WHO has gone rogue on tobacco policy – millions at risk from tired dogma and a refusal to grasp innovation

A message for World No Tobacco Day, 31 May 2021 If you just want to go straight to our unforgiving […]

WHO has a self-defeating approach to the global burden of tobacco-related death and disease

A message for World No Tobacco Day, 31 May 2021

If you just want to go straight to our unforgiving and detailed letter to WHO – it is here.

  1. A response to WHO’s terrible press release
  2. Comments on tobacco harm reduction from expert stakeholders
  3. Addendum: it’s all about the smoke (Lynn Kozlowski)
  4. Addendum: environmental vapour risk (Roberto Sussman)
  5. Addendum: pro-THR statements by organisations (via Charles Gardner)
  6. Addendum: The WHO and tobacco policy: a seven-point reform agenda

1. A response to WHO’s terrible press release

The World Health Organisation and many, perhaps most, activists in tobacco control really do not understand anything about the changes going on around them.  The latest press release from the World Health Organisation is a case in point:

WHO’s press release, World No Tobacco Day (31 May 2021)
Click here >  Quit tobacco to be a winner

I’m all for people quitting smoking. I’ve devoted a substantial part of my career to it and my dad died of smoking-induced heart disease (I’m convinced he’d have been a vaper and still with us today). But what I cannot fathom is the ideological opposition from WHO to a whole platform of products that, beyond any reasonable doubt, are far less risky than smoking. So with David Abrams and Ray Niara of New York University, School of Global Public Health and David Sweanor of the University of Ottawa, we have put together a detailed critique of WHO’s approach, based on its World No Tobacco Day press release.

Our response to WHO: a detailed critique of the WHO’s press release.
Click here >  World Health Organisation must stop its baseless and irresponsible attack on tobacco harm reduction

A 14-page letter and briefing to Dr Tedros Adhanom Ghebreyesus, Director-General WHO from David Abrams, Clive Bates, Ray Niaura, David Sweanor.

Our letter and briefing develop nine themes:

  1. WHO has the wrong analysis of the problem – the focus must be on smoking
  2. WHO misrepresents risks and denies the value of switching from smoking to vaping
  3. WHO ignores compelling evidence that vaping is displacing smoking
  4. WHO fails to grasp the importance of flavours and how vaping works for smokers
  5. WHO backs untested and inadequate smoking cessation measures
  6. WHO has based its campaign on arcane special interests
  7. WHO must disclose and be accountable for interim results
  8. WHO has failed to understand a major technology transition but is trying to block it
  9. WHO should apply the first-do-no-harm principle – and stop what it is doing

2. Comments on tobacco harm reduction from expert stakeholders

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

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

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

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
Universty 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 ODE, PhD
Emeritus Professor of Health Psychology
University College London

The World Health Organisation 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
Barts and The London School of Medicine and Dentistry
Queen Mary University of London

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
Medical University of South Carolina, USA

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

Too few of my colleagues in public health research know people who smoke; they become abstractions to us. Existing smoking cessation aids have been available for many years; evidence suggests they don’t help most smokers. Let’s treat smokers like fellow human beings and provide them with a range of options they actually want and can live with (pun intended).

Cheryl K. Olson, Sc.D.
San Carlos, California
Behavioral research consultant,
Previously on Harvard Medical School psychiatry faculty

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

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

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

COI: LS has received a research grant, honoraria for talks, consultancy and travel expenses to attend meetings and workshops from pharmaceutical companies that make smoking cessation products (Pfizer; Johnson & Johnson). He has never received any funding or other monetary benefits from the tobacco or e-cigarette industry.

We fully endorse the letter sent by Bates, Sweanor, Abrams and Niaura. It’s appalling that an organisation that claims to work for health protection and health improvement refuses to listen to researchers, scientists, policy-makers, clinicians and consumers who have a different opinion. What does it take to see that vaping displaces smoking and saves lives? How many people have to suffer smoking-related disease and an early death because the WHO cannot admit they could be wrong?’

Louise Ross,
Vice Chair, New Nicotine Alliance.

I am employed by the Smoke Free app and the National Centre for Smoking Cessation and Training. I have no financial ties to the tobacco, vaping or pharmaceutical industry

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
No conflict of interest to report.

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

No conflicts to declare.

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

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.

Pulmonologist- Addictologist
Tunisian Society of Tobacology and Addictive Behaviors ( STTACA) Chairman

I have no conflicts of interest with tobacco, vaping or the pharmaceutical industries.

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.
I have no conflicts of interest with respect to tobacco, vaping or pharmaceutical industries

As I write these words, thousands upon thousands of people are losing their lives because of tobacco smoking. Each of these lives had a story—a story cut short because health authorities including the WHO are not using scientific and regulatory resources to make harm reduction products and information fully available to the public. Let us finally come to our senses and stop these unnecessary deaths by embracing the science of harm reduction.”

Bethea A Kleykamp,
Research Associate Professor,
University of Rochester Medical Center

COI: I currently have no conflicts of interest with respect to tobacco, vaping or pharmaceutical industries. From May 2014 to September 2018, I provided harm reduction consulting services to an e-cigarette company (NJOY) and a tobacco company (RJ Reynolds) through my work at PinneyAssociates.

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

I had ‘given up giving up’ cigarettes and first tried vaping with a view to reducing the cost of smoking. I intended to dual use. But the first puff of espresso flavoured aerosol with a strong nicotine content, made me realise I was an ex-smoker! It’s superior in every way.

Andrew Thompson
Webmaster of The THR Blog.

As an ex-smoker who quit thanks to vape in 2014, I experienced my health improvement with a harm reduction approach. The denial of the right to take care of one’s own personal integrity with harm reduction tools seems only to benefit the interests of smoking profiteers. I lost all confidence in WHO.

Philippe Poirson
Sovape, French non-profit association for harm reduction.

No financial links to any industry or business, including philanthropy ones.

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 (ie, 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 T. Patterns of Smoking and Snus Use in Sweden: Implications for Public Health. Int. J. Environ. Res. Public Health 2016, 13, 1110 link)

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

Give people a chance to quit smoking by telling them that there are differences in harm depending how they get their nicotine.

Traditional cigarettes are lethal; half of the smokers die as a direct result of their smoking.

Look at the Swedish statistics. Swedish men have the lowest incidence of tobacco related death within the EU according to EU statistics although around 30 percent of Swedish men use nicotine on a daily basis. The reason is that about twothirds of the men that use nicotine daily use snus which does not cause cancer.

Governments and public agencies as well as intergovernmental agencies should tell people the truth – there are differences in harm to health between different sources of nicotine. Allow people to make choices based on correct information.

Anders Milton MD, PhD
Chairman of the Snuscommission (snuskommissionen.se)

The World Health Organisation push to eliminate all tobacco and nicotine, regardless of the method of use or relative risk associated with the different ways tobacco can be used, contravenes the United Nations Declaration on the Rights of Indigenous People (UNDRIP). The UNDRIP states that Indigenous peoples have the right to maintain their traditional ways of life and develop their culture.

Tobacco and other plants containing nicotine have a long history of use among some Indigenous peoples of the world dating back at least 8000 years. To be consistent with the rights of Indigenous peoples, policies and laws intended to stop tobacco use, should exclude tobacco growing, manufacture and use where those practices are part of the traditional way of life or a traditional source of livelihood or a craft of an Indigenous people.”

Professor Marewa Glover
Director, Centre of Research Excellence: Indigenous Sovereignty & Smoking
New Zealand

Disclosure statement: The Centre of Research Excellence: Indigenous Sovereignty & Smoking programme of work was funded with a grant from the Foundation for a Smoke-Free World, a US nonprofit 501(c)(3) private foundation with a mission to end smoking in this generation. The Foundation accepts charitable gifts from PMI Global Services Inc. (PMI); under the Foundation’s Bylaws and Pledge Agreement with PMI, the Foundation is independent from PMI and the tobacco industry. The contents, selection, and presentation of facts, as well as any opinions expressed herein are the sole responsibility of the authors and under no circumstances shall be regarded as reflecting the positions of the Foundation for a Smoke-Free World, Inc.

Between 2019 and 2020 the Canadian Tobacco and Nicotine Survey (administered by Statistics Canada) reports that current smoking of those aged 20-24 fell from 13.3% to 8%. This is an unprecedented decline.

It indicates that those who began to vape prior to their twenties treat vaping as a substitute for combustibles. Vapes are a proven reverse gateway. If public policy were actively directed towards inducing smokers of all ages to migrate to alternative nicotine delivery systems, Health Canada’s 2035 target of a 5% smoking rate for the whole population is well within reach.

Canada sees 40,000 premature smoking-related deaths each year. These deaths are preventable by embracing harm reduction in an active manner.

Ian Irvine,
Professor, Economics, Concordia University, Montreal Canada.

Disclosure. I have advised the federal government of Canada on alcohol and tobacco policy, and also advised lawyers in the private sector on tobacco.

If Michael Russell was correct that “people smoke for the nicotine, but they die from the tar”, WHO would think that means “let’s get rid of the nicotine and keep the tar”?

If millions die from smoking cigarettes every year, WHO would think it best to restrict, regulate, and demonize any potentially attractive alternative product?

Christopher E. Lalonde, PhD
Professor of Psychology
University of Victoria

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
The Counterfactual
Former Director Action on Smoking and Health (UK)
I have no conflicts with respect to the tobacco, nicotine or pharmaceutical industries

Addendum: it’s all about the smoke (Lynn Kozlowski)

Professor Lynn Kozlowski draws attention to just how much of the “tobacco epidemic” is in fact a “smoking epidemic”.

To be fair and accurate, if an agency wants to emphasize the massive risks of one type of tobacco product, they should also inform of the known lower risks of other tobacco or nontobacco, nicotine products. It is as if the risks of death in motor vehicles were promoted only as those from motorcycles: “Per vehicle mile traveled in 2010, a motorcyclist was about 30 times more likely than a passenger car occupant to die in a motor vehicle traffic crash . . . .”

Bostic et al.10 are concerned that the field not get “sloppy on ANDS” (Alternative Nicotine Delivery Systems). They provide no citations on differential product risk or lack thereof. For a right based on health, the magnitude of health effects is important for judging the priority to be placed on this among the many other important issues that affect health. The core evidence for tobacco’s great burden in death and disability comes from smoking. The 2016 GBD study was the first to include smokeless tobacco and specified that most of the death and disability observed from tobacco is “attributable to smoking tobacco” (p. 1403). GBD results from 2017 are shown in Figure 1. Nearly all of the deaths (98.9%) in users of tobacco were from smoking versus chewing tobacco.

From:  Kozlowski LT. Policy Makers and Consumers Should Prioritize Human Rights to Being Smoke-Free over Either Tobacco- or Nicotine-Free: Accurate Terms and Relevant Evidence. Nicotine Tob. Res. 2020;22(6):1056–1058. [link]

Addendum: environmental vapour risks (Roberto Sussman)

These are three flawed arguments by the WHO on environmental vaping

  1. Equating e-cigarette aerosol “particles” to air pollution PM2.5 or tobacco smoke particles (TAR). This is mistaken. The “particles” are completely different (and must not be made equivalent). Emphasizing particle numbers & deposition is irrelevant without considering their physical and chemical properties
  2. Indoor vaping bans are justified by misleading comparisons with SHS and air pollution “particles” and by ideological arguments. This is unacceptable, public policies on indoor vaping must be based on facts, not on false equivalences with SHS or air pollution. Justifying indoor bans to prevent the “re-normalizing” of smoking is an unacceptable ideological argument.
  3. The environmental safety of e-cigarettes is evaluated through an extreme precautionary approach in which protection of vulnerable populations becomes the only paramount criterion. This is unacceptable, it must be evaluated in its full context, in comparison with other indoor pollutants and adult habits (alcohol drinking, smoking), and not ONLY on its effect on vulnerable populations.

In other words, you don’t ban whisky for adults in bars because it might harm toddlers in a kindergarten or you don’t ban vacuum cleaners at home because of what can happen if a toddler is glued to the vacuum machine, you just recommend common-sense precautions (why should it be different with vaping?)

When the WHO has evaluated health risks from exposure to Environmental E-cigarette Aerosols (EEA) there is a string emphasis on the danger that fine and ultra-fine “particles” in these aerosols pose to bystanders, as these “particles” can be deeply deposited in the lungs. The WHO often conflates these e-cigarette “particles” with suspended particles (fine particulate matter PM2.5) of air pollution, using air pollution risk benchmarks. However, invoking only particle size and deposition without considering the physicochemical properties of the “particles” is a complete misrepresentation. The physicochemical characteristics of the involved “particles” are completely different:

The “particles” in EEA are rapidly evaporating liquid droplets composed almost exclusively of volatile low toxicity chemicals (propylene glycol, glycerol, nicotine, humectants). Toxicants (volatile organic compounds and metallic ions) may found in negligible trace levels

The “particles” PM2.5 in air pollution are mostly combustion originated and are composed by numerous semi-volatile and non-volatile compounds whose potential for toxicity and carcinogenic effects is high: primary and secondary organic carbon (including sooth), nitrates, sulphates, metals and crustal material (dust).

But most importantly, the exposure times frames (which determine the dose) are also different: bystanders are exposed to EEA droplets intermittently as the latter disperse and particle numbers return to base levels in 5-20 seconds per puff (under normal conditions), whereas air pollution is a continuous 24 hour exposure (between 40-70% of indoor pollution originates outdoors).

The WHO must recommend that public policy planing on indoor exposure to environmental e-cigarette aerosol (EEA) must be guided by evidence that assesses health risks by considering (1) puffing regimes representative of average usage of the devices under normal conditions; (2) appropriate reference to the physicochemical properties of its “particles” (liquid droplets), (3) appropriate exposure times and toxicological benchmarks, (4) it is necessary to avoid assuming unproven equivalence in risks with combustion generated PM2.5 (environmental tobacco smoke or air pollution) and (5) comparison with other household sources of inner pollution: cooking, candle lighting, vacuum cleaning, odorizing, as well as pollutants from perfumes, carpets, clothing and furniture.

The WHO often evaluates risks from exposure to environmental e-cigarette aerosol (EEA) only on the grounds of protecting vulnerable populations and proceeding along an extreme form of the Precautionary Principle applied to environmental tobacco smoke (ETS). However, recommendation on exposure to ETS do not apply to EEA. The WHO must proceed with the same level of precautionary recommendations for e-cigarettes as with other adult usage consumer products (alcohol drinking) or other household risks (cooking and indoor pollutants). Recommendation on usage of adult consumer products cannot be based only on their effect on vulnerable populations.

Dr Roberto A Sussman
Institute of Nuclear Sciences
National Autonomous University of Mexico UNAM

Addendum: pro-harm-reduction statements by organisations (Charles Gardner)

A Twitter thread (1/55)

Documentation and referencing for statements: via Google Docs: Tobacco Harm Reduction Statements

Note:  None of these organizations are funded or influenced by the tobacco industry or vape industry.

Addendum: The WHO and tobacco policy: a seven-point reform agenda

See my article in Tobacco Reporter: The WHO and tobacco policy: a seven-point reform agenda (1 May 2021)

These are the seven points for reform set out in more detail the article:

  1. Commit to the goals that make a real difference (i.e. concentrate on smoking)
  2. Embrace innovation in the tobacco and nicotine market (see the opportunity in non-combustibles)
  3. Implement harm reduction in the Framework Convention on Tobacco Control (apply risk-proportionate regulation)
  4. Take a more sophisticated approach to policy appraisal (consider unintended consequences)
  5. End the drive for prohibition (it always fails and is doubly foolish when the much less risky product is banned)
  6. Rethink the stakeholder landscape (value diverse perspectives and break out of the echo chamber)
  7. Show some leadership (stop following billionaire money and work for ordinary citizens)


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29 thoughts on “WHO has gone rogue on tobacco policy – millions at risk from tired dogma and a refusal to grasp innovation”

  1. Fantastic response from the THR experts.The Vape family love your efforts to help us ex and future ex smokers. The WHO are causing us all so much anxiety and fear. Blatantly trying to steer us back to smoking, with their dismally negative portrayal of novel nicotine products,
    WHO’s conflicts of interests, being funded by competing THR and treatment providers – pharmaceutical / medical industries. Which have not presented their own versions of these successful novel products. With the exception of Bloomberg philanthropy a major WHO sponsor, who’s namesake figure head is funding a vape development, via the medical approval route, estimated to be released 2025. The question is clearly, are the WHO working to dismantle the current vape industry competition, for his future monopolistic benefit and both organizations future profit?
    The FCTC is massively conflicted also, with member states governments also being major shareholders in state tobacco industries and or recipients of huge tobacco tax windfalls, ultimately being the larges profiteers from tobacco sales. Behind closed doors these protected tobacco stakeholders are also bringing HNB / SNP products through regulated channels to gain competitive monopolies. Severely restricting the founding vaping industries is clearly a benefit to their substantially similar product offerings, which science shows are not even as safe as consumer vaping products.

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  3. Pearson Robert

    I had smoked for 44 years, stents fitted in my late 50s. I HAD to stop smoking and tried and tried, suffered from depression due to my continued failure to stop. It was an awful time, the pressure to stop for my own health was enormous. Had dabbled with cigalikes, they helped, but weren’t a substitute for my Marlboroughs.

    Went into a vape shop on the spur on the moment and came out with one of the very early sub ohm tanks and a dual battery mod. I had thought to use it a substitute for some of the cigarettes I was smoking. To my surprise I stopped smoking tobacco in 36 hours and haven’t had a cigarette since. I was astonished at how effective that device was, and how easy it was to stop lighting up.

    Six years on I still vape, still using sub ohm tanks. I have at least three flavours on the go at any one time, typically cookies & cream, vanilla custard and the like. I use 3mg nicotine, a tiny amount, although I started on higher strength nicotine.

    I’ve lost count of the number of friends and colleagues that have permanently stopped smoking using ecigs. These things work, and it’s completely bewildering and difficult to understand the vocal and powerful opposition to their use. I am certain that ecigs had extended my life expectancy substantially. I am fitter now at 65 than I was a decade ago when I was still smoking.

  4. Sure e-cigarettes may be less harmful than conventional cigarettes. But why should they be available to anyone over the counter? Let’s do what Australia is planning and make them available via prescription for those who need them. Young people who don’t smoke don’t need them!

    1. So the underage can continue to get the 8x magnitude (58,000x) less safe product, cigarettes, from their parents and older friends? While harm reduction seekers won’t be able to get a script (7 current doctors prepared to prescribe for 500,000 vapers, it’s a ban by stealth) and the possibly curious won’t even bother, we’ve all had a hell of a time getting scripts thus far, and yes they’ve always been a requirement to import/possess nicotine, yet less than 1% have been able to get a script. Pharma medical don’t make any money from vape, only NRT which hasn’t stopped the billion current smokers in 40 years. Unlike vaping, HnB etc which has 100 million users from mainly the last 5 years, with little or no government support,and mainly dissuasion and misinformation. Plainly a product with a 99.5% less life time cancer risk, and at least a 95% safer estimate from PHE and UKRAGCP, supported by UKLung, CancerUK and nearly all of their prestigious orgs, should be on the tobacconist shelf’s instead of cigarettes. Follow the money, tobacco tax, sales and sickness are the worlds biggest industry. 30%+ of pharma, medical would cease to exist without smoking. And our governments can’t afford pensioners now, so definitely don’t want another 15% of the population living another 10 to 15 years being smoke free.

    2. I am Australian, and was at a stage where I was done talking with doctors about my smoking. Thought I’d try vaping to help cut the cost of smoking. How silly I was ‘trying’ it. Turns out I far preferred it to smoking, and have had no interest in smoking cigarettes since (over 6 years now).

      Everyone who smokes, everyone who might otherwise smoke or might benefit from nicotine, needs consumer access to nicotine based e-cigarettes.

      I expect Australia’s ‘prescription model’ will fail, and fail badly. Why not wait till 6 months after it has been implemented (October 1st), before recommending doing it the way Australia is going to?

    3. Bizarre reasoning Dan, when conventional cigarettes remain openly on sale to all adults, why would you put obstacles in the way of what you concede is a safer product.
      Smokers and Vapers do not consider themselves as sick, so to have them visit a (largely ignorant) doctor for a prescription will simply ensure that Smoking numbers will remain high.
      There is zero merit in the proposed Australian approach whatsoever, with vanishingly small numbers of doctors prepared to prescribe nicotine for Vaping, whilst tobacco cigarettes are freely available.
      Only one outcome can be expected with such a blinkered approach:- increased Smoking rates

    4. The right to quit smoking with a product that promises success shouldn’t be based on the age of the person who smokes. The only criteria that counts is smoking. WHO data tell us that the majority of the people who smoke start before their 18th birthday. I don’t want underage non-smokers to vape, but I want underage smokers to have access to a much less harmful substitute.

  5. Adult people who enjoy safer nicotine instead of toxic tobacco are appalled by the World Health Organization’s continuing war against us. Our voices must be heard. Our lived experience matters. As ex-smokers, we are deeply concerned that the WHO’s prohibitionist recommendations will reduce safer options for the world’s 1.1 billion smokers, and people who use toxic forms of oral smokeless tobacco.

  6. Adam Metelmann

    In this world of instant information and data, how is it possible that the WHO and the many Org’s are able to spread so much misinformation? Irrespective of billionaire philanthropy, the science should be a clear winner. In fact, it pains me to say that all I’ve learned about the goings on from lobbying and the agenda of those involved in ‘protecting health’, it now makes me question every single diagnosis of any medical/health professional I may need to see, and this statement in itself is ridiculous. These industry experts are supposed to be the one untouched form of
    information, our heroes, our guiding light that uses science based evidence- not policy based recommendations. If any form of lower risk alternative works to help quit/switch/stop combustible tobacco use – This should be the primary focus. Instead, is just politicking and out of touch policy that does nothing to save lives.

  7. Damian Sweeney

    The stance the WHO is taking on safer nicotine products is quite rightly described as anti-science, but it goes much further than that. The signal they are sending out to the millions of people that have quit smoking with vaping, snus, nicotine pouches and heated tobacco products is that we don’t matter, our lived experience doesn’t matter because we didn’t quit the ‘right way’. I find that attitude reprehensible and bordering on criminal. We know better than anyone what it takes to kick the smoking habit and they should be asking for our advice rather than dismissing us. The WHO needs to wise up while there is still time to do the right thing.

  8. Damian Sweeney

    In 2001 I held my fathers’ hand as he passed from this world at the age of 56, after a short battle with cancer that he was never going to win. He started smoking at the age of 13 and tried countless times to quit smoking over the years, but any success was short lived. That’s the reason I’m a tobacco harm reduction advocate now. If the options that are available now were available then, I firmly believe the outcome would have been very different. Opposition to tobacco harm reduction is putting millions of lives at risk and it needs to stop now.

  9. John Summers

    I smoked 40+ cigarettes a day which was having massively deleterious effects on my health. I’d tried multiple NRT attempts, was denied Champix etc due to depression and Anxiety. I tried cold turkey etc and it was futile.

    Then 12 years ago I saw mention of electronic cigarettes. Being a technologist I bought one, tried it and found it to be pretty poor. These were the early cigalike products. I persevered for 2 years trying different iterations and dual-using. Then by chance I found one of the early “open-system” tanks and devices. Wasn’t intentional but that was the very last day I smoked. 11 years later I still vape but I haven’t smoked since. My lung function and heart function is good, BP normal, oral health excellent, fitness improved.

    In the year before finally leaving smoking behind I had bronchitis 5 times. In the 11 years since I have had 2 chest infections and no bronchitis.

    I detest tobacco flavours, part of the reason the early cigalikes failed. For me fruit and dessert flavours work and a variety of flavours is important.

    I volunteer as a first aider, a hospital carer and a vaccinator. I should be confident in the WHO and its messages but when I see the bad faith actions, the lies and the sheer unfounded arrogance around the WHO approach to reduced risk nicotine products I find myself unable to support their messaging on anything.

    The WHO must bring the FCTC groups to heel, reign in the bad actors and divorce itself from the undue influence of billionaires. If not they will find a rapidly expanding call for their de-funding and dissolution.

  10. Marion Burt

    I want to thank all those who support me and the millions around the world who, like me, were able to throw away our tobacco cigarettes when we switched to regulated nicotine vaping. We wish that the WHO would pay some attention to our health and our well-being instead of listening to professional lobbyists and special interest groups who either know little about vaping or who have a vested financial interest in keeping people smoking.
    I started smoking at 19 and smoked for decades. I tried to stop many times through will power and self-help books and managed to stop for a number of years, but always fell back in times of stress or weakness. I tried the “effective” patches and gum, and found them utterly useless.
    When my doctor warned me that I was in danger of developing COPD, I did online research, found out about vaping, and ordered a starter kit online. My order arrived on April 27, 2014 and I smoked my last cigarette while the battery was charging.
    In the subsequent 7+ years, I have never been tempted to smoke even once. I enjoy vaping and because of the wonderful flavours I didn’t experience the massive weight gain that had accompanied my previous cessation “triumphs”.
    I am tired of being ignored by the people whose jobs are to protect my health. I’m tired of officials making lofty pronouncements based on spurious research and claims. I’m now retired and have time to follow the international research; I have learned that much of it is biased, poorly designed, and almost certainly published in an attempt at anti-vaping propaganda. This is shameful.
    I demand that the WHO shake its head, think about its responsibilities, and wake up to the fact that millions of smokers will die of smoking-related illnesses because of this propaganda and the WHO’s pronouncements.
    Every smoker in the world deserves the better health and overall well-being that I have enjoyed since I switched to vaping. No one should be denied the chance for this “second life”.

  11. It took me about 9 months to stop smoking cigs once I found a decent vaporizer and some good flavors. That was almost 10 years ago. I still enjoy smoking now and then if I’m having a drink with other smokers. Vaping is more enjoyable!
    #CASAA #WVD21

  12. I have followed this blog for more than 8 years after switching to Vaping from a 40 cigarette/day habit, without fail the rationale advanced aligns closely with my lived experience and outlook.
    In just one area of health will I advance my personal experience, my sleep was continually disturbed with coughing via excess catarrh, this rapidly cleared up after ceasing Smoking.
    My partner also Smoked and in combination, I calculate we have saved £90k over the 8 years since switching.
    Undoubtedly conspiracy theories exist as to why the WHO have adopted a negative outlook towards Vaping, but it is undeniable that their approach lacks credence from either a lived experience or rigorous Independent Scientific analysis.

  13. Pingback: Letter: WHO must urgently reassess its tobacco & nicotine policy and stop causing harm « The counterfactual

  14. Nancy Loucas

    I smoked for 30 years, I’ve been vaping exclusively for 11. I need to be here for my children and grandchildren – something that was denied my own mother, both my grandfathers and numerous friends and acquaintances who left behind families.

    What frightens me the most about the propaganda from WHO/Bloomberg and affiliated science deniers in Public Health is the toll on human lives this type of behaviour will eventuate.

    Those of us who have lost loved ones will never get them back, and as we fight to prevent others from experiencing those same types of loss, heartache and grief, we are castigated as the “bad guy” by those who wish to silence us, and the facts and evidence.

    There are people out there who want a way out, but because of this kind of propoganda, which they see in the media; which their governments take as “facts” they are denied the right to switch away from the one thing that is KNOWN to kill.

    As more people are denied the right to health and harm reduction, even as the evidence mounts that the alternative is safer – more will be harmed, more will die.

    At what point will enough be enough? At what point will WHO and Bloomberg and all those associated in that cabal of misery accept that they are complicit in wholesale manslaughter for money?

    That is the real question.

  15. Daniel Sussex

    I have been dual using for about 4 years, after a health scare, i switched exclusively to vaping. I wouldn’t have been to quit without a convincing substitute.

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  19. Once again, WHO ignores the scientific evidence. Once again they ignore youthful curiosity and blame flavors for young people’s willingness to experiment. Once again they discard the lived experience of millions of people as “anecdotes”. Once again, the demands of US billionaires and the vested interests of the pharmaceutical industry are worth more than human lives.

    What else is there to say? I’m so tired of fighting against lies and disinformation. After 46 years I finally was able to quit smoking in 2018. Since then, I’ve lived in constant fear that I might be forced to smoke again. It would be very easy, just banning dessert flavors.
    My brother died of lung cancer because he believed the WHO and other shady public health organizations. He thought that vaping was “too big a risk” to take. I told him that he was being lied to and he called me crazy. Now he is dead. He died as a smoker.

    There was a time when I had a lot of respect for the WHO. With their attitude towards vaping they have maneuvered themselves into a dead end. Today to me they are a gang of self-righteous, corrupt ignoramuses who follow a dogma that kills people. FCTC has no longer a right to exist.

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