Current challenges that governments face in smoking control – Panel discussion

September 21, 2022

There is a growing trend today to adopt Harm Reduction Strategies as a complementary strategy to smoking cessation and smoking prevention and to evaluate Tobacco Harm Reduction as another pillar of public health strategies. While the end goal remains a “smoke free world”, THR advocates believe that governments should adopt a pragmatic public health perspective for smokers who fail to quit.

The challenges that governments face currently in smoking control have been discussed in a panel with Vassilis Kontozamanis, previous Minister of Health of the Greek Republic, and SCOHRE founding members David T. Sweanor J.D. (Canada), who moderated the discussion, Karl E. Lund (Norway), Sharifa Ezat Wan Puteh (Malaysia), and Michael G. Toumbis (Cyprus).

Smoking control is a global issue and needs to be seen from a global perspective, said the moderator Prof. Sweanor, and asked the panelists to share their views about the importance of integrating harm reduction strategies to the smoking control efforts in their countries, the ways they use to decrease smoking prevalence and the results they have seen until now.

In Norway, Dr. Karl E. Lund said, smoking initiation among young people is below 2% and regular smokers are approximately 9% of the population. So, the main challenge that Norwegian government faces in tobacco control might appear quite different from these in countries where smoking remains more prevalent. In Norway, people consume nicotine in other forms, the panelist explained, they use mainly the oral tobacco product called snus which has taken the place of cigarettes in the nicotine market and has been for decades the most popular method to quit smoking. Since snus has served as a very effective harm reduction alternative to cigarettes, he added, the authorities have recognized the fact that snus has played a role in smoking reduction, the risk differences between snus and cigarettes have been communicated and the product has lower taxation than cigarettes. Now, the upcoming strategy plan goes a step further, including measures to minimize all kinds of nicotine use, meaning that fight against smoking has become more a fight against nicotine. So, the tobacco harm reduction debate in Norway is about to be replaced by a debate where the authorities seek justification for restricting use of recreational nicotine products. It is very interesting to observe and monitor the several arguments in this debate, Dr. Lund said, about several issues, such as the users’ addiction to lower risk products etc.

Smoking is an issue of high importance in Malaysia, Prof. Dr. Sharifa Ezat Wan Puteh said, since it is very prevalent. About 40% of males 15-year-olds and above in the country smoke and tobacco use is the leading cause of cancer, contributing to 22% of total cancer-related deaths, she explained. Although the tobacco prevalence shows a gradual decrease during the last two decades, Dr. Wan Puteh continued, it seems to fall short of Malaysia’s goal of 15% decrease until 2025. One of the reasons that Malaysia faces such a huge problem of smoking, she underlined, is that the country still remains the world’s largest market for illicit cigarettes. According to the results of a recent study conducted by Nielsen on illicit cigarettes, she noted, 57.7% of cigarette consumption in the country was illicit. In an attempt to solve the problem, Malaysia’s Ministry of Health has proposed a generational tobacco ban, which (if passed) will come into effect from 2025, when those born in 2007 turn 18. According to this ban, anyone born after Jan 1, 2007, will face a high fine if caught buying tobacco and vape products, she explained, adding that there is a huge support for this generation smoking ban among smokers, vapers and non-smokers/vapers. Unfortunately, Dr. Wan Puteh said, most people believe that, without implementing other harm reduction measures, this ban will only increase black market sales without decreasing smoking prevalence.

There is no objection that harm reduction strategies have a role in tobacco control strategies, Dr. Michael G. Toumbis said. Tobacco harm reduction can be used as a complementary strategy, but our first priority in Cyprus is the full implementation and use of WHO – FCTC (Framework Convention on Tobacco Control). Unfortunately, he explained, the main problem with harm reduction is that we don’t have one product, but we need to implement rules for thousands of novel products. The most impressive example of harm reduction is coming from Sweden and Norway with snus, Dr. Toumbis indicated. Their harm reduction strategy has shown really impressive results for tobacco control, but these countries have only one product to control. The first and most important step in using harm reduction is to have control and knowledge of what you offer as an alternative, and it is not so easy to regulate and control so many harm reduction products.

Speaking about the situation in Greece, Mr. Vassilis Kontozamanis underlined that the country has managed to accomplish a paradigm shift to its healthcare system. The country’s strategy is to put the public health forward and not just to manage the everyday healthcare system problems, he explained. The “anti-smoking” law that was effectively installed a few years back underlined the government’s will to fight the effects of smoking―he added―and the fact that almost the whole population complied with the new legislation was very impressive. Of course, he added, we cannot ban everything at once, we must do it step by step, apply smoking control policies and harm reduction policies. This is why we passed a legislation that provides some differentiation to potentially less harmful tobacco products, he said, and we created experts’ committees that evaluate all new, innovative products, as well as surveillance services to make sure that everything is run according to the law. Harm reduction products can be important tools for smoking control strategies, but we have to make sure that they are safe, through sufficient and well-established monitoring mechanisms; also, of course, to install a regulatory framework to protect the youth from smoking initiation. Eventually, we would all like to live in a smokeless world, he concluded, but at this moment we must take care of all those who are smokers and do not want or cannot abandon the use of nicotine, and for doing that we need regulations, surveillance and further observational comparative studies.

At the end of the discussion, all panelists agreed that good scientific research and good policies could benefit all countries, and that it is duty of researchers to inform consumers about the alternatives they are offered.