Over 168 countries are signatories to the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO FCTC) treaty with 181 countries partied to the governing provisions of the landmark international agreement. With the stated mission of reducing the use of combustible tobacco all over the world, the treaty was drafted in a manner to promote harm reduction as a viable public health strategy that aligns with elements of international law. According to the official draft of the agreement, harm reduction is a recognized approach in the field of tobacco control that aims “to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke,” via the WHO’s definition of the actual term of “tobacco control.” The treaty entered into force in 2005.

The most obvious is the failure of the WHO to acknowledge harm reduction strategies that prove successful in curtailing the use of combustible tobacco.

While it is my opinion that the FCTC has been a success in several areas, there are elements of the treaty that have failed. The most obvious is the failure of the WHO to acknowledge harm reduction strategies that prove successful in curtailing the use of combustible tobacco. Benjamin Mason Meier and Donna Shelley, both affiliated with Columbia University at the time of publication, wrote in a 2006 edition of the Public Health Reports academic journal that the WHO FCTC lacks the necessary verbiage to compel action when it comes to the promotion of harm reduction strategies. They also note that the WHO’s failure to focus the organization’s efforts on health-related approaches to tobacco cessation has been overshadowed by its global activism for non-health related methods (e.g., pushing for taxation, bans, and other policy-oriented strategies).

Alternative nicotine products (ANPs) such as e-cigarettes, snus, and heat-not-burn devices have become hits with consumers all over the world wishing to quit combustible tobacco cigarettes.

Meier and Shelley note: “Harm reduction is not a panacea for the ills of tobacco, but it could be, at best, a synergistic complement to the other tobacco-control approaches employed by the FCTC.” They additionally note that curtailing combustible tobacco use requires a comprehensive and aggressive implementation of biological and psychological processes due to the highly addictive nature of nicotine. In recent years, the private sector has managed to fill the FCTC’s gap of harm reduction acknowledgment without the need for governmental intervention. As a result, alternative nicotine products (ANPs) such as e-cigarettes, snus, and heat-not-burn devices have become hits with consumers all over the world wishing to quit combustible tobacco cigarettes.

Countries follow the World Health Organization

Though the increase in ANPs has been noteworthy on a global scale and many researchers, including myself, attribute the decreases in smoking in the developed world to these products, WHO still fails to recognize the benefits of ANP solutions as viable harm reduction strategies. The WHO applauds countries that tightly regulate or ban alternatives to smoking tobacco. E-cigarettes and other electronic nicotine delivery systems (ENDS), for example, currently on the market are victim to bans in several developed and developing countries with international condemnation from anti-tobacco interests and the WHO. Not only is this the most blatant example of an organization founded to protect public health dismissing proven harm reductions strategies, but it is also the most prominent injustice to the field of tobacco harm reduction (THR) and tobacco control to date. These deceitful actions from the WHO encourages countries to dismiss proven harm reduction methods.

Country-level tobacco harm reduction “friendliness”

World map regulation for nicotine products

Public health is harmed when alternative nicotine products are tightly regulated or outlawed at the national levels thus forcing smoking rates to increase.

In a previous commentary, I wrote on the theory that I’m researching, the proliferation dynamic of harm. Using Saudi Arabia as a model country for the initial case study, I concluded that public health is harmed when alternative nicotine products are tightly regulated or outlawed at the national levels thus forcing smoking rates to increase. “The proliferation dynamic applies to the population-level disparity between countries that have vaping bans and the ones that allow vaping in a market-friendly, regulated environment,” reads my commentary. “Ultimately, the proliferation dynamic multiplies when there is a vaping ban, and the cigarette smoking rates increase, among other factors (e.g., regulation, other cessation methods, taxation, etc.). The proliferation dynamic only decreases when vaping is legalized in a jurisdiction thus contributing to the reduction of overall cigarette smoking rates, among the same additional factors.” For matters on this immediate analysis and the future advancement of this theory, vaping and e-cigarettes will be included under the catch-all term of “alternative nicotine products.” I digress, though.

For ANPs to be accepted as harm reduction strategies, an inventory of a nation’s culture, government, laws, and economic environment needs to be accomplished.

When we consider the idea of allowing the widespread availability of ANPs in a national consumer market, we can attribute consumption of alternatives to combustible tobacco as a net-benefit for overall public health among a nation’s population. But for ANPs to be accepted as harm reduction strategies, an inventory of a nation’s culture, government, laws, and economic environment needs to be accomplished. The visible areas to review include national smoking rates, mortality rates tied to smoking, overall birth-death rates, and monetary metrics (i.e., HDI, GDP, GNP, and Gini coefficient). This inventory would also require an analysis of global economic freedom, human freedom, human rights, and the overall form of government in a particular country. These metrics and analyses could lead to a suggestion of what the culture in a country is like and whether or not smoking or the use of certain “sin” products (e.g., alcohol, cannabis, etc.) is socially acceptable. Other indicators can be reached in an economic analysis of whether a country’s economy is market driven, socialist, or mixed and if its low income, middle income (subdivided into the lower, middle, and upper middle), or high income based on the measurement of Gross National Income. Once all of these elements are added together, then a numerical proof can be attached to measure how “THR-friendly” a country is. Numerical proofs, in this case, would be measured on a scale of -10 to +10 with the matter of subjectivity left up to the researcher. The lower the score, the more friendly a country is to harm reduction strategies and products such as ANPs. Calculations also consider external factors to the case of a country that focuses predominately on intergovernmental organizations (e.g., WHO) and multinational corporations (e.g., big tobacco companies, big pharmaceutical companies, etc.).

Holistic approaches

The realm of thought behind this idea derives from a body of work that suggests ANP use reduces overall cigarette smoking rates among population samples. I’ve spoken to industry and academic leaders on this infant idea at great length in recent weeks. My conversation with Bengt Wiberg, the inventor and patent holder of sting free snus, focused on how any research, including my own, needs to approach harm reduction through a holistic understanding of all ANP and similar products available to consumers.

“At [the Global Forum on Nicotine 2018], many VIP’s spoke of how we advocates should acknowledge the fact that there is not just “one” cure for helping people quit smoking. There are several, and thus we should all join hands and not battle civil wars saying stupid things like  “snus stinks” or the opposite, “vape suffocates me.” By acknowledging both e-cigs and snus as great products of harm reduction, we will reach the facts that 1+1 > 2.” Wiberg wrote in an email. “I’m a former smoker that quit thanks to snus, I’ve had some short relapses to smoking but then I discovered e-cigarettes and since then no relapses.”

Snus and the European Union

Much of the reasoning behind the banning of snus and other related products were similar to the claims that e-cigarettes are just as harmful or worst than combustible tobacco.

Wiberg pointed to the challenging tale of Swedish snus as a potential example of the theory. European Union regulators outlawed the use of snus with Article 17 of the 2014 EU Tobacco Products Directive (TPD). This provision in the directive explicitly states: “Member States shall prohibit the placing on the market of tobacco for oral use, without prejudice to Article 151 of the Act of Accession of Austria, Finland, and Sweden.” Tobacco for oral use, as explained by Tobacco Tactics, is defined “as tobacco products for oral use, except those intended to be inhaled or chewed, made wholly or partly of tobacco, in powder or in particulate. This includes moist snuff and snus, but does not include chewing tobacco or nasal snuff.” Sweden was exempt from the regulation when the country joined the EU as a member state in the mid-1990s. Much of the reasoning behind the banning of snus and other related products were similar to the claims that e-cigarettes are just as harmful or worst than combustible tobacco.

Research and the progression of time have proven that line of reasoning wrong. In a prior Vaping Post report, we covered how Sweden boasts the lowest smoking rate in the EU with only 5 to 7 percent of the population indicating that they smoke combustible tobacco regularly. A group of researchers found that snus attributed to lower smoking rates in Sweden and other jurisdictions that allow snus consumption based on criteria that reveal regulators adopted THR-friendly policies that were evidence-based. Now, according to Wiberg, snus is no more taboo than drinking alcohol. Bulgaria, France, and Greece have the highest smoking populations in the EU and are a part of the more substantial bloc of member states that recognize the transnational ban on oral tobacco products.

The fatwa against Malaysians vaping and key takeaways

For another example, look at Malaysia. The Malaysian national government outlawed vaping for all of the country’s Muslims in 2015 when the National Fatwa Council declared e-cigarettes and vaping products as “haram” or forbidden under Islamic Sharia law. “From the [Sharia] aspect, it is detrimental to health. Islam forbids its followers from using things that can harm them directly or indirectly; immediately or gradually that can lead to death, damage the body, result in dangerous illnesses or harm the mind,” a statement from the council reads. “We are seeing women and school children showing interest in vape. The decision is made to prevent an unhealthy culture from spreading to future generations.” But, according to the latest WHO data on smoking rates in Malaysia, the prevalence of combustible tobacco use is among the highest in the region. Forty-three percent of males over the age of 15 years smoke combustible cigarettes daily while a total of 22.8 percent of the population smokes combustible cigarettes. At one point, Malaysia was estimated to be the second largest market for e-cigarettes, after the United States, with millions of consumers and thousands of vape shops.

Though these two cases are causal, they can be measured under these justifications to conclude that eliminating ANPs do cause “unintended consequences” against the overall public health. As my research into this theory progresses and I monitor the changes in the global harm reduction market, there will be more immediate and available proof to point too. At least in the United States, I can measure the impacts of harm reduction marginalization with a closer eye. Because the United States is headed down a regulatory avenue that emulates the exponential progression of Australia’s vaping ban and criminalization, proof of harm reduction, ANPs, and the existence of a THR-friendly country is seen elsewhere. In the United Kingdom, the regulation, though invasive for my American standards, is based on evidence of improved public health outcomes, facts, and an informed population.

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