Expert statements on WHO and tobacco harm reduction

100 experts sign a public letter on the failure of the WHO approach to tobacco smoking and public health. In this post, they express their views in their own words 

100 experts have come together to publish a joint letter expressing grave concerns about the approach taken by the World Health Organisation to tobacco science and policy.  We believe WHO is on the wrong track.

The letter in PDF form in English, French, and Spanish and the full text were published on 18 October and will be sent to delegates of the Ninth Session of the Conference of the Parties (COP-9) of the Framework Convention on Tobacco Control, a global intergovernmental treaty in which WHO plays a major role. This meeting will be held on 8-13 November 2021: details are on the COP-9 website. 

In this post, several of those signing the letter provides their own perspective in their own words.

We start with a statement by Professor David Nutt of Imperial College, London commenting on the publication of the letter. Following that, the are statements from several other signatories to the letter about WHO and its approach to tobacco science, policy and practice.

Statement by Professor David Nutt, Imperial College, London

Smoking causes a massive burden of death and disease worldwide, killing about eight million people annually and so on a similar scale to the COVID pandemic so far. But we now have vaping and other smoke-free alternatives to cigarettes that can dramatically cut the risks for people who cannot or do not want to quit using nicotine. There is no real scientific doubt that these smoke-free products are much safer than smoking and that they can help smokers quit. So we should be working hard to make that happen.

And yet the World Health Organisation has dug in against vaping and the other alternatives and is throwing every possible obstacle in the way. WHO continues to insist that smokers should just stop, even though we know millions of smokers simply will not do that and millions will continue to take up the habit. There are no other areas of public health where just demanding abstinence or trying to enforce abstinence via prohibition is seen as a credible strategy, but that is exactly what WHO is advocating for nicotine. The idea of harm reduction is deeply embedded in drugs and sexual health policy, for example. But for nicotine, it seems WHO would rather adopt an ideological stance and fail than take a pragmatic approach and save lives.

One hundred experts have come together to call for an independent review of WHO’s scientific and policy analysis and to challenge its decision-making. We are calling on the WHO leadership to launch a comprehensive rethink. We need to see some sign that WHO is embracing innovation, not squandering the opportunity to make a real difference to the global burden of cancer, heart disease and crippling lung conditions.

Professor David Nutt DM FRCP FRCPsych FBPhS FMedSci DLaws
Edmond J Safra Chair and Director
Centre for Neuropsychopharmacology
Division of Brain Sciences
Department of Medicine
Imperial College, London

Notes: Professor Nutt’s biography. Signed statement PDF.

Comments on WHO and tobacco harm reduction from other letter signatories

The statements and declarations below were provided by experts in tobacco and nicotine policy who signed the letter. The comments were provided for World No Tobacco Day, 31 May 2021.  Unless stated explicitly, the authors have no conflicts to declare.

We are extremely disappointed by WHO’s illogical and perverse approach to reduced-harm nicotine delivery products, such as vaping, which are a way of limiting the harm caused by burnt tobacco. A key challenge in global tobacco control is to assist cigarette smokers to transition from burnt tobacco products to much less harmful options that provide the nicotine without the toxic smoke. WHO’s continuing disregard of the wealth of evidence on the value of these products is condemning millions of smokers to preventable disease and premature death.

Ruth Bonita, MPH, PhD, MD (hon)
Former Director of WHO Department of NCD Surveillance
Robert Beaglehole, MD, DSc
Former Director WHO Department of Chronic Disease Prevention and Health Promotion
Emeritus Professors
University of Auckland, New Zealand

Effective public health efforts need to be based on science, reason and humanism. Yet the world’s premier health body is aligning itself against all three when dealing with nicotine. The result is that one of the greatest opportunities to improve global health, separating nicotine use from smoke inhalation, is being squandered.  Global trust in health authorities, and the WHO in particular, has never been so important. Yet the WHO is abandoning science, rationality and humanism on nicotine and instead apparently pursuing the moralistic abstinence-only agenda of external funders. This is a public health tragedy that extends well beyond the unnecessary sickening of the billion-plus people who smoke cigarettes.

David Sweanor, JD
Adjunct Professor of Law
Chair of the Advisory Board of the Centre for Health Law, Policy and Ethics
University of Ottawa, Canada

WHO of all Institutions should base its policies and recommendations on the best and strongest scientific evidence available. The WHO can do better at saving the lives of over a billion smokers by updating its science and by correcting the massive misinformation that all forms of nicotine and tobacco -products are equally deadly and thus smokers should quit or die rather than reduce their harms dramatically by using dramatically less harmful modes of nicotine delivery.

The WHO misinformation is not science at its best,  it is tantamount to embracing propaganda. Propaganda that  conflates all tobacco and nicotine products as being equally harmful. This is unacceptable from such an august and respected body as WHO, it is antithetical to the core values of WHO –  of social justice, eradication of preventable chronic diseases where combusted (smoked ) tobacco and some forms of smokeless tobacco but not nicotine itself is the primary driver of chronic diseases, death and untold suffering.

David B Abrams PhD.
Professor of Social and Behavioral Sciences
New York University School of Global Public Health

Misinformation that conflates the term tobacco control with all forms of nicotine delivery regardless of harm thus egregiously deprives smokers, the public, policymakers and governments of responsible policymaking and individual choice, grossly ignores the full weight of current scientific evidence, evidence that can and should more rapidly make the most lethal combusted forms of smoked tobacco obsolete and save millions and millions of lives and suffering much sooner that could otherwise be achieved.  Telling the whole truth to the world should be the sole mission of WHO and it can and should do better.

Raymond Niaura PhD.
Professor of Social and Behavioral Sciences
New York University School of Global Public Health

Vaping and snus are likely to be the greatest health advance of this coming century and could save nearly a billion lives. The WHO should embrace the opportunity not block it 

David Nutt DM FRCP FRCPsych FMedSci DLaws
Edmond J. Safra Professor of Neuropsychopharmacology
Imperial College London

The WHO blithely, and quite wrongly, claims that switching from smoking cigarettes, by far the leading preventable cause of premature death and disability, to far less harmful e-cigarettes—which they cleverly but unscientifically imply may be deadly—is not quitting,

Clifford E. Douglas, J.D.
Director, Tobacco Research Network
Adjunct Professor, Department of Health Management and Policy
University of Michigan School of Public Health

Health policy should be driven by science, not prejudice or dogma. Vaping has already provided an effective gateway out of smoking for millions of people, unequivocally benefitting individual smokers, public health and wider society. It beggars belief that the WHO appears to be incapable of understanding the basic science, or designing rational policy to capitalise upon, rather than reject, the opportunities that harm reduction offers. By seeking to block access to less hazardous nicotine products, other than licensed medicines, the WHO is adding and abetting the tobacco industry to kill millions of people.

John Britton, MD
Emeritus Professor of Epidemiology
School of Medicine
Nottingham University

For pregnant women who smoke, quitting smoking is the most important health behaviour change to make to improve the chances of having a healthy, term baby. It is much safer to switch to using a nicotine containing e-cigarette or nicotine replacement therapy if that helps the woman stay completely smoke free, as it is the carbon monoxide in tobacco smoke, not the nicotine, that reduces blood flow through the placenta during pregnancy. Pregnant women may need to use higher strength nicotine containing products to help them stop smoking tobacco completely. Metabolism is faster during pregnancy so women need more nicotine, not less, so that they do not experience withdrawal when they try to stop smoking. It is vital that pregnant women who quit do not relapse back to tobacco smoking.’

Caitlin Notley, PhD
Professor of Addiction Sciences
Norwich Medical School
University of East Anglia

It is the smoke from cigarettes that kills, not the nicotine. The starting point for rational regulation of tobacco has to be to an appreciation of the risks: favour non-combustibles and bear down on cigarettes and other combustibles. It’s a no-brainer.

Martin Jarvis OBE, PhD
Emeritus Professor of Health Psychology
University College London

The World Health Organisation is on the wrong track

When smokers switch to vaping, they maintain nicotine use, but their intake of toxicants responsible for the main health risks of smoking is almost entirely removed. Yet time and again, in a stark contrast to its proclaimed mission to promote health, the World Health Organisation (WHO) has been urging regulators to prevent such switching and discouraging smokers from attempting it. Their latest pronouncement that switching from smoking to vaping ‘is not quitting’ shows the bizarre moralistic underpinning of their stance. Low-risk alternatives to smoking represent the best chance we ever had of eradicating smoking-related disease and death. The efforts to stop this happening pose a reputational risk to the whole organisation.

Peter Hajek, PhD
Professor of Clinical Psychology
Director of the Health and Lifestyle Research Unit
Wolfson Institute of Preventive Medicine
Queen Mary University of London

The evidence base is growing that when you regulate e-cigarettes so they are harder to purchase and/or less appealing to use, there is more combustible tobacco product use across all populations. WHO should acknowledge that e-cigarettes (and snus) are safer products, and advocate regulating proportionate to risk, in order to improve population health.

Michael F. Pesko, PhD
Associate Professor
Department of Economics
Andrew Young School of Policy Studies
Georgia State University

Closing the life-saving escape route that smokers can have in snus and e-cigarettes is a bit like closing the door to the fire escape because the steps may be slippery

Karl E Lund, PhD
Senior Researcher
Norwegian Institute of Public Health

The status-quo is unacceptable – 8-million deaths from cigarettes just this year, more next and the year after that.  WHO’s ideologic, non-science based position on lower risk nicotine products as substitutes for deadly cigarettes is costing lives and protecting the profits of the very companies they wish to put out of business. Please update your tobacco control playbook, lives are stake.”

K. Michael Cummings, PhD, MPH
Professor,
Medical University of South Carolina, USA

Evidence from six completely different sources demonstrates that vaping is increasing smoking cessation.

1. Randomized controlled trials. The Cochrane Review, the gold standard of scientific credibility, says there is “moderate certainty evidence” that vaping increases smoking cessation more effectively than do nicotine replacement therapy products.
2. Population studies find e-cigarettes increasing smoking cessation, especially when people use e-cigarettes frequently.
3. As e-cigarette sales rise, cigarette sales fall. Econometric studies confirm the two products are substitutes.
4. Other studies have found that policies intended to decrease youth vaping have increased youth smoking. Another study found that a tax on e-cigarettes in Minnesota increased adult smoking and decreased smoking cessation.
5. Multiple simulation analyses have concluded that the potential benefit of vaping for adult smoking cessation substantially outweighs any risk that vaping might increase youth smoking.
6. Swedish men’s substituting snus, a smokeless tobacco product, for cigarettes demonstrates the potential for lower-risk products to dramatically reduce tobacco-produced diseases.

Tragically, public health organizations that focus exclusively on the potential risks of vaping for young people – risks that, frankly, have been grossly exaggerated – are likely to be damaging the health of the public.

Kenneth Warner, PhD
Avedis Donabedian Distinguished University Professor Emeritus of Public Health,
Dean Emeritus of Public Health
University of Michigan

Long-term smoking cessation is notoriously difficult to achieve, and tobacco use results in millions of avoidable deaths each year. The aim of tobacco control should be to reduce tobacco-related preventable morbidity and mortality. To achieve this goal, as the WHO statement says, “we must be guided by science and evidence”. It is therefore disappointing to see that this WHO statement makes questionable and anti-scientific claims about the role that e-cigarettes can play in helping smokers to quit and live longer.

There is now substantial evidence, both from clinical trials and real-world studies, that e-cigarettes are as effective as other proven cessation medications and have helped millions of smokers, who have struggled to stop with other means, to quit cigarettes for good. While not harmless, numerous studies have shown that compared with cigarettes e-cigarettes significantly reduce exposure to toxic and carcinogenic compounds that cause the majority of smoking-related illnesses. This will like reduce the death toll if smokers switch over to e-cigarettes completely. We should provide smokers with all available support to achieve a smokeless society, much of which is detailed by the WHO statement, but based on latest scientific and evidence, this should also include e-cigarettes.

Lion Shahab, PhD CPsychol AFBPsS
Professor of Health Psychology
University College London, UK

An evidence-based approach dictates the integration of tobacco harm reduction in a holistic strategy towards a smoke-free world. Public health is about preventing harm rather than judging behaviors. A carefully-regulated environment that promotes reduced-risk nicotine products to smokers is a historical opportunity to make smoking obsolete. It is also in alignment with the Ottawa declaration of empowerment in health. The WHO should re-examine its position, explore both intended benefits and potential, unintended harms, and establish a stance based on the totality of evidence, avoiding prejudice and predisposition.

Konstantinos Farsalinos, MD, MPH
Department of Pharmacy, University of Patras, Greece
Department of Public and Community Health, University of West Attica, Greece

A myriad of studies link e-cigarette price increases and access-restrictions to greater smoking rates. Findings from biochemical analyses suggest that such regulations are likely to be harmful on net: vaping nicotine appears to produce substantially lower levels of key toxicants than smoking cigarettes; and, adverse respiratory and cardiovascular outcomes as well as biomarkers for major carcinogens generally fall when smokers switch to nicotine e-cigarettes. Thus, for smokers who do not want to quit tobacco or who want to quit but have been unsuccessful in their cessation attempts, substituting towards electronic nicotine delivery systems offers a means to reduce their risk of tobacco-related illness. The public health community and World Health Organization have a moral obligation to clearly communicate these facts to smokers and their families, and to advocate for policies that reflect tobacco products’ relative risks.

Abigail S. Friedman, Ph.D.
Assistant Professor,
Department of Health Policy and Management
Yale School of Public Health

It took WHO all too many years to embrace “harm reduction” thinking and policies vis a vis consumers of illicit drugs but it eventually did. Hundreds of thousands, possibly millions of lives, could have been saved if WHO had acted earlier to transcend the political forces and counterproductive ideologies and rhetoric that drove the war on drugs and its insistence on punitive abstinence-only policies.

Yet now we see WHO repeating very similar mistakes as it resists and dismisses the technological innovations in tobacco and nicotine products that could radically reduce associated harms to both consumers and society at large. The organization’s leaders need to open their eyes and summon the courage to follow the science, not the politics. Failure to do so may ultimately result in the emergence of an international tobacco/nicotine prohibition regime with all the failures, costs and counter-productive consequences of the failed global drug prohibition regime.

Ethan A Nadelmann
Founder & Former Executive Director (2000-2017)
Drug Policy Alliance
New York and International

The guiding principles of harm reduction are to respect the rights of people who use substances, to reduce stigma, to work with the networks that support people who use substances and to follow the scientific evidence. There is strong evidence that tobacco harm reduction can achieve these goals, but we need all major health organisations to support this vision – and that includes WHO. Denial or selective interpretation of the evidence, including deliberate conflation of nicotine and tobacco, means those individuals facing severe disadvantage will continue to be left behind and continually stigmatised, and tobacco health inequalities will remain entrenched. If the WHO engaged with the evidence for tobacco harm reduction with genuine objectivity and dispassion, we could all work together to accelerate progress on reducing major diseases and health inequalities, leaving no smoker behind.

Sharon Cox, PhD
Senior Research Fellow
University College London

Slightly more than one in ten people in the world (10.7%) present a mental health disorder like Depression, Bipolarity, Schizophrenia, anxiety disorders, substance use disorder, Alcohol use disorder, Drug use Disorder and eating disorders ( IHME’s Global Burden of Disease 2017) with a high prevalence of smoking in this specific population and low rates of long term abstinence. Many of them present a quantitative or qualitative dysfunction of the nicotinic alpha 7 receptor and disturbances in attention and need to boost their cognition by the use of nicotine. Depriving them of the use of a much less toxic source than conventional cigarettes such as no smoking nicotine products is a kind of stigma. The same is true for all marginalized populations in developed countries and low and middle-income countries. WHO gains by making its strategies more flexible by adopting risk reduction as an effective tool alongside other means of helping to quit smoking.

Fares Mili MD-CTTS- NCTTP
Pulmonologist- Addictologist
Tunisian Society of Tobacology and Addictive Behaviors ( STTACA) Chairman

Smoking kills because combustion kills (as well as misinformation). Non-combustible forms of nicotine (snus, NRT and vaping products) have helped millions of smokers to stop smoking worldwide. As a smoking cessation specialist in France, I have helped hundreds of smokers to stop smoking with NRT and vaping products. Denying smokers to use non-combustible forms of nicotine of any sort by demonizing or banning them is against human rights to choose their way out of smoking.

Jacques Le Houezec, PhD
Neuroscientist and Smoking cessation specialist
Manager Amzer Glas – CIMVAPE, training and certification organisation, Rennes, France.

In 1976 Professor Michael Russell famously said: “People smoke for nicotine but they die from the tar”. The situation has changed. Now people smoke for nicotine but they die from the intransigence of opponents to tobacco harm reduction. The World Health Organisation opposed drug harm reduction in 1999 but began supporting harm reduction in 2000, required urgently at that time to control HIV among and from people who injected drugs. Public health practitioners and organisations opposed to tobacco harm reduction risk serious reputational damage”.

Novel forms of drug harm reduction are often vigorously resisted initially. Opposition may continue long after benefits have been shown to far exceed adverse effects. The development of a growing range of reduced risk options for ingesting nicotine offers spectacular potential public health gains, especially in low- and middle-income countries, in reducing deaths from smoking tobacco and oral smokeless tobacco”.

Opposition to reduced risk nicotine options inevitably protects the smoking of tobacco which is responsible for the deaths of over half of long term smokers. Vaping is now not only the world’s most popular form of quit smoking aid but also the most effective”.

Dr. Alex Wodak AM
Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital
Director, Australian Tobacco Harm Reduction Association

Over a billion people smoke tobacco. All smokers should be informed that many sources of nicotine are far less harmful than cigarettes. Keeping people ignorant of this fact denies the basic human right to accurate information and impairs their ability to make informed choices that affect their health.

Nicotine in its most harmful and addictive form—the cigarette—is typically cheap, available everywhere, to take for as long as you like, and in many parts of the world (including the USA) comes with minimum information on health risks. It is time for regulation of all nicotine-delivery products to provide access inversely proportional to harmfulness (the opposite of the current situation). [Foulds & Kozlowski, 2007]

Jonathan Foulds PhD
Professor of Public Health Sciences & Psychiatry
Penn State University, College of Medicine
United States

Snus is the most commonly used self-treatment aid for smoking cessation. Quit attempters using snus as a cessation aid have a significantly higher success rate than those using other aids. All these effects yield favorable consequences for public health, suggesting that snus has been a major factor behind Sweden’s record-low prevalence of smoking and its position as the country with Europe’s lowest level of tobacco-related mortality among men based on analysis of data from a WHO report.”(Ramström L, Borland R, Wikmans (link)

Lars Ramström PhD
Principal Investigator
Institute for Tobacco Studies
Täby, Sweden

WHO is fighting a futile battle in the wrong war using failed tactics and baseless propaganda. WHO needs to stop and rethink right now. Instead of opposing innovations like vaping and raving about the tobacco industry, it should be giving 100 per cent priority to helping people to quit smoking by whatever method works. For millions of people, that includes vaping and smoke-free tobacco and nicotine products.  WHO appears to be more interested in who makes these products than in their enormous potential to stop millions of people dying in agony from cancer or living in misery with emphysema.

Clive Bates
Director, The Counterfactual
Former Director Action on Smoking and Health (UK)

This year approximately 8 million people will die prematurely from smoking. I am deeply disappointed with what can only be described as an ongoing ‘dark ages’ approach to tobacco control.  While many traditional forms of tobacco control remain useful and effective, little has been done by the WHO and many other mainstream public health organizations to acknowledge and think about how regulation, research, technology and innovation can be collectively harnessed  to give the billion addicted cigarette smokers viable science based lower risk products.  Science and ‘safe-haven’ engagement and debate continues to be displaced with polarized thinking that often is more focused on getting media attention than actually finding workable win-win solutions for the good of society.

Scott D. Ballin, JD
Health Policy Consultant
Former Vice President and Legislative Counsel, American Heart Association
Former Chairman of the Coalition on Smoking OR Health (AHA, ASCS. ALA)

It is extremely disappointing that the World Health Organisation’s policies towards e-cigarettes (and other reduced risk nicotine and tobacco products) are so hostile to the interests of smokers who wish to use them to quit smoking or as a substitute for smoking cigarettes. WHO has used legitimate concerns about youth uptake to justify a de facto prohibition of e-cigarettes for smokers. A more balanced and sensible public health policy would allow smokers to access e-cigarette s in ways that minimise youth uptake and maximise the potential for e-cigarettes to eliminate the global use of combustible tobacco products.

Wayne Hall
Emeritus Professor
National Centre for Youth Substance Use Research
The University of Queensland

Over the past decade, as an academic researcher, I have thoroughly reviewed the thousands of scientific studies relevant to an analysis of the value of Tobacco Harm Reduction (THR) in general, and of the e-cigarette in particular, in the fight against smoking and its detrimental health effects. Also, my own research over the past decade has been devoted exclusively to various facets of THR.

If the e-cigarette is to be used as a THR tool, it is important to demonstrate that (a) it is indeed a low-risk nicotine product, but also (b) that it is accepted by current smokers and that it is effective with respect to smoking cessation, while (c) it does not attract substantial numbers of non-smokers and especially does not cause smoking initiation in (young) people who would otherwise not start smoking.

Based on my analysis of the literature and on my own research, I conclude that vaping passes these three critical tests with flying colors.

(a) Even the strongest anti-vaping activists will at least admit that there is no doubt that vaping is significantly less harmful than smoking; as a matter of fact, the harmfulness of vaping is only a tiny fraction of that of smoking.

(b) There is converging evidence from multiple different sources that e-cigarettes are a valuable tool for many smokers to help them quit smoking.

(c) Regular vaping among non-smokers is rare, and there is no evidence of a “gateway effect” from vaping to smoking, including in young people.

WHO’s stance on THR is anti-scientific, morally reprehensible, and diametrically opposed to its primary mission:  it costs lives rather than saving them.

Frank Baeyens, PhD
Professor of Psychology,
KU Leuven (Belgium)

The need to reduce the global burden of disease caused by smoking is incontestable.  This will not be achieved however, if the WHO continues to reject tobacco harm reduction.  Smoking related harms are overwhelmingly due to combustion – the long-term exposure to toxins in tobacco smoke. Switching to non-combustible products such as e-cigarettes can significantly reduce or eliminate exposure to these toxins. Given that 95% of quit attempts end in failure, e-cigarettes offer a lifeline for smokers who are unwilling or unable to stop. The WHO should therefore be enabling and encouraging adult smokers to access these products. Discouraging uptake and presenting inaccurate or misleading information about the reduced risk status of e-cigarettes means millions of smokers who might otherwise have switched, will suffer the health consequences of continued smoking. As an editorial in The Lancet in 1991 concluded, “there is no good reason why a switch from tobacco products to a less harmful nicotine delivery system should not be encouraged”.

Lynne Dawkins, PhD
Professor of Nicotine and Tobacco Studies
Centre for Addictive Behaviours Research
London South Bank University

There are two plausible goals for the elimination of smoking as a mass consumer activity: eliminate all forms of tobacco and nicotine use, or the less ambitious one of eliminating smoking using the less harmful forms as substitutes.    I have spent much of the last 35 years focusing on the former, both studying the impacts of tobacco control policies on smokers and developing and evaluating smoking cessation interventions capable of large-scale uptake. As a result of my research and that of others, I have unfortunately reached the conclusion that with current methods we have no reasonable chance of eliminating smoking without the help of alternative nicotine containing products that are sufficiently consumer attractive to dependent smokers.  Further, the concern that such products might encourage smoking are increasingly being shown to be unfounded. The bulk of substantial evidence points to use of alternative products actually helping reduce smoking uptake in adolescents, albeit with no decline in total nicotine use and in some cases likely increases.  The good intentions of many in tobacco control of trying to limit low toxin alternatives to smoking are in all likelihood paving the way to the hell of prolonging the epidemic of smoking-caused harm.

There are increasing signs that there are now a range of alternative products that will go a long way to helping achieve the harm reduction goal of a smoke free society, but not one free of recreational nicotine use especially if coupled with existing policies constraining smoking. These include some of the more modern nicotine vaping products, heated tobacco products and some forms of oral tobacco and nicotine. 

Ron Borland PhD,
Professor -Health Behaviour,
Melbourne Centre for Behaviour Change, School of Psychological Sciences,
The University of Melbourne,
Australia