The WHO Strategies to Reduce Tobacco-Related Deaths Are Insufficient

Correspondence: papers@team.qeios.com — Qeios will forward to the authors

The World Health Organization’s Framework Convention on Tobacco Control (FCTC) is an international treaty established in 2005 that provides a framework for tobacco control measures to be implemented at the national, regional, and international levels. ^[1] It has been ratified by 182 countries, thereby making them parties to the FCTC. Every second year, the parties come together at a conference to discuss current matters.

Preparations are now underway for the 10^th Conference of the Parties (COP10) in Panama in November 2023. At the same time, smoking continues to be the number one preventable cause of death and disease in the world. This calls for improved measures to reduce smoking. However, several prominent experts have raised concerns about whether the scientific advice provided to date by the WHO to the parties of FCTC accurately reflects our scientific knowledge of how the FCTC could do more to reduce smoking-related death and disease. ^[2][3]

Analyses of the impact of the FCTC so far have shown mixed results. For example, a study published in the British Medical Journal in 2019 reported that after the adoption of the FCTC in 2005, a decrease in annual cigarette consumption had occurred only in High-Income and European countries, whereas Low- and Middle-Income and Asian countries showed an increase. These findings should caution against complacency in the global tobacco control community and encourage the design of more effective tobacco control policies. ^[4]

At the heart of the debate at COP10 will be the question of how governments should deal with “novel and emerging tobacco and nicotine products.” This essentially means e-cigarettes (non-tobacco products that vaporize a liquid solution typically containing nicotine), low-risk oral tobacco (primarily Swedish snus, a product consisting of finely ground tobacco that is not to be burned but just placed under the upper lip), heated tobacco products (products that are heated but not burned), and nicotine pouches (small teabag-like sachets containing nicotine but no tobacco).

The WHO’s view, which is largely reflected in current FCTC/COP reports and decisions taken to date, is that these products are a new danger to public health, threatening to unwind decades of progress in fighting smoking. However, increasing numbers of scientists and national governments assume that these alternative products represent an opportunity that can accelerate the demise of smoking. ^[5] Because they don’t burn tobacco, they are estimated to be far less harmful than smoking. To the extent that they can act as a substitute, they can displace smoking and improve public health. ^[6][7]

Most of what we know as “tobacco-related” deaths are, in fact, “smoking-related” deaths caused by repeated inhalation of the smoke that is emitted when tobacco is lit on fire. Nearly all cases of smoking-related disease (cancer, heart disease, etc.) are caused by the combustion products, not by the nicotine. When burning is taken out of the equation, the harm can be dramatically reduced. We have known for decades that “people smoke for nicotine but die from the tar.” ^[8]

Although the proportion of smokers has been declining in many countries, we are not winning the battle against deaths attributable to smoking. The data from the seminal study, Global Burden of Disease (GBD), show that age-standardised rates of death from lung cancer, the cause of death most strongly related to smoking, remain unchanged in low- and middle-SDI (Socio-demographic Index) countries and have declined in high-SDI countries only. ^[9]

The best example of how products that don’t burn tobacco can benefit public health comes from Sweden, which has the lowest smoking prevalence among men in the European Union and consequently the lowest tobacco-related mortality. This is because in previous decades, men in Sweden have increasingly abandoned cigarettes in favour of snus (a similar trend is now happening among women). Already in 2008, a report by the Tobacco Advisory Group of the Royal College of Physicians stated, “Swedish data provide proof of concept that substitution of smokeless for smoked tobacco can be effective as a harm reduction strategy.” ^[9] Further data have been provided by later studies, for example, a Swedish survey of a representative sample containing 60,675 respondents published in 2016 in the International Journal of Environmental Research and Public Health. ^[10] Some of the main conclusions are:

• In Sweden, increasing initiation of snus use has been accompanied by decreasing initiation of smoking and an increasing proportion of non-initiation of any tobacco use.
• Smokers who have taken up daily snus use are significantly more likely to become smoke-free than those without uptake of snus.
• Snus as a self-administered aid for smoking cessation yields higher success rates than nicotine gum or a patch.
• Snus favours public health both by decreasing initiation of smoking and by increasing cessation of smoking.

Yet, the WHO’s scientific advisory body persists in arguing against endorsing the use of less harmful nicotine products (including snus) to reduce tobacco-related deaths. It is alleged that the benefits have not been demonstrated, while the potential for harm remains. ^[11] Recently, the WHO reiterated that all tobacco and nicotine products should be restricted and taxed the same. ^[12] This is consistent with the WHO’s earlier implicit, and sometimes explicit, recommendation that countries ban these products outright or regulate them the same as deadly cigarettes, despite the vast differences in health risks and the fact that smokers in more countries than Sweden have started switching to the alternative, far less harmful products. ^[13]

Norway is now following a similar trajectory as Sweden, with daily smoking at record-low levels and virtually on the brink of extinction among some population groups, largely due to snus.

In Japan, large numbers of smokers have switched to heated tobacco products, contributing to a decline in smoking never seen before, falling from around 20% in 2014 to 13% in 2019.

In New Zealand, the use of e-cigarettes, “vaping,” has helped reduce daily smoking to 8% and contributed to a rapid fall in smoking rates, even among Pacific and Māori populations where traditional interventions have been failing.

Even in the United States, despite concerns about youth vaping, the data are remarkably positive, indicating that youth experimentation with vaping does not translate into more young adults using nicotine or smoking. In fact, the biggest declines in smoking are among young adults, the population with high uptake of vaping, with overall nicotine use (vaping and smoking) falling more rapidly than in other age groups.

But despite the evidence, the WHO’s advice on heated tobacco products and e-cigarettes has been similar to their previous advice on snus, highlighting risks that these products may present and downplaying the evidence that shows how they can reduce smoking.

Experts have warned that the WHO’s scientific advice misrepresents the evidence and may even be counterproductive, as significant restrictions on alternative products could lead to the unintended effect of increasing smoking. ^[14] There are also concerns that the WHO’s spread of misinformation is likely to deter smokers from switching to a much less risky alternative. ^[15]

The meeting of the world’s health leaders in Panama in November represents a unique opportunity to take a fresh look at the most recent evidence with an open mind. After all, if Sweden had followed the WHO’s advice from twenty years ago and banned snus, tobacco-related deaths in Sweden would have been far higher, and the only unintended beneficiary profiting from such advice would be the cigarette industry. The measures for Demand Reduction and Supply Reduction recommended by the WHO are certainly valuable tools. But the fight is not maximally effective without the third pillar stated in Article 1d of the FCTC - Harm Reduction. The COP10 meeting in November could be an opportunity for FCTC countries to urge the WHO to apply the clear evidence that replacing cigarettes with less harmful products can save lives.