Time ripe for inclusion of harm reduction in tobacco control policy

Islamabad : With the draft National Tobacco Control Policy in the process of being finalized, the time is just right for Pakistan to incorporate the concept of harm reduction as a key component of the policy, thereby enabling smokers to quit or to switch over to alternatives that are proven to be less damaging than combustible cigarettes.

Even though the World Health Organization (WHO) and donor agencies supporting Pakistan in its fight against tobacco use are currently not giving specific focus to the concept of Tobacco Harm Reduction (THR) on the grounds that such interventions can potentially interfere with cessation and fuel initiation of tobacco use, developed countries—most prominently United Kingdom and New Zealand—have carried out studies that establish THR as a public health strategy which reduces health risks for tobacco users, lowers illnesses induced by tobacco use, leads to declining smoking prevalence, and paves the way for smoking cessation.

New Zealand, for instance, is reporting a massive decline in cigarette sales as a growing number of smokers are switching over to alternatives like vaping. The country sold 2,132 million cigarettes in 2019, which was 193 million fewer than 2018. In just two years (2017-2019), cigarette sales have reportedly dropped by 410 million, both due to a substantial increase in the prices of cigarettes (from $16.39 in 2011 to S41.89 in 2020) and switching over from high-risk smoked products such as cigarettes to low-risk smoke-free products such as e-cigarettes, heated tobacco products, and smokeless tobacco.

The concept of THR dates back to 1976 and was first voiced by Professor Michael Russell who said, “People smoke for nicotine but they die from the tar.” Most of the harm caused by smoking results from toxins released through tobacco combustion. And although non-combustible tobacco and pure nicotine products also have addictive properties, they are relatively less harmful.

Cigarette smokers who switch over to alternatives that do not involve combustion and only provide nicotine can save themselves from the health risks associated with smoking. The concept is supported by many scientists and policy experts worldwide, and also finds a mention in Article 1 of the WHO Framework Convention on Tobacco Control (FCTC), where the term ‘tobacco control’ has been defined as meaning “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.”

In October 2018, as many as 72 experts from around the world wrote a letter to WHO, making a case for THR. The letter said, “These are established and new technologies that deliver nicotine to the user without combustion of tobacco leaf and inhalation of tobacco smoke. These technologies offer the prospect of significant and rapid public health gains through ‘tobacco harm reduction.’ Users who cannot or choose not to quit using nicotine have the option to switch from the highest risk products (primarily cigarettes) to products that are, beyond reasonable doubt, much lower risk than smoking products (e.g., pure nicotine products, low-toxicity smokeless tobacco products, vaping or heated tobacco products). We believe this strategy could make a substantial contribution to the Sustainable Development Goal to reduce premature deaths through non-communicable diseases (SDG Target 3.4).”

WHO, however, sees THR as a manipulative tobacco industry-driven strategy adopted by it to “gain the appearance of respectability.” It believes that the promotion of “odour-free” or “smoke-free” products claimed to have “reduced risk” and projected as being “cleaner alternatives” to conventional cigarettes only downplays established facts that cigarettes still comprise 97% of the worth of the global tobacco market. In Pakistan, which has more than 24 million tobacco users (with 31.8% men and 5.8% women using tobacco in any form), THR is yet to gain acceptance, largely because of concerns such as youth uptake, long-term health effects which will unfold over years, and most importantly, the absence of a regulatory mechanism that would firewall any adverse effects.

“We strongly believe that tobacco harm reduction should be part of the draft national policy on tobacco control. Moreover, it would be expedient if the policy is shared with all stakeholders before its finalization,” said Arshad Ali Syed, project lead of Pakistan Alliance for Nicotine and Tobacco Harm Reduction (PANTHR)—an initiative working to promote innovative solutions for smoking cessation. He added that support for smoking cessation needs to be strengthened in Pakistan. “If smoking is to be eradicated, we need to understand the perspective of smokers and see what is needed to help them give up the habit of smoking.”