53 public health specialists write to WHO about alternatives to smoking – here’s the letter

Here below is the text of the letter sent to WHO this week, and full list of signatories (as a […]

Here below is the text of the letter sent to WHO this week, and full list of signatories (as a PDF here).  Now published on the next page – a reader’s guide to this letter.

Statement from specialists in nicotine science and public health policy

Dr Margaret Chan
Director General
World Health Organisation

CC: FCTC Secretariat, Parties to the FCTC, WHO Regional Offices

26 May 2014

Dear Dr Chan

Reducing the toll of death and disease from tobacco – tobacco harm reduction and the Framework Convention on Tobacco Control (FCTC)

We are writing in advance of important negotiations on tobacco policy later in the year at the FCTC Sixth Conference of the Parties. The work of WHO and the FCTC remains vital in reducing the intolerable toll of cancer, cardiovascular disease and respiratory illnesses caused by tobacco use.  As WHO has stated, up to one billion preventable tobacco-related premature deaths are possible in the 21st Century.  Such a toll of death, disease and misery demands that we are relentless in our search for all possible practical, ethical and lawful ways to reduce this burden.

It is with concern therefore that a critical strategy appears to have been overlooked or even purposefully marginalised in preparations for FCTC COP-6.   We refer to ‘tobacco harm reduction’ – the idea that the 1.3 billion people who currently smoke could do much less harm to their health if they consumed nicotine in low-risk, non-combustible form.

We have known for years that people ‘smoke for the nicotine, but die from the smoke’: the vast majority of the death and disease attributable to tobacco arises from inhalation of tar particles and toxic gases drawn into the lungs.   There are now rapid developments in nicotine-based products that can effectively substitute for cigarettes but with very low risks. These include for example, e-cigarettes and other vapour products, low-nitrosamine smokeless tobacco such as snus, and other low-risk non-combustible nicotine or tobacco products that may become viable alternatives to smoking in the future. Taken together, these tobacco harm reduction products could play a significant role in meeting the 2025 UN non-communicable disease (NCD) objectives by driving down smoking prevalence and cigarette consumption.  Indeed, it is hard to imagine major reductions in tobacco-related NCDs without the contribution of tobacco harm reduction. Even though most of us would prefer people to quit smoking and using nicotine altogether, experience suggests that many smokers cannot or choose not to give up nicotine and will continue to smoke if there is no safer alternative available that is acceptable to them.

We respectfully suggest that the following principles should underpin the public health approach to tobacco harm reduction, with global leadership from WHO:

1. Tobacco harm reduction is part of the solution, not part of the problem. It could make a significant contribution to reducing the global burden of non-communicable diseases caused by smoking, and do so much faster than conventional strategies. If regulators treat low-risk nicotine products as traditional tobacco products and seek to reduce their use without recognising their potential as low-risk alternatives to smoking, they are improperly defining them as part of the problem.

2. Tobacco harm reduction policies should be evidence-based and proportionate to risk, and give due weight to the significant reductions in risk that are achieved when a smoker switches to a low risk nicotine product. Regulation should be proportionate and balanced to exploit the considerable health opportunities, while managing residual risks. The architecture of the FCTC is not currently well suited to this purpose.

3. On a precautionary basis, regulators should avoid support for measures that could have the perverse effect of prolonging cigarette consumption. Policies that are excessively restrictive or burdensome on lower risk products can have the unintended consequence of protecting cigarettes from competition from less hazardous alternatives, and cause harm as a result. Every policy related to low risk, non-combustible nicotine products should be assessed for this risk.

4. Targets and indicators for reduction of tobacco consumption should be aligned with the ultimate goal of reducing disease and premature death, not nicotine use per se, and therefore focus primarily on reducing smoking. In designing targets for the non-communicable disease (NCD) framework or emerging Sustainable Development Goals it would be counterproductive and potentially harmful to include reduction of low-risk nicotine products, such as e-cigarettes, within these targets: instead these products should have an important role in meeting the targets.

5. Tobacco harm reduction is strongly consistent with good public health policy and practice and it would be unethical and harmful to inhibit the option to switch to tobacco harm reduction products. As the WHO’s Ottawa Charter states: “Health promotion is the process of enabling people to increase control over, and to improve, their health”.  Tobacco harm reduction allows people to control the risk associated with taking nicotine and to reduce it down to very low or negligible levels.

6. It is counterproductive to ban the advertising of e-cigarettes and other low risk alternatives to smoking.  The case for banning tobacco advertising rests on the great harm that smoking causes, but no such argument applies to e-cigarettes, for example, which are far more likely to reduce harm by reducing smoking.  Controls on advertising to non-smokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal. It is inappropriate to apply Article 13 of the FCTC (Tobacco advertising, promotion and sponsorship) to these products.

7. It is inappropriate to apply legislation designed to protect bystanders or workers from tobacco smoke to vapour products.  There is no evidence at present of material risk to health from vapour emitted from e-cigarettes. Decisions on whether it is permitted or banned in a particular space should rest with the owners or operators of public spaces, who can take a wide range of factors into account. Article 8 of the FCTC (Protection from exposure to tobacco smoke) should not be applied to these products at this time.

8. The tax regime for nicotine products should reflect risk and be organised to create incentives for users to switch from smoking to low risk harm reduction products. Excessive taxation of low risk products relative to combustible tobacco deters smokers from switching and will cause more smoking and harm than there otherwise would be.

9. WHO and national governments should take a dispassionate view of scientific arguments, and not accept or promote flawed media or activist misinterpretations of data. For example, much has been made of ‘gateway effects’, in which use of low-risk products would, it is claimed, lead to use of high-risk smoked products.  We are unaware of any credible evidence that supports this conjecture. Indeed, similar arguments have been made about the use of smokeless tobacco in Scandinavia but the evidence is now clear that this product has made a significant contribution to reducing both smoking rates and tobacco-related disease, particularly among males.

10. WHO and parties to the FCTC need credible objective scientific and policy assessments with an international perspective. The WHO Study Group on Tobacco Product Regulation (TobReg) produced a series of high quality expert reports between 2005 and 2010. This committee should be constituted with world-class experts and tasked to provide further high-grade independent advice to the WHO and Parties on the issues raised above.

The potential for tobacco harm reduction products to reduce the burden of smoking related disease is very large, and these products could be among the most significant health innovations of the 21st Century – perhaps saving hundreds of millions of lives.  The urge to control and suppress them as tobacco products should be resisted and instead regulation that is fit for purpose and designed to realise the potential should be championed by WHO. We are deeply concerned that the classification of these products as tobacco and their inclusion in the FCTC will do more harm than good, and obstruct efforts to meet the targets to reduce non-communicable disease we are all committed to.  We hope that under your leadership, the WHO and FCTC will be in the vanguard of science-based, effective and ethical tobacco policy, embracing tobacco harm reduction.

We would be grateful for your considered reaction to these proposals, and we would like to request a meeting with you and relevant staff and a small delegation of signatories to this letter. This statement and any related information will be available on the Nicotine Science and Policy web site (http://nicotinepolicy.net) from 29 May 2014.

Yours sincerely,

Signatories this statement at 26 May 2014

Professor David Abrams
Professor of Health Behavior and Society.
The Johns Hopkins Bloomberg School of Public Health. Maryland. USA.  
Professor of Oncology (adjunct). Georgetown University Medical Center,
Lombardi Comprehensive Cancer Center. Washington DC.
United States of America
Professor Tony Axéll
Emeritus Professor Geriatric Dentistry
Consultant in Oral Medicine
Professor Pierre Bartsch
Respiratory physician,
Faculty of Medicine
University of Liège
Professor Linda Bauld
Professor of Health Policy
Director of the Institute for Social Marketing
Deputy Director, UK Centre for Tobacco and Alcohol Studies
University of Stirling
United Kingdom
Professor Ron Borland
Nigel Gray Distinguished Fellow in Cancer Prevention at Cancer Council Victoria
Professorial Fellow School of Population Health and Department of Information Systems
University of Melbourne,
Professor John Britton
Professor of Epidemiology;
Director, UK Centre for Tobacco & Alcohol Studies,
Faculty of Medicine & Health Sciences
University of Nottingham,
United Kingdom
Associate Professor Chris Bullen
Director, National Institute for Health Innovation
School of Population Health,
University of Auckland,
New Zealand
Professor Emeritus André Castonguay
Faculty of Pharmacy
Université Laval,
Dr Lynne Dawkins
Senior Lecturer in Psychology,
Co-ordinator: Drugs and Addictive Behaviours Research Group
School of Psychology,
University of East London,
United Kingdom
Professor Ernest Drucker
Professor Emeritus
Department of Family and Social Medicine,
Montefiore Medical Center/Albert Einstein College of Medicine
Mailman School of Public Health
Columbia University
United States of America
Professor Jean François Etter
Associate Professor
Institut de santé globale,
Faculté de médecine,
Université de Genève,
Dr Karl Fagerström
President, Fagerström Consulting AB,
Dr Konstantinos Farsalinos
Researcher, Onassis Cardiac Surgery Center, Athens, Greece
Researcher, University Hospital Gathuisberg, Leuven,
Professor Antoine Flahault
Directeur de l’Institut de Santé Globale
Faculté de Médecine, Université de Genève, Suisse/ Institute of Global Health, University of Geneva, Switzerland
Professor of Public Health at the Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité,
Dr Coral Gartner
Senior Research Fellow
University of Queensland Centre for Clinical Research
The University of Queensland,
Dr Guillermo González
Comisión de Rehabilitación en Enfermedad Mental Grave
Clínica San Miguel
Dr Nigel Gray
Member of Special Advisory Committee on Tobacco Regulation of the World Health Organization
Honorary Senior Associate
Cancer Council Victoria
Professor Peter Hajek
Professor of Clinical Psychology and Director, Health and Lifestyle Research Unit
UK Centre for Tobacco and Alcohol Studies
Wolfson Institute of Preventive Medicine,
Barts and The London School of Medicine and Dentistry Queen Mary University of London,
United Kingdom
Professor Wayne Hall
Director and Inaugural Chair, Centre for Youth Substance Abuse Research
University of Queensland
Professor John Hughes
Professor of Psychology, Psychiatry and Family Practice
University of Vermont
United States of America
Professor Martin Jarvis
Emeritus Professor of Health Psychology
Department of Epidemiology & Public Health
University College London,
United Kingdom
Professor Didier Jayle
Professeur d’addictologie
Conservatoire National des Arts et Métiers
Dr Martin Juneau
Directeur, Direction de la Prévention
Institut de Cardiologie de Montréal
Professeur Titulaire de Clinique
Faculté de Médecine,
Université de Montréal,
Dr Michel Kazatchkine
Member of the Global Commission on Drug Policy
Senior fellow, Global Health Program, Graduate institute, Geneva,
Professor Demetrios Kouretas
School of Health Sciences and Vice Rector
University of Thessaly,
Professor Lynn Kozlowski
Dean, School of Public Health and Health Professions,
Professor of Community Health and Health Behavior,
University at Buffalo,
State University of New York,
United States of America
Professor Eva Králíková
Institute of Hygiene and Epidemiology
Centre for Tobacco-Dependence
First Faculty of Medicine
Charles University in Prague and General University Hospital in Prague,
Czech Republic
Professor Michael Kunze
Head of the Institute for Social Medicine
Medical University of Vienna,
Dr Murray Laugesen
Health New Zealand, Lyttelton,
New Zealand
Dr Jacques Le Houezec
Consultant in Public Health, Tobacco dependence, Rennes,
Honorary Lecturer, UK Centre for Tobacco Control Studies,
University of Nottingham,
United Kingdom
Dr Kgosi Letlape
President of the Africa Medical Association
Former President of the World Medical Association
Former Chairman of Council of the South African Medical Association
South Africa
Dr Karl Erik Lund
Research director
Norwegian Institute for Alcohol and Drug Research,
Dr Gérard Mathern
Président de l’Institut Rhône-Alpes de Tabacologie
Professor Richard Mattick
NHMRC Principal Research Fellow
Immediate Past Director NDARC (2001-2009)
National Drug and Alcohol Research Centre (NDARC)
Faculty of Medicine
The University of New South Wales,
Professor Ann McNeill
Professor of Tobacco Addiction
Deputy Director, UK Centre for Tobacco and Alcohol Studies
National Addiction Centre
Institute of Psychiatry
King’s College London,
United Kingdom
Dr Hayden McRobbie
Reader in Public Health Interventions,
Wolfson Institute of Preventive Medicine,
Queen Mary University of London,
United Kingdom
Dr Anders Milton
Former President of the Swedish Red Cross
Former President and Secretary of the Swedish Medical Association
Former Chairman of the World Medical Association
Owner & Principal Milton Consulting,
Professor Marcus Munafò
Professor of Biological Psychology
MRC Integrative Epidemiology Unit at the University of Bristol
UK Centre for Tobacco and Alcohol Studies
School of Experimental Psychology
University of Bristol,
United Kingdom
Professor David Nutt
Chair of the Independent Scientific Committee on Drugs (UK)
Edmund J Safra Professor of Neuropsychopharmacology
Head of the Department of Neuropsychopharmacology and Molecular Imaging
Imperial College London,
United Kingdom
Dr Gaston Ostiguy
Professeur agrégé
Directeur de la Clinique de cessation tabagique
Centre universitaire de santé McGill (CUSM)
Institut thoracique de Montréal,
Professor Riccardo Polosa
Director of the Institute for Internal Medicine and Clinical Immunology,
University of Catania, Italy.
Dr Lars Ramström
Institute for Tobacco Studies
Dr Martin Raw
Special Lecturer
UK Centre for Tobacco and Alcohol Studies
Division of Epidemiology and Public Health
University of Nottingham,
United Kingdom
Professor Andrzej Sobczak
Department of General and Inorganic Chemistry,
Faculty of Pharmacy and Laboratory Medicine,
Medical University of Silesia, Katowice, Poland
Institute of Occupational Medicine and Environmental Health
Professor Gerry Stimson
Emeritus Professor, Imperial College London;
Visiting Professor, London School of Hygiene and Tropical Medicine
United Kingdom
Professor Tim Stockwell
Director, Centre for Addictions Research of BC
Professor, Department of Psychology
University of Victoria, British Columbia,
Professor David Sweanor
Adjunct Professor, Faculty of Law, University of Ottawa
Special Lecturer, Division of Epidemiology and Public Health,
University of Nottingham,
United Kingdom
Professor Umberto Tirelli
Director Department of Medical Oncology
National Cancer Institute of Aviano
Professor Umberto Veronesi
Scientific Director
IEO Istituto Europeo di Oncologia
Former Minister of Health,
Professor Kenneth Warner
Avedis Donabedian Distinguished University Professor of Public Health
Professor, Health Management & Policy
School of Public Health
University of Michigan
United States of America
Professor Robert West
Professor of Health Psychology and Director of Tobacco Studies
Health Behaviour Research Centre,
Department of Epidemiology & Public Health,
University College London
United Kingdom
Professor Dan Xiao
Director of Department Epidemiology
WHO Collaborating Center for Tobacco or Health
Beijing Institute of Respiratory Medicine,
Beijing Chao-Yang Hospital,
Dr Derek Yach
Former Executive Director, Non-Communicable Diseases
Former Head of Tobacco Free Initiative,
World Health Organisation (1995-2004)
Senior Vice President Vitality Group plc
Director, Vitality Institute for Health Promotion
United States of America
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17 thoughts on “53 public health specialists write to WHO about alternatives to smoking – here’s the letter”

  1. How disappointing that this is the official response of UK’s Faculty of Public Health
    “E-cigarettes need same controls as tobacco

    Commenting on a letter published today to the World Health Organisation (WHO), from researchers and public health specialists about electronic cigarettes, Professor John Ashton, President of the Faculty of Public Health said:

    “FPH has concerns about the potential risks of e-cigarettes. Electronic cigarettes can certainly help people quit smoking. However, we need to weigh up the benefits of fewer people smoking against the risk of electronic cigarettes leading to more people starting to smoke, particularly children.

    “Most people start smoking when they under 16. That’s why many public health experts are concerned that the advertising of advertising electronic cigarettes could make it normal again to think smoking is glamorous, when it is anything but.

    “It’s too early to know if the reduction in harm from using e-cigarettes instead of smoking is greater than their potential risks. We don’t want to undermine efforts to help people quit smoking. What we really need is for electronic cigarettes to be subject to the same controls as tobacco, and e-cigarettes to be treated as a tobacco product, so they cannot be marketed or advertised.”

  2. Kurtis Sunday

    Reply to UK’s Faculty of Public Health:

    So e-cigarettes should not be marketed or advertised …

    … yet e-cigarettes “can certainly help people quit smoking” …

    … so, joining up the dots, you mean a product which can “certainly help people quit smoking” should not “be marketed or advertised”.

    Couldn’t make it up!

  3. Thrilled to see so very many distinguished people in the field of health write this brilliant letter to the WHO. How can they ignore this? I hope that, if they should do so, I do hope that the signatories will go to the media and tell people about it!

  4. Is it also not a straight-up untruth that “Most people start smoking when they under 16”?

    Carl Phillips has claimed that, although this was true historically, most people starting to smoke NOW are starting at the age of majority or above.

    1. Well, I think they meant 18 (as about 2/3rds of presently smoking people in GB started before that age, it’s about 30-40% before 16), but if we graciously assume that is an honest mistake then there is still the question if whether the age of initiation in GB *now* (for young people starting smoking today) is different to what it was decades in the past (when most current smokers started).

      Carl highlighted that in the US it appears that the age of initiation has been rising over time – http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm#ch5.10 – with a growing proportion of initiation at 18 or over.

      We puzzled over equivalent statistics for GB in a facebook discussion, but unfortunately the format of the routine national statistics here don’t really allow it to be so easily analysed as in the US. We speculated that something different might be happening here compared to the US, but it is hard to say without access to the original data (which I tried to get, but the most recent data wasn’t available to me from the national data archives). Will keep poking around to try to find out something more definite…

  5. Jill Rutter

    Hi Clive

    So how big would be the public health gain if

    a) none of the 20% of population smoked cigarettes any more and
    b) the entire population used ecigarettes.. (which must be the outer limit of public health/BMA nightmare)

    1. @Jill Rutter – massive, is the word. Given that the “health harms” of nicotine are on a par with caffeine (as John Britton points out, amongst others), and since getting on for 100% of the adult population of the UK drinks coffee habitually, without any apparent ill effects, then, logically, your point b) would not be an unpleasant situation. Well, not for normal, non-Prohibitionist puritans, at any rate.

    2. Clive Bates

      Hi Jill

      The DH puts the economic value of stopping smoking at £74,000 [see MHRA: Impact Assessment – Unlicensed Nicotine Containing Products

      The value of the health gains associated with a single successful quit attempt is very substantial – The Department of Health estimates it to be £74,000.

      This is based on a value of a life-year of £60,000 and estimate that average quit is worth 1.24 life years. So if all 10 million UK smokers switched that would give an upside of £740 billion. Crikey!

      However, assume there is a downside associated with e-cig use. It really is hard to know what this might be: it could be zero – and it could be welfare enhancing (ie. benefit), given people are paying for it and like it. This Multi Criteria Decision Analysis puts the relative harm at 1-3% depending on how you look at it. If adult smoking prevalence is 20% and the are 10 million smokers that implies a total of 50 million adults would take up vaping under the Rutter scenario.

      So take 3% as the relative risk of vaping to smoking (giving a £2,220 cost of vaping) and assume 100% adults vape. Do the numbers and you end up with a vaping cost of £111 billion and net benefit of £629 billion for the wholesale switch for 20% smoking to 100% vaping.

      Please view the calculation at this spreadsheet: Smoking to vaping cost benefit analysis.

  6. Alan Depauw

    The trouble is, despite our best efforts, despite what seems to be all the evidence supporting our argument, our detractors keep hammering out the same tired and discredited dogma to justify laws that destroy not only liberty but lives.

    Here in France, it’s likely that on 17 June legislation will be proposed that will prohibit vaping wherever smoking is banned. We await the justification but it will probably be that vaping is an incitement to smoke.

    It seems our legislators subscribe to the belief that if you repeat a lie often enough, people will believe it, and you will even come to believe it yourself.

    How to destabilise them? How to stall their legislative steamroller? This experts’ letter to the WHO is a mighty spanner in the works, which is up to the rest of us to wield and to tweet and to share and to quote as often as we can.

    1. Kurtis Sunday

      Yes, the French government intention is depressing – but is there not a very well organised vaping lobby in France? That is ground for hope.

      Here in Germany, yesterday, there was a two minute TV spot – all the usual stuff, aimed at children to get them to start ‘smoking’, ‘worse than cigarettes because there are not as dangerous as cigarettes’ (I will not even try and explain the ‘logic’ of that) and so on … However, earlier in the week there was a four-page article in Der Spiegel which was balanced and thus inevitably very positive.

      What I have observed is that very often sound-bite and text-bit coverage is very bad, rolling out the usual misinformation-hysteria – but that once journalists actually start doing proper investigating (which some of them do) a lot of the misinformation-hyteria sort of ‘vapourises’ because there is so little, if anything, behind it …

      You can also see this when on TV shows where anti-vapers have to argue with those who are supportive/knowledgable or simply reasonably objective. …

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  10. please someone reach the kenyan government, health officials and antitobacco campaigners please do…… we need help

    i have been seeking an audience to explain on electronic cigarettes but to no avail…. since there are distinguished doctors in this article…. are they able to reach the kenyan health professionals?

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