Despite increasing scientific evidence that alternative nicotine products can benefit smokers who switch from traditional cigarettes, acceptance remains limited. Only a few countries, such as the UK and New Zealand, have adopted such strategies, while resistance continues -fueled by the uncompromising stance of the World Health Organization (WHO).
In this highly interesting session, chaired by Dr. Lina Nikolopoulou, Managing Director of SCOHRE, distinguished speakers from Italy, Greece and the Czech Republic highlighted the growing international debate on the role of harm reduction in tobacco control strategies, and shared concrete progress and methodology to pursue the wider adoption of THR.
Smoking is the biggest risk for public health around the globe, Dr. Nikolopoulou said in her opening remarks. SCOHRE, an international nonprofit organization from experts around the globe, with more than 80 members from 30 countries, aims to advocate about harm reduction and to reshape strategies to include harm reduction as a pillar for smoking control strategies. Aim of this session is to raise awareness of existing knowledge and expertise from other countries regarding the role of THR in smoking control. “We cannot go against WHO —she said— we just need to be able to affect their perspective and advocate for THR based on solid scientific evidence and good practices from around the world.”
The Italian Consensus paper
Professor Pasquale Caponnetto presented the Italian approach that resulted to the first Italian Consensus paper regarding new strategies against smoking.
Smoking rates in Italy are about 20%, Prof. Caponnetto stated at the beginning of his presentation. And despite the decline in tobacco consumption in 2023, current control measures remain insufficient to achieve the WHO goal of 30% reduction by 2030. Hence, it is necessary to implement innovative strategies, and to use all the available resources, since every smoker is different and needs a tailored approach, the speaker underlined.
The objective of this consensus paper, he said, was to analyze prevention, cessation, and harm reduction strategies, to evaluate the role of combustion-free alternatives and to identify areas of consensus and controversy. The methodology followed was the Delphi Method, a structured technique used to reach consensus among 20 Italian experts through multiple rounds of anonymous evaluation. The importance of expert consensus arises from the need to identify combustion-free alternatives, such as electronic cigarettes and heated tobacco devices, to reduce smoking-related harm in Italy.
There is a need to invest in scientific information on new products. There are several clinicians that don’t know about the new reduced risk products, and many health professionals in Italy are not trained to the practice of smoking cessation. To balance public health protection with harm reduction strategies, it is important to have a risk proportionate regulation, a regulation based on the products’ risk profiles.
It is also important to promote prevention strategies and have a good policy for tobacco cessation by offering smokers several alternatives in order to obtain the principal objective that is the complete cessation, or as alternative, the smoking harm reduction.
Based on the results presented in the consensus paper, out of the 38 statements presented, 24 achieved consensus (> 85%), among which:
- Harm reduction as a valid strategy.
- The need for regulation based on scientific evidence.
- The importance of clear communication about alternatives.
- How electronic cigarettes (e-cig) and heated tobacco products significantly reduce the production and exposure to many harmful substances generated by combustion.
Now the paper needs to be disseminated in Italy, and then around the world, Professor Caponnetto said. We need to disseminate it for the new generation, since training to smoke cessation and tobacco reduction is the future.
Almost eight years back, Dr. Nikolopoulou commented, we ran a consensus panel in Greece with regulators, academia, and public health people (fewer clinicians). And the consensus we achieved at the time was a lot less than 85%, because the issue was immature, and there were a lot of gray areas. A Delphi panel and expert opinion is more or less the main tool used for evidence-based policymaking, when you need to engage many stakeholders, such as consumers, regulators, government officials, industry, the ministry and organizations, families etc., explained Dr. Nikolopoulou. Otherwise, without consensus or acceptance of society, very little can be done, she added.
Memorandum and advocacy efforts in the Czech Republic
The next speaker, Professor Lubos Petruzelka presented a Memorandum based on the first consensus on harm reduction in cancer prevention in the Czech Republic.
Four out of 10 most frequent cancers are linked to preventable risk factors, and tobacco smoking is the most important of these factors, Professor Petruzelka said. The Memorandum motto is that since complete elimination of risk factors is not always possible, harm reduction is the way to mitigate risk through practical, innovative, and accessible evidence-based approaches.
Harm reduction is a preventive strategy that focuses on minimizing risk factors contributing to cancer, as it is not always possible to completely eliminate risk. The goal of the harm reduction approach is to reduce the overall harm caused by unhealthy lifestyles, environmental factors, and exposures known to increase the likelihood of cancer. This involves reducing risks in practical, innovative, and accessible ways that are scientifically proven to improve overall health outcomes. The concept of harm reduction is an integral part of primary prevention and the concept of harm reduction approach is internationally supported with endorsement by important societies such as the American Society of Clinical Oncology, the Royal College of Physicians, and FDA, Prof. Petruzelka added.
The conclusion of our Memorandum, he continued, is that an individual’s oncological risk accumulates throughout life, and individual risk factors reinforce each other. The harm reduction concept should not be limited to a single area but applied wherever it may bring benefits, he added.
Future objectives of the working group include the use of artificial intelligence to individualize risk assessment and, in the context of harm reduction, to recommend tailored preventive strategies and increase the likelihood of timely intervention or more effective prevention. “We need to call to action and integrate harm reduction into national tobacco control strategies, educate health professionals, and avoid waiting decades for epidemiological data when current evidence is strong,” the speaker concluded.
THR implementation issues
Today, we have enough data to implement the harm reduction strategies; unfortunately, we miss the courage to do that, Dr. Jiri Votruba said. In Czech Pulmonary Society, there is still no consensus about THR. Older pulmonologists are completely against the alternatives, because they believe that anything coming from the producers of cigarettes is evil. Unless they change their mind about harm reduction, the struggle between people who think about the consequences and people who think about the past will continue for years. The situation for smokers who cannot quit smoking is a little bit difficult nowadays in our country, Dr. Votruba said, but we are doing our best to surmount this obstacle.
Prevention is a continuum, an important part of which is also the reduction of harm, Prof. Francesco Fedele said. Harm reduction can be a very effective tool in the strategy of prevention. Smoke-free alternatives are not risk-free, but there is good evidence that they are associated with reduced harm versus cigarettes.
Fortunately, in Greece, Prof. Ignatios Ikonomidis said, the Ministry of Health has accepted that these novel alternative to conventional cigarettes products are linked to a reduced exposure to toxicants compared to combustible cigarettes. This is a step forward, but recently the Minister of Public Health discussed about the fear that these products may replace smoking in young people, and may cause a new generation of vapors. So, they sort of equalize smoking with the use of novel products. However, the claim of reduced exposure to toxicants for the adults remain.
Cardiovascular and respiratory evidence from switching to smoke-free alternatives
Professor Francesco Fedele presented multiple studies highlighting the health benefits of transitioning from traditional cigarettes to electronic cigarettes and HTPs. Key findings included improved cardiovascular metrics, such as left ventricular function and aortic elasticity, as well as enhanced respiratory outcomes, including reduced exacerbation rates in COPD patients.
Smoke-free alternatives are not risk-free, but research consistently shows that they are associated with reduced harm compared to traditional cigarettes, Prof, Fedele said. Of course, he added, there is a need for long-term real-world studies to confirm these findings.
A lot of the data or information which have been heard are conclusive, Dr. Votruba commented. We do have conclusive information about the risk reduction of alternative products, we do have enough to change the policy, but we are not policymakers, so we should do something about it.
We have to fight against misinformation concerning THR, Dr. Nikolopoulou said, which is against the evidence from research. She read a post published earlier that day from Wopke Hoekstra, the Dutch EU Commissioner for Climate, as an example of misleading message, coming regrettably from the highest level: “We all know the dangers of tobacco, but nicotine in new products like vapes and e-cigarettes is also extremely harmful. It damages blood vessels, impairs vascular function, and stimulates growth tumours.”
We must ally and convey the message about the importance of this strategy for public health to the first level of doctors, i.e. medical students, she added. People trust their doctors more than their governments or other authorities.
SCOHRE’s Consensus
Today there’s mounting evidence that the use of harm reduction strategy, the use of alternative and lower risk products, is a policy that works and can improve smokers’ health, Professor Ignatios Ikonomidis, President of SCOHRE, underlined. Despite the opposite opinion of WHO and EU politicians’, evidence from countries that have adopted harm reduction policies, like United Kingdom, Sweden, Japan, Greece, and Czech Republic shows reduction in the number of smokers using combustible cigarettes. The use of novel smoking products is a reality, and we have data showing that switching to less harmful products can have a tremendous positive effect. People should be informed of all this data, Professor Ikonomidis said, and this includes patients, doctors, politicians, and regulators. Authorities have the obligation to inform citizens about the relatively lower risks that the newer products have vs. the undoubtedly deadly cigarettes. The failure to inform the public on relative risks and to encourage cigarette smokers to switch to less harmful nicotine alternatives is a violation of consumer rights.
Professor Ikonomidis reaffirmed SCOHRE’s commitment to reshaping tobacco control: “Harm reduction must become a recognized pillar of public health policy, alongside prevention and cessation. Increasing the knowledge of healthcare professionals, regulators, policymakers, and the public is essential. The evidence is undeniable: switching from cigarettes to less harmful nicotine products can save lives. Yet, misconceptions, resistance, and misinformation continue to hold back progress.”
Science, not ideology, should guide policy, and collaboration is essential — across countries, professions, and communities. Together, with partners and stakeholders, we are building momentum for a smoke-free world, he concluded.