SEATCA policy position on tobacco harm reduction

The WHO FCTC defines tobacco control as “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke (Article 1(d)).

Proponents of ENDS and HTPs cite this definition as a justification for e-cigarettes and vaping to be legitimized and included in the tobacco control toolbox. They argue that shifting smokers to vaping results in reduced tobacco harms. Even tobacco companies now admit that the best choice any smoker can make is to quit cigarettes and nicotine altogether, but, expectedly, they also say those who don’t quit should shift to their “reduced risk” products (ENDS and HTPs). To be valid, however, a tobacco harm reduction strategy should clearly demonstrate that it not only results in significantly reduced harm but also does not itself cause harm.

Vaping proponents also like to quote Michael Russell, a British psychologist, who in 1976 said, “People smoke for nicotine but they die from the tar,” implying that nicotine is safe and theorizing that removing the harmful tar from a cigarette will make it safe. Often left unsaid is Russell’s industry-funded collaboration with British American Tobacco[1] to study “safer” cigarettes (which we now know are impossible to develop because of the inherent toxicity of tobacco) and the fact that since 1976, there has been much more evidence showing that nicotine is not a benign substance; in addition to its being highly addictive, nicotine increases the risk of cardiovascular, respiratory, gastrointestinal, and reproductive and perinatal disorders, suppresses the immune response, and plays a clear role in carcinogenesis through cell proliferation, oxidative stress, apoptosis, and DNA mutation, as well as tumor growth, metastasis, and chemoresistance[2]. It has also been shown to impair adolescent brain maturation with short-term and potentially severe long-term consequences for teen addiction, cognition, and emotional regulation[3],[4].

With their wrong premise of nicotine’s harmlessness, vaping proponents often argue that ENDS and HTPs, because of their lack of combustion, are generally harmless, initially claiming that e-cigarettes are “95% less harmful” than cigarettes (or after the “95% safer factoid was debunked, “orders of magnitudes less harmful” without presenting any valid measure for these “magnitudes”) and therefore safe to use. Interestingly, Public Health England (often cited by pro-vaping groups outside of England) has said ENDS are 95% less harmful than cigarettes, but considers HTPs (because they contain tobacco) more harmful than ENDS; yet it does not attempt to quantify the level of harm of HTPs. It is rather strange that a “95% safer” claim can be made for ENDS and not for HTPs when the reason for the “95% safer than cigarettes” claim is that there’s no combustion or burning that produces the harmful chemicals in cigarette smoke.

Contrary to the misleading perception that ENDS and HTPs only generate steam or water vapor with “negligible other things,” these products actually emit chemical aerosols (smoke is also a chemical aerosol) composed of particulate matter suspended in gas. Even if temperatures applied are lower than in conventional cigarettes, heating e-liquids and/or tobacco results in pyrolysis or thermal decomposition without combustion and creates many of the same toxic chemicals found in cigarette smoke, and because there is a non-linear dose-response relationship between exposure and health risks, it remains unproven by credible and long term scientific evidence that lower exposure will equate to reduced risks or reduced harm. As an analogy, jumping from the 5th floor of a building will not be less harmful than jumping from the 100th floor.

The real question that should be asked is “how much more harmful are ENDS and HTPs compared to not using them?” As of this time, there is simply no answer to this question. It took many decades before scientists and health authorities recognized how harmful smoking was and is. ENDS and HTPs haven’t been around long enough to conclude if and how much less harmful these products are compared to cigarettes, but there are already multiple studies and reports of actual and potential health harms of these products, including lung and cardiovascular effects, appeal to and uptake by youths, and dampening of smoking cessation at the population level. There have also been many cases of nicotine poisoning, use of illegal drugs in e-cigarette devices, and exploding devices.

This is why the World Health Organization (WHO) itself declared that e-cigarettes are “undoubtedly harmful” and not a safer alternative to regular cigarettes[5], while maintaining that all forms of tobacco use are harmful.

There are multiple arguments for why a harm reduction strategy shouldn’t be used as a population-based tobacco control strategy, and these are enumerated and succinctly explained in a May 2019 position paper of the European Respiratory Society (ERS)[6]. The ERS presents seven arguments for why a harm reduction strategy should not be used as a population-based strategy in tobacco control:

  1. The tobacco harm reduction strategy is based on incorrect claims that smokers cannot or will not quit smoking.
  2. The tobacco harm reduction strategy is based on undocumented assumptions that alternative nicotine delivery products are highly effective as a smoking cessation aid.
  3. The tobacco harm reduction strategy is based on incorrect assumptions that smokers will replace conventional cigarettes with alternative nicotine delivery products.
  4. The tobacco harm reduction strategy is based on undocumented assumptions that alternative nicotine delivery products are generally harmless.
  5. Alternative nicotine delivery products can have a negative impact on public health even if “stick-by-stick” they turn out to be less harmful than conventional cigarettes.
  6. Smokers see alternative nicotine delivery products as a viable alternative to the use of evidence based smoking cessation services and smoking cessation pharmacotherapy.
  7. The tobacco harm reduction strategy is based on incorrect claims that we cannot curb the tobacco epidemic.

In summary, the evidence to date shows that e-cigarettes are not harmless and can kill people. Whether they are less harmful and how much less harmful compared to cigarettes is still undetermined. E-cigarette devices and their use are attractive even to youths. SEATCA therefore maintains that while strengthening proven tobacco control measures to help smokers quit, strong precautions must be taken to prevent a new epidemic. Thus a ban on the manufacturing, import, distribution, marketing, and sale of these products is warranted, particularly in countries where the vaping epidemic is only beginning and where robust regulatory capacity is lacking. Where a ban is not possible, strict regulations must be enforced in line with the regulations for other tobacco products: high excise taxes that reduce affordability and discourage use, a comprehensive ban on all advertising, promotion, and sponsorship; a ban on use in all indoor public places, workplaces, public transportation, and other relevant public places; prominent and effective pictorial health warnings on packages and mass media messages warning about nicotine addiction and other health harms; increased access to cessation services to end nicotine addiction; and measures to prevent industry interference in policy development and implementation.

[1] Elias J, Ling PM. (2018). Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products. Tobacco Control 2018;27:s96-s101. http://dx.doi.org/10.1136/tobaccocontrol-2018-054433
[2] Mishra A, Chaturvedi P, Datta S, et al. (2015). Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology. DOI: 10.4103/0971-5851.151771
[3] Goriounova, N. A., & Mansvelder, H. D. (2012). Short- and long-term consequences of nicotine exposure during adolescence for prefrontal cortex neuronal network function. Cold Spring Harbor perspectives in medicine, 2(12), a012120. doi:10.1101/cshperspect.a012120
[4] Yuan, M., Cross, S. J., Loughlin, S. E., & Leslie, F. M. (2015). Nicotine and the adolescent brain. The Journal of physiology, 593(16), 3397–3412. doi:10.1113/JP270492
[5] World Health Organization. (2019). WHO Report on the Global Tobacco Epidemic, 2019. Geneva: World Health Organization.
[6] European Respiratory Society. ERS Position paper on tobacco harm reduction, May 2019. Available at: https://www.erseducation.org/Media/Media.aspx?idMedia=417874