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Creative tobacco harm reduction initiatives such as the UK’s “swap to stop” program utilizes reduced-risk alternatives to provide smokers with choices rather than bans.
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Snus has been instrumental in Sweden’s harm reduction success story, along with other less harmful alternatives.
UK leads the way: Swap to stop
The UK government affirmed once again its world-leading approach to public health when it announced last month it would be giving out vaping starter kits to one million smokers to encourage them to “swap to stop.” The program, the first of its kind in the world, will cost an estimated £45 million and will be rolled out nationwide over the next two years.
Health minister Neil O’Brien said government policies aimed at driving smoking rates down below 5% by 2030 will focus on “helping people to quit” rather than imposing bans. This includes not raising the minimum age for the sale of cigarettes from 18 as recommended in a review led by Javed Khan last year, which called for the minimum age to be increased by one year, every year “until no one can buy a tobacco product in this country.” Interestingly, a key recommendation in Khan’s report was support for vaping.
The UK is one of the countries successfully implementing tobacco harm reduction (THR) initiatives and policies. In 2015 Public Health England (PHE) reported findings from an independent expert review showing that vaping was about 95% less harmful than smoking conventional cigarettes. PHE actively encouraged vaping as a less harmful alternative to help smokers quit. In 2021, the number of smokers in the UK dropped to a record low at 13.3%, the lowest since 2011 when the annual population survey started recording smoking prevalence. The number of people using vapes was also the highest among current cigarette smokers at 25.3% and ex-smokers at 15%.
The Swedish experience: E-cigs, HNB, and snus
Sweden is another good example of successful THR implementation. While Sweden does use tobacco control methods such as banning smoking in certain places, it also accepts products such as vapes, heated tobacco, nicotine pouches, and, in particular, snus as less-harmful alternatives to combustible cigarettes. Rather than embracing a quit-or-die approach, Sweden used a combination of tobacco control and THR strategies that resulted in the country’s smoking rate dropping from 15% to 5.6% of the population in 15 years, putting it on track to achieve smoke-free status (below a 5% smoking prevalence rate) in a matter of months and 17 years ahead of the European Union’s 2040 target.
Sweden also has the lowest percentage of tobacco-related diseases in the EU and a 41% lower incidence of cancer than other European countries. A report commissioned by Health Diplomats, an international organization working to improve access to healthcare, encourage innovation and the use of harm reduction to minimize the negative impact of alcohol, food, nicotine, and drugs, highlighted the fact that Sweden’s approach benefited from employing tobacco control measures to make combustible cigarettes less attractive while facilitating the use the of less-harmful alternatives, making them accessible, affordable, and acceptable to the population.
Smoking prevalence in the three most populous EU countries, namely Germany, France, and Italy, show a smoking prevalence of 23.8%, 25.5%, and 24.2%, respectively, despite the adoption of EU-wide tobacco control measures and a concerted public health anti-smoking effort. The current average smoking rate in the EU is 23%, which is almost five times higher than Sweden’s.
Other countries that saw their smoking prevalence drop after consumers had access to less-harmful alternatives include Japan, where heat-not-burn products entered the market in 2014 and the smoking rate drop by 10% between 2016 and 2019. Even New Zealand, the first in the world to introduce a generational tobacco ban, suggests vaping as a smoking alternative for those looking to quit and saw its smoking rate drop to 8%, the lowest it has ever been, with the number of adults vaping daily rising to 8.3% in 2022.
It is noteworthy that the key to success here is not complete prohibition of all tobacco products, but rather embracing less-harmful tobacco products. Or, as James Murphy, director of research and science at British American Tobacco (BAT), described THR at a recent conference, it’s “zero combustion, not zero nicotine use.”
Enter health practitioners and policymakers
Health practitioners and policymakers play influential roles in THR simply by the fact that the outcomes of their actions directly affect consumers.
A recent survey released by Altria Group found two-out-of-three Americans support THR, with 79% saying that if certain tobacco products have been scientifically shown to be less risky than cigarettes, physicians have a responsibility to communicate this information to their patients who are adult tobacco consumers and have not successfully quit smoking by using traditional cessation therapies.
In addition to general population adults, the survey asked primary care physicians about their views on tobacco harm reduction. Of those surveyed, 89% support tobacco harm reduction as a public health concept and 85% believe it is important for FDA to focus on making smoke-free tobacco products available to adult smokers to help them switch from cigarettes to less harmful alternatives.
Policy professionals were also surveyed and overwhelmingly believe that harm reduction is a better approach for FDA to focus on than prohibition (78%), that tobacco products should remain legal so they can be properly regulated (77%) and that FDA has a responsibility to accurately inform adult tobacco consumers about the different levels of risk associated with tobacco products (96%).
FCTC COP10
With that being said, it should be interesting to see what comes out of COP10 this November in Panama. THR was conveniently removed from COP9’s agenda, postponing to COP10. However, if COP10 continues in the tradition of previous sessions where only a few select groups of like-minded, prohibition-keen people with anti-tobacco blinkers on are allowed to attend, it would probably be safe to say it’ll be the same old, same old as usual.