A powerful declaration makes a compelling case for tobacco harm reduction

The post provides the text of a letter sent to the public health authorities in Spain and related commentary. To go straight to the letter in PDF format, it’s here: Less Harm: International Declaration for a Smoke-free Spain, in English and en español.

• Introduction
• Text of the open letter
• Less Harm: International Declaration for a Smoke-free Spain
• 1. Anti-smoking policies must offer realistic solutions for smokers.
• 2. Harm reduction as a complementary tool for advancing the fight against smoking.
• 3. Scientific advances, not opinions, must be the cornerstone of the fight against smoking.
• 4. More training for health professionals and more information for smokers.
• 5. Harm reduction products need differentiated treatment and regulation.
• 6. More restrictions on combustible tobacco products.
• 7. Learn from the experience of other countries in the fight against smoking.
• 8. Promoting research on these products through public-private sector collaboration.
• Launch video channel
• My public comment
• Short overview video
• Data: Spain is behind the EU average on smoking and lagging on harm reduction

Introduction

With around one-third of Spanish adults still smoking, 170 national and international experts have come together to sign an open letter to call for new thinking regarding tobacco harm reduction. The letter is directed to the Spanish authorities as they consider changes to tobacco and nicotine policy over the next few months. It could apply anywhere.

The letter sets out the reasoning for a more open approach to the use of smoke-free alternatives as part of a broad government strategy. Smoke-free products (vaping, nicotine pouches, heated tobacco products etc.) will drive out cigarettes and make major health improvements among those who switch or are diverted from smoking.

Spain has a well-funded and vocal tobacco control movement, but it’s ideas are not succeeding in terms of the results that count. Spain has above the EU average smoking prevalence and a very low rate of the use of smoke-free alternatives.

Our letter argues that it is time for a rethink…

The full letter, references and signatories (including me) and here in English; en español

Text of the open letter

Starts here…

Less Harm: International Declaration for a Smoke-free Spain

The signatories of this declaration, “Less Harm: international declaration for a smoke-free Spain” are public health experts and social-health professionals committed to the fight against smoking, to which doctors and scientists from Spain and 38 other countries have adhered, whose common objective is to reduce the number of smokers.

In Spain, smoking policies have been focused solely on prevention and cessation. However, these measures alone are not enough as they fail to reduce smoking rates or bring them out of stagnation, as the most recent data show. According to the latest EDADES 2019/2020 survey, Spain today has the same smoking rates, 32.3% of the population between 15 and 64 years of age, as in 2005, 32.8%, just before the approval of what is known as the first anti-smoking law.

On the other hand, we would like to point out that many countries recognized for their anti-smoking policies, such as the United Kingdom, New Zealand, Canada, France, and the United States, have responded to the exhaustion of traditional policies with innovative approaches that, on the one hand, take into account the current behaviour of smokers, new forms of consumption and the most advanced science and, on the other, seek to provide pragmatic solutions to the thousands of smokers who are unable or unwilling to quit smoking.

For this reason, we believe that the Spanish authorities have a golden opportunity to apply new measures in the fight against the diseases caused by smoking that are giving significant results in those countries where they are already being applied.

For this reason, and with the aim of contributing to a more effective and rapid reduction in the number of smokers in Spain, we present “Less Harm: International Declaration for a Smoke-free Spain“, which includes a series of proposals for a comprehensive approach in the fight against smoking that takes into account the society and the reality of the 21st century.

1. Anti-smoking policies must offer realistic solutions for smokers.

Prevention and cessation have been and are key pillars in the fight against smoking. We agree that these types of actions are fundamental and should continue to be a central support to avoid initiation and achieve smoking cessation. However, cessation and prevention alone are not efficient to reduce the high smoking rates most effectively, as they do not offer a sufficient solution for those people who do not manage to quit smoking through the usual tools. In this sense, it is necessary to incorporate new tools that help modernize policies and minimize the harm that smoking causes to people who smoke.

2. Harm reduction as a complementary tool for advancing the fight against smoking.

There are a lot of smokers in Spain. At least 4.5 million people are unable to quit smoking despite having tried to do so, and according to different studies, only 35% of smokers succeed in quitting with the usual cessation tools; furthermore, relapse rates are very high. In addition, many people who smoke simply do not plan on quitting. For this reason, it is essential to support tools that provide a solution to this problem. In this sense, policies aimed at reducing the harm caused by smoking are an additional route to cessation and prevention in order to achieve this. There is strong scientific evidence and international experience showing that alternative products, such as electronic cigarettes or smoke-free tobacco, can be part of the solution and not part of the problem in the fight against smoking.

3. Scientific advances, not opinions, must be the cornerstone of the fight against smoking.

As with any issue affecting public health, science should be at the core of any health plan, not preconceived ideas, sensationalism or opinions. In the case of e-cigarettes, heated tobacco, snus and other nicotine products with harm reduction potential, science has already proven in many cases that they are far less toxic than combustible cigarettes and can also help people quit smoking and reduce disease rates in the population, making these devices potentially great tools to help those who do not succeed in quitting, as long as they are properly and specifically regulated to avoid use by never smokers. For example, as a result of this scientific evidence, the UK public health agency recently announced that the UK will be the first country to prescribe medically authorised e-cigarettes for smoking cessation within its National Health Service.

On the other hand, it is essential to listen to all scientific perspectives without exclusion or censorship of any kind in order to optimise the effectiveness of anti-smoking policies. Therefore, the proposed comprehensive tobacco control plan should consider all the available scientific evidence and not just a part of it. Scientific debate, dialogue and not an excluding monologue, is the key for science to move public policies forward. Authorities must listen to the opinion of all professionals and experts who face the daily damage caused by smoking, without persecution or false accusations.

4. More training for health professionals and more information for smokers.

There is a considerable lack of knowledge among the medical community about the potential of harm reduction products in the fight against smoking. Therefore, taking science as the backbone of our proposal, training programmes should be implemented for health professionals (both in the public and private sectors) on the characteristics of these tools and the cases in which they can play a beneficial role. Simultaneously, smokers should have as much information as possible about them. To this end, objective and scientifically validated public information should be provided, always contextualising the fact that these products are not harmless and should only be considered by adult smokers who have tried to quit smoking and have not succeeded. Likewise, efforts must be redoubled to ensure that minors and non-smokers do not start using either traditional tobacco or these new products, without harming adults who need to quit smoking.

5. Harm reduction products need differentiated treatment and regulation.

Harm reduction products such as e-cigarettes and heated tobacco should be regulated as they are not risk-free. However, as they have scientifically proven benefits that can be of significant help to many smokers, they should be clearly regulated differently from traditional combustible cigarettes and should take into account the lower health risk compared to combustible tobacco products. Treating them as the same in terms of public health is a serious mistake, as the message to smokers is that both products have the same impact on their health and therefore removes any incentive to consider switching to less harmful alternatives when other attempts to quit have failed. Making these products equal in terms of access restrictions of any kind for adults, taxation, properties and image to conventional tobacco will only result in thousands of people continuing to smoke and, unfortunately, becoming ill and dying.

6. More restrictions on combustible tobacco products.

Smoking tobacco, which involves inhaling smoke produced by combustion, is the most harmful form of nicotine consumption and the most widespread among the population. It is therefore necessary to strengthen measures against these products, especially the ones most widely consumed by young people, such as roll-your-own tobacco and manufactured cigarettes. The consumption of these products causes the death of 60,000 people a year in Spain.

Therefore, we will support any measure included in the plan that is aimed at increasing taxes and the application of generic packaging for combustion cigarettes, as well as awareness campaigns.

7. Learn from the experience of other countries in the fight against smoking.

Countries such as the UK and New Zealand, among others, are already successfully implementing policies that combine particularly restrictive treatment and regulation of combustible tobacco use with strategies that encourage the use of harm reduction tools for adult smokers. According to the latest Eurobarometer, which also includes the United Kingdom, the smoking rate in this country stands at 12%, five points lower than in 2017. Likewise, in New Zealand, since its Ministry of Health launched its campaign to support the e-cigarette as a tool to quit smoking, the reduction in smoking rates has seen a significant acceleration, reaching a historic decrease of almost 3 points in a single year.

8. Promoting research on these products through public-private sector collaboration.

Scientific advances and technological developments encourage us to believe that the goal of progressively making harm reduction products practically safe for the consumer is achievable. Following the example of other countries, we propose to promote a programme of continuous communication from public authorities to encourage the private sector to devote all possible resources to research into harm reduction products, with the ultimate goal of ending the lethal combustible tobacco use as soon as possible.

With the first Anti-tobacco Law, Spain was at the forefront of the fight against smoking in 2005, becoming an international benchmark. Therefore, more than fifteen years later, Spain has the opportunity to lead this fight again, combining and increasing the effective actions of the past with innovative strategies that are committed to measures adapted to the current reality and that take into account all the new evidence and scientific contributions, as has already been done in nearby countries. Forgetting these strategies, which minimize the damage, will soon make us lead in the rate of diseases caused by smoking at European level.  To this end, the proposals contained in this declaration are intended to advance along these lines with the aim of reducing the number of smokers and the impact of diseases caused by smoking in Spain.

End of letter text.

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Launch video channel

My public comment

For the millions of people who use nicotine, there will eventually be a seismic shift from the use of high-risk cigarettes to low-risk smoke-free products. This is inevitable. The main question is how fast that shift will happen and how much death and disease we suffer in the meantime. Will governments and anti-tobacco activists obstruct the transition and prolong the smoking problem or will they encourage smoke-free innovation to address the disease burdens of smoking?

170 national and international experts have come together to make pragmatic proposals to address the burden of disease caused by smoking. If the Spanish authorities take up the proposed tobacco harm reduction strategy, we can expect to see Spain’s smoking rates fall rapidly.

There is a powerful, well-funded tobacco control establishment in Spain, but the data shows that its ideas have not been working that well for public health. Their defensive hostility to innovation in this field is misplaced and irresponsible. Right now, they are doing more harm than good, and that has to change

Clive Bates, Director, Counterfactual Consulting, a sustainability and public health consultancy, and former Director of Action on Smoking and Health (UK).

Short overview video

In this two-minute video, I make five main points:

1. We now have smoke-free products (vaping, heated tobacco, pouches, snus etc), and we know beyond any reasonable doubt are much less risky than smoking. We know this from measurements of toxicants in blood, saliva and urine – in smoke-free products, most toxicants are either not detectable or present at much lower levels.
2. We know vaping products displace smoking and function as substitutes -for adolescents and adults. We know this from randomised controlled trials, observational studies, population trends and economic data.
3. The public has a very poor understanding of the relative risks of smoking and vaping. It is a professional responsibility for health professionals, government officials, and advocates to communicate the benefits of switching from smoking to vaping honestly and candidly.
4. The uptake of smoke-free products by adolescents is a legitimate concern. But we must get this in perspective – most teenage is experimental, transient, and not very risky. But for some teens who would otherwise have smoked, it is potentially a highly beneficial diversion from cigarettes.
5. The policy approach for tobacco and nicotine products should be “risk proportionate”, applying the strictest measures to the most dangerous products (cigarettes). For smoke-free products, we should use proportionate regulation to underpin consumer protection and confidence and to encourage switching from high-risk to low-risk products.

There is a tremendous opportunity now available to address the burden of disease and death caused by smoking. We have a profound responsibility to make that opportunity work for public health. We must not squander it for ideological reasons or take a just-say-no or war-on-drugs mindset about nicotine. That is the road to failure.

Data: Spain is behind the EU average on smoking and lagging on harm reduction

Data from the European Union Eurobarometer Survey 506 (data) shows Spain has above the average EU daily smoking prevalence and considerably below the average uptake of e-cigarettes. That could change for the better, but only with the right mix of policy and communications and some fresh thinking from Spain’s tobacco control establishment.