THR challenges & prospect: From scientific evidence to people’s needs satisfaction

September 26, 2022

A common goal of all SCOHRE members is to start an open and constructive dialogue to help come up with a better approach to the global burden of smoking, to provide stakeholders with science-based and balanced information on the effects of nicotine, to raise awareness on existing knowledge on Tobacco Harm Reduction, to benefit from already existing solid expertise in many countries and bring THR higher in the agenda of politicians and regulatory authorities.

At the end of the second day of the 5th Scientific Summit on Tobacco Harm Reduction, THR organizations representatives participated in an open panel discussion, coordinated by Lina Nikolopoulou (SCOHRE Director, Greece) and Solomon T. Rataemane (THR Expert, South Africa), Rapporteur. During the session, participants shared experiences, good practices and ideas and tried to explore how they can create more opportunities for education of health policy experts, regulators, and the public, and advocate for new research to generate more data, and for evidence-based policies.

European Medical Association (EMA) is an independent, non-profit organization, located in Brussels, Belgium, created in 1990, by and for the Doctors of the European Members States, with multiple partnerships dedicated to improve the quality of healthcare and medical conditions in the European Union, Dr. Manuel Pais-Clemente (EMA representative, Portugal) stated. The organization’s most important philosophy is synopsized in the following statement: “better informed doctors make better-treated patients”. Harm Reduction is here to stay, Dr. Clemente pointed out. Although the best approach is never smoking, smokers who are not able to quit smoking should not be abandoned to their fate, they should be at the core of the solutions, just as physicians place their patients at the core of their actions, he added. Consumers, politicians and regulators should be informed about the developments and technology innovations of smoking, in order to take the most correct decisions, legal measures and policy recommendations. It is in our hands, he underlined, to build up the construction of modern societies, with new and safer alternatives to the traditional cigarette smoking, promoting a new strategy at governmental level of different countries, led by an international organization that has demonstrated capacity of leadership, like SCOHRE.

ETHRA is a European advocacy group comprised of 25 consumer organizations across 17 countries, and representing approximately 27 million users across all EU, Tom Gleeson (European Tobacco Harm Reduction Advocates – ETHRA representative, Ireland) said. ETHRA supports and advocates for tobacco harm reduction, working with regulatory authorities and promoting the accessibility of THR products to smokers, since they enhance their ability to quit. Regulation must always consider the minimal risks of harm reduced products versus the large risks of smoking, he explained, and it is extremely important to evaluate THR products compared to combustible cigarettes and not the fresh air. The health and lives of adult smokers and ex-smokers should always be taken into account when quantifying the risk to young people, he continued. A main challenge today, he highlighted, is to generate sufficient and strong data in order to inform accurately consumers, doctors, regulatory authorities and politicians about all products and their comparative risks.

Charles Gardner (International Network of Nicotine Consumer Organizations – INNCO representative, USA) spoke about INNCO, a non-profit organization with 37 member organizations all over the world, which has the mission to support the rights of 112 million adults worldwide who use safer nicotine to avoid toxic forms of tobacco. INNCO has an open-door policy to researchers to help them recruit patients for clinical trials and strongly recommends the creation of good research practices in the field of HR, Charles Gardner said. We need comparative studies between THR products and combustible cigarettes, he emphasized. Mentioning that SCOHRE has a powerful potential role to play in the development of curricula in continuing medical education, the Executive Director of INNCO concluded that today there are safer alternatives to traditional combustible cigarettes, and it is pure “negligent homicide” not to be recommended to people who need them.

As Professor Sweanor has mentioned earlier today, Lina Nikolopoulou agreed with his comment, many years back we sued tobacco industry because they didn’t appropriately inform smokers about the risks of smoking in their lives and now, we have governments and authorities that prohibit the flow of information about the less harmful or potentially less harmful products to the public.

Dr. Emil Toldy-Schedel (Hungarian Scientific Association for Harm Reduction and Environmental Diseases representative, Hungary) commented that informing society about Harm Reduction is truly a matter of high importance. Last year, he said, the Hungarian Scientific Association for Harm Reduction and Environmental Diseases started to carry out in a regular basis training programs at Nursing university schools about Harm Reduction, as well as a program to inform medical societies about the issue through regular meetings. During the same year, the organization also run a very successful awareness campaign aiming to explain to the society what the meaning of Harm Reduction is, he added. Understanding the true meaning of HR is the key to acknowledge its high value for Public Health, he concluded, thus campaigns should be conducted in every country.

Actions on THR require a balanced approach, Dr. Fernando Fernández Bueno (Platform for the Reduction of Harm due to Tobacco Consumption, Spain) said. In Spain, the approach used for smoking control has proved insufficient and leaves all smokers who cannot quit without support options, he added. In this regard, health authorities have not put forward other options or innovative measures to facilitate smokers to reduce the harm caused by tobacco. Although the recently published by the Ministry of Health prevalence of smoking in the country ―34% of the adult population aged 18-64 years― highlights the need for adopting a more realistic approach, unfortunately traditional cigarettes and THR products are considered the same. The current government refuses to discuss with stakeholders, he said, and doctors and scientists who defend THR are actually suffering harassment and coercion by the authorities. This must change, he stressed, both the public and doctors must be provided with accurate information about the actual differences between products.

All members of SCOHRE have a common agenda, Lina Nikolopoulou commented, they want the public and the doctors to be better informed, and HR to be accepted as a pilar by regulatory authorities to complement their strategies. Therefore, she underlined, we have to work on common messages and on common actions. Although communication campaigns may present differences between countries―based on the different cultures and environments― in the case of education of professionals and research we need common protocols.

In Indonesia, smoking is extremely prevalent, since approximately 65 million of the population are smokers, Dr. Amaliya Amaliya (Indonesian Tar Free Coalition – KABAR, Indonesia) said. Koalisi Indonesia Bebas TAR (KABAR) is an alliance comprised of associations and organizations in the health sector that focus on reducing the dangers of tobacco and related to smoking health risks. Since its introduction to the public, KABAR has actively carried out various initiatives to educate the public about the dangers of TAR from tobacco combustible products, such as education programs, roadshows and an online information platform; has advocated for THR directly with Indonesian government and media; has achieved various research collaborations and has also participated in policymaking. In order to reduce smoking prevalence in the country, it is necessary to provide to the people accurate education and information on the dangers of smoking and the different risks of cigarettes and alternative tobacco products, and to support the tobacco harm reduction concept and its implementation in Indonesia. Unfortunately, the country has adopted WHO’s agenda which is very dogmatic; THR products do not have zero risk, she said, but significantly lower risk can save lives.

Directory of Information for Tobacco Harm Reduction (DIRETA) is an organization created to represent consumers of nicotine in Brazil and to share information about THR in order to reduce the impact of smoking, Alexandro Lucian (president of DIRETA, Brazil) said. The organization was formed by a group of specialists in pulmonology, psychiatry, toxicology, and harm reduction. Describing the situation in Brazil, Alexandro Lucian said that due to an immoral campaign of misinformation, most doctors along with the general population believe that vaping is as harmful as or even more harmful than combustible cigarettes. Vaping is not 100% safe, but it’s much less harmful than smoking conventional cigarettes, the speaker underlined. Still, we have to remember that this conclusion can only be made in regulated markets, where the quality of the products is controlled. In Brazil, recent data show high prevalence of vaping in the country; 7.3% of adults, more than 10 million consumers, have access to products without any sanitary control or quality assurance. Vaping, despite the fact that―although not safe― is evidently less harmful than the traditional combustible cigarettes, is considered much more dangerous in Brazil because of the misinformation, disinformation and lack of regulation, he concluded.

Dr. Fares Mili (Chairman of the Tunisian Society of Tobaccology and Addictive Behaviors – STTACA, Tunisia) then presented the main objectives, activities and achievements of STTACA. STTACA was created in 2017 as a no-smoking association promoting pharmacotherapy and counselling in smokers motivated to quit. Cognitive behavioural therapy is a powerful approach in addiction therapy and must be applied in tobaccology since smoking is an addictive behaviour, Dr. Mili said. STTACA’s activities include training projects aiming at smoking cessation and prevention of addictive behaviours, spreading scientific evidence about Tobacco Harm Reduction, and research in tobaccology and addictive behaviours. Since its foundation, the organization continuously advocates for THR, Dr. Mili said; a major success has been that the Society recently succeeded regulation of novel THR products in Tunisia. Currently, STTACA’s main project is its collaboration in the Tunisian Guidelines on Tobacco Addiction, along with several scientific societies and experts, adapting the NICE UK guidance on tobacco dependence, Dr. Mili concluded.

Smoking cessation and Harm Reduction go hand by hand and side by side, and they are two tasks that must be pursued, Professor Ignatios Ikonomidis (President of SCOHRE – International Association on Smoking Control & Harm Reduction, Greece) commented. Smoking cessation clinics, despite counselling and pharmacotherapies offered to smokers that struggle to quit, unfortunately face a lot of relapses, he explained, and we have seen that THR products can help people, if not to stop smoking, at least to reduce substantially the damage caused by this unhealthy behaviour to their health. Of course, all new products must be properly evaluated and regulated, he said, but you cannot compare the novel THR products with fresh air; they should be compared with cigarettes. Doctors should have all available data; they should be well educated and informed about all cessation methods, including Harm Reduction, he added, to be able to inform their patients correctly. As far as policymaking is concerned, in Greece the government created a Committee where the industry can submit claims about their products, Prof. Ikonomidis said. Such legislative and regulatory bodies should be formed in all countries, he concluded.

Summarizing the results of the discussion, Prof. Solomon T. Rataemane said that there is need for more research, increased and better communication of available data and information, as well as educational programs to medical and other university schools. Science communication should be improved to all stakeholders, he explained, and governments should understand that THR interventions improve public health.

We must all unite forces to advocate for HR, Lina Nikolopoulou added; we have to persuade politicians and regulators by informing them about the evidence step by step. Although there is mounting scientific evidence that innovative tobacco products are less harmful, invariably the argument used by government authorities is that the data are not yet adequate. However, there are obstacles to conduct research to build further the evidence. This is against the principles and values of scientific ethics, she underlined. SCOHRE advocates for more data to be generated and for further discussion, she said, and invited the members to participate in the drafting of an advocacy statement as conclusion of this Summit.