How Do You Evaluate the Penetration of Tobacco Harm Reduction in Public Health Policies?

October 31, 2023

In order to be effective health and public health policymaking must be based on scientific evidence, but this is not always the case. Tobacco Harm Reduction is an example of that; despite the evidence showing the value of this strategy, its implementation still faces many obstacles worldwide. The penetration of tobacco harm reduction in public health policies was discussed by a group of experts from different countries and continents in a highly interesting session, moderated by Professor Sharifa Ezat Wan Puteh from Malaysia.

If we look at the map of the world, we can see that it is divided in three groups, three areas regarding THR, Dr Fares Mili from Tunisia pointed out at the beginning of his speech; one area in which Tobacco Harm Reduction is implemented officially as part of the public health policies (countries such as USA, UK, New Zealand); another one in which THR is discussed but is not yet implemented, and a third one where THR is not accepted at all and is banned. Countries where policies are based on science and evidence, Dr Mili explained, recognize the value of THR and include it in their health improvement strategies, while in countries where there are not enough scientific societies and politics is not based on evidence, THR advocates face many difficulties.

Describing the situation in Tunisia, Dr Mili said that since there is not a national tobacco program, the country is trying to implement the WHO’s international tobacco program, but unfortunately the EMPOWER program is costly and thus very difficult to be implemented in lower income countries. That’s why Tobacco Harm Reduction is a necessity for these countries and not a choice, he emphasized. So, in Tunisia, as part of the efforts to find a solution to help people minimize the damage caused by smoking, smoking and addiction have been reframed. Dealing with addictive behaviours is not the same than dealing with non-addictive behaviours, Dr Mili said. But nicotine is not the only responsible for the smokers’ addiction, he continued. Nicotine is delivered with some ‘boosters’, molecules called monoamine oxidase inhibitors, that are present only in smoke produced when tobacco is burned and contribute to nicotine addiction. These molecules do not exist in heated tobacco products and e-cigarettes, and this is why these products are not as addictive as the conventional cigarettes. The effort to reframe smoking in the context of addictive behaviours was successful―Dr Mili said―and as a result, 2 years ago in Tunisia a national guideline for tobacco addiction was launched that includes Tobacco Harm Reduction in its recommendations. It is important that smoking must not continue to be perceived as a consumer behaviour but as an addictive behaviour, Dr Mili concluded, since in this context Tobacco Harm Reduction will be a requirement and not a choice.

Many countries have different attitudes regarding public health policies, Professor Solomon Rataemane from South Africa said, some are very controlling while other have a more open, ‘democratic’ point of view. In South Africa, there is a number of people talking about how tobacco affects the human body and how the alternative methods of delivering nicotine could help in reducing tobacco-associated harm. Public health policymakers should always consider how the information shared will reach its target population group and check how the knowledge has changed people’s understanding, he noted. An intervention at population level is always a challenge, Prof. Rataemane said, since to be successful, such intervention should reach and benefit even the more disadvantaged groups, and also contribute to reduction of health inequalities. Not everyone has access to the knowledge about tobacco harm reduction, he explained, there are still people that do not use the internet or modern technologies to get informed. Also, the intervention should include restrictions of smoking in workplaces and public spaces, as well as restrictions of sales to minors, health warnings on tobacco products, and different pricing methods of tobacco products.

According to the Singapore study, a policy modelling study which evaluated 12 policy scenarios on their impact on smoking prevalence and annual quality-adjusted life years (QALYs) gained, policies with the best modelled outcomes were an aggressive tax regime that increases prices every 2 years and the prohibition of smoking amongst all individuals born after some point in time, Prof. Rataemane said.

The harm reduction framework in South Africa is an evidence-based approach that includes community-driven public health strategies, such as prevention, risk reduction and health promotion strategies, empowering people who use drugs and their families to choose a healthy lifestyle. It emphasizes engaging directly with people who use drugs to prevent overdose and infectious diseases transmission and to improve their physical, mental and emotional well-being, while it also builds awareness of existing services for helping with substance abuse and mental disorder treatment programs. All people should have the chance to make informed choices, Prof. Rataemane added, but some people―although informed―will still make the wrong choices. Countries can’t ignore these people since they are part of their population.

To assess the penetration of Tobacco Harm Reduction in public health policies of different countries, Prof. Rataemane concluded, we should look at the number of existing smoking cessation clinics and practitioners trained in THR programs; advocacy and knowledge distribution programs supported by government and NGOs; and meetings and conferences held to discuss nicotine science and tobacco harm reduction.

In his speech, Dr Lorenzo Mata explained how embracing Tobacco Harm Reduction through policy and regulation became reality in Philippines. “In my country, we are strong believers of the concept of Tobacco Harm Reduction―he said―since it offers new choices to millions of people worldwide who want to switch away from smoking or other dangerous forms of tobacco use but have been unable to do it with the options previously available.”

According to the 2021 Global Adult Tobacco Survey, Dr Mata said, in Philippines there are approximately 14 million smokers of combustible cigarettes, and 117,000 people die each year due to tobacco smoking, while the quit rate is only 4%. A noteworthy trend observed in the country, he added, is that the same survey showed a correlation between the decline from 2009 to 2021 of smoking prevalence and the rise of use of vaping products.

Vape Law in the Philippines, Dr Mata said, promotes Tobacco Harm Reduction as a State Policy, sets a differentiated regulatory framework for smoke-free alternatives, protects minors, non-smokers, and consumers with specific provisions, curbs illicit trade and ensures tax collection. Vape Bill is accepted by the whole society in the country, since doctors describe it as the ‘best hope’ to help millions of Filipinos who smoke to quit, consumers strongly support it, and government leaders characterize it as their ‘gift’ to save smokers’ lives. The ideal regulatory framework is differentiated, recognizing the differences between combustible cigarettes and smoke-free products, it is sufficiently protective for consumers and the industry, and it supports accessibility by providing smokers with reasonable access to regulated and less harmful alternatives to cigarette smoking.

Only when we provide less harmful options to adult smokers, we shift the balance in favour of the individual for a more inclusive public health policy, Dr Mata pointed out. Of course, the Law by itself is not enough, he added, since its success depends on the actual change it will bring to the society. Therefore, it is essential to further expand our circle of advocates within both civil society and the government, to continue educating smokers on cessation options, to monitor and advocate for the faithful implementation of the Vape Law (by the national and the local governments), and to open a dialogue on global best practices for vape regulation.