Reduction (THR) More details on all of this (and papers related to this talk coming soon) at TobaccoHarmReducation.org Disclosure: I and my colleagues who promote THR try to work with manufacturers of THR products, and sometimes receive funding from them, and we are frequently attacked by the anti-tobacco lobby. See my papers at the website for further details.

15. Tobacco Harm Reduction (THR) China has e-cigs, but non-tobacco products have Western price points and cannot compete with locally-produced tobacco for most of the population. So, the focus must be on ST for much of the world.

16. ST-based THR is promising in the developing world because… Tremendously beneficial: effectively the same public health benefit as nicotine-eradication but without the loss of the benefits from nicotine

17. ST-based THR is promising in the developing world because… Cheap requires only education and product availability (which already exists in some cultures, though could be improved) Easy to support engineer favorable policies and suppliers will do all the work Politically expedient

18. What more can we ask for in a public policy? • target population (some of them) would voluntarily comply if educated • private actors with a profit motive will do most of the work with minimal coercion • does not crowd out more urgent health expenditures • limits risk of corruption compared to aggressive policies

19. In short, give nicotine users a satisfying low-risk alternative, give cigarette manufacturers/merchants an alternative that loses them nothing, nudge everyone requires some force of tax or regulation, but far less than required for abstinence and elimination

20. Problem: Anti-tobacco activists who dominate discourse and policy and fiercely oppose THR. Have actively endeavored to vilify THR policies, mislead people that all nicotine products have same risks, discourage harm reduction. Why? How can that be??!

21. Anti-tobacco activists are typically mis-identified as part of the public health community • but public health strongly favors harm reduction in general (seatbelts, condoms, clean needles) That was once true. But now tobacco policy discourse dominated by anti-tobacco extremists • oppose tobacco/nicotine use, regardless of welfare or health effects • interested in purifying behavior and simply winning rather than 99% reduction in risk.

22. THR is almost perfect from the perspective of public health, but no net gain from the perspective of anti-tobacco extremism (risk is almost eliminated and people are happy, but people get to keep using tobacco or nicotine)

23. The extremists try to justify anti-THR by suggesting that all nicotine use should and can be eliminated through greater use of current coercive methods. As weak as this argument is empirically (and ethically) for the West, it clearly absurd for poor countries

24. Yet the official policy demands WHO et al. are attempting to enforce (see the "Framework Convention for Tobacco Control") dictates expensive and marginally effective Western-style tobacco eradication policies. • funding medical interventions (cessation programs, pharmaceutical products) in countries that cannot even afford bed nets or antibiotics • high taxes even when untaxed sales are easy and taxes hurt the poor and create corruption • "just say no" indoctrination that is barely effective even in the U.S. where the "health promotion" ethic is widely accepted

25. We can do better than this! THR is well understood and developed in the West. Is there a way to introduce it elsewhere? (I really mean that as a question!)

26. Summary / Call for Action • THR has been recognized as effective in the West for more than a decade. • But entrenched interests and infrastructure create strong resistance • Problem/Opportunity: The developing world could thus leap ahead (cf wireless communication, electric cars)

27. Summary / Call for Action • First Steps: • Advocates for health in the developing world need to push back against Western anti-tobacco extremism when it is anti-health. • Policy makers need to be empowered to resist such pressure like the Framework Convention. • Progress in one country would completely change the landscape.

28. Questions? Ideas? Prof. Carl V. Phillips: cvphilo@gmail.com Dr. Karyn Heavner: karynkh@aol.com Tobacco harm reduction group at the University of Alberta (Canada) School of Public Health: TobaccoHarmReduction.org