I am writing as you gather in Seoul with colleagues from around the world from 12-17 November 2012 for the fifth Conference of the Parties of the FCTC. Your work is vitally important in the global struggle against cancer, cardiovascular disease and respiratory illness, and I wish you well with your negotiations and deliberations this week. However, I would like to ask you to consider two important and difficult but related issues:
1. What strategies are available to protect the health of those who are addicted to tobacco and nicotine and who are either unable or unwilling to quit smoking? If the only possible answers are ‘smoking cessation’ or ‘complete abstinence’, then many older, often poorer smokers will continue to smoke and we know that half of those will eventually die prematurely as result. Certain groups will be severely disadvantaged: for example, those with mental illness where smoking prevalence is very high and nicotine has therapeutic effects. A crude ‘quit or die’ philosophy should have no place in a WHO health treaty. Strategies for dealing with nicotine addiction must take account of real people and real-world behaviour, and use any possible strategy to reduce the harm caused by tobacco, even if that means using tobacco or nicotine products with greatly reduced risk as alternatives to the most harmful and dominant form – namely, cigarette smoking.
2. How should the FCTC and national legislators treat nicotine-containing products that have very low risks relative to smoking cigarettes (a few percent at most), but are viable alternatives to smoking? If these products are to be banned or over-regulated, then a very serious problem arises: why should a health treaty deny a person addicted to nicotine access to products that greatly reduce their risk of disease? There are no precedents for banning or marginalising safer alternatives to a harmful market leader (cigarettes in this case) and it is absolutely unethical to do so. The further danger of bans or excessive regulation of low risk, non-combustible nicotine sources is that they protect the cigarette market. It would be a terrible failing of the FCTC if it was unwittingly doing the dirty work of the cigarette industry.
I have been prompted to write to you because during COP-5 you will be considering two papers prepared by the Secretariat:
- FCTC/COP/5/12: Control and prevention of smokeless tobacco products
- FCTC/COP/5/13: Electronic nicotine delivery systems, including electronic cigarettes
These papers share a serious weakness: they do not properly consider the role of smokeless tobacco or electronic nicotine delivery systems as credible alternatives to smoking. Therefore their potential positive health value in reducing the burden of disease associated with smoking is ignored or marginalised. In one country, Sweden, we know with certainty that the use of smokeless tobacco (‘snus’) has greatly reduced the burden of tobacco-related disease. You can read a summary of the evidence about smokeless tobacco at taging2.clivebates.com or a peer-reviewed academic review here. The ‘harm reduction’ case for novel nicotine delivery devices is even stronger, the risks even less, and the opportunities for public health are substantial.
The briefing papers of the NGO Framework Convention Alliance on smokeless tobacco and electronic nicotine delivery systems similarly overlook value of reduced-risk products in reducing harm. I am concerned that a dangerous group-think may set in around the FCTC, which would have serious negative consequences for health if not challenged by delegations who insist on a relentless and rigorous focus on health outcomes.
As you consider how the international community should address these challenges, I would like to ask each delegation to do three things:
- First do no harm – please do not agree to regulations, internationally or domestically, that deny smokers access to ways of taking nicotine with greatly reduced risk. This misguided prohibitionist agenda would be harmful to health, highly unethical and amount to support for the cigarette industry.
- Look beyond the two secretariat papers above – they overlook the most important issue and opportunities for considerable health benefits. Delegates should insist on a broader assessment and should request an impartial scientifically credible assessment of harm reduction strategies for the next COP or other appropriate FCTC forum.
- Begin to consider what form of regulation would create an ‘enabling framework’ for nicotine products that could displace cigarettes for continuing nicotine users and thereby greatly reduce the burden of disease arising from smoking. The FCTC was set up to protect health, and tobacco harm reduction is a vital and powerful health strategy. Such regulation would be designed to build confidence in these products as alternatives to cigarettes and to promote switching from smoking to non-combustible forms of nicotine delivery.
I am sorry I cannot join you in Seoul, but I hope you have a productive week. If you would like a balanced, humane and rational view on tobacco harm reduction, I recommend viewing a short video by Gerry Stimson, a renowned expert in public health.
Former Executive Director, Action on Smoking Health (UK) (1997-2003)
Founder member of the Framework Convention Alliance (1999-2003)
Disclosure: I am writing strictly in a personal capacity and from long-standing personal commitment to the goals of the FCTC. I have no conflicting interests, in particular no financial or material links with the tobacco industry, nicotine device industry or pharmaceutical industry, or their agents.