Technical ReportPDF Available

Where there's no smoke, is there still fire? Ethical aspects of Tobacco harm reduction

Authors:

Abstract and Figures

Tobacco smoking is harmful in many ways. Globally, more than 1 billion people smoke tobacco and 5 million people die each year as a direct result of tobacco use. One quarter of all lifelong smokers will succumb in middle age, and smoking costs the global economy more than $1 trillion per year, almost four times the amount generated through tobacco excise duties. The Framework Convention on Tobacco Control (FCTC) by the World Health Organization (WHO) is the conventional reference point for all stakeholders who agree that tobacco is harmful. The FCTC came into effect in 2005 and is legally binding in 180 countries. It focuses on the production, sale, distribution, advertisement, and taxation of tobacco. There is no doubt that these measures are important and that the FCTC has had a positive impact, but only up to a point. Long term projections are that current measures will reduce smoking gradually. Globally, the WHO projects that smoking prevalence will reduce from 22.1% in 2010 to 18.9% in 2025, a reduction of only 3.5%. A concept that deserves serious attention is tobacco harm reduction, which can make a contribution to a much more comprehensive approach to tobacco control. This topic is controversial and includes both scientific and legal components, but ultimately is based on a simple objective – the reduction of harm. The concept hinges on the logic that was neatly articulated more than 40 years ago by Professor Michael Russell, the South African born pioneer in the field of smoking behaviour, namely that smokers smoke for nicotine but are killed by tar. Simply put, tobacco harm reduction is defined as any measure that decreases the risk attached to using tobacco or nicotine. Cigarette substitutes such as vaping products and smokeless tobacco are examples. Vaping is the act of inhaling and exhaling the vapour produced by an electronic cigarette (e-cigarette). The main arguments in favour of the use of e-cigarettes are: • It is 95% less harmful than smoking; • It can be effective as a smoking cessation tool; and • It is more popular than other nicotine replacement therapy (NRT) products because it mimics the smoking ritual. The main arguments against the use of e-cigarettes are: • It is more harmful than quitting smoking altogether; • Anything that is associated with the tobacco industry cannot be trusted; • There is not enough long-term data available to make informed decisions; • There is a conflict of interest – it is not possible to sell the problem and the solution (although this is true only for tobacco companies); • It re-normalises smoking; and • It is a gateway to smoking, especially amongst youth. The overall finding of study by the Royal College of Physicians in the United Kingdom (UK) has been quoted extensively in this debate: “Large-scale substitution of e-cigarettes, or other non-tobacco nicotine products, for tobacco smoking has the potential to prevent almost all the harm from smoking in society. Promoting e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible, as a substitute for smoking, is therefore likely to generate significant health gains in the UK.”
Content may be subject to copyright.
ETHICAL ASPECTS OF TOBACCO HARM REDUCTION
WHERE THERE’S NO SMOKE,
IS THERE STILL FIRE?
31 MAY
2017
TABLE OF
CONTENTS
Disclaimer
Executive Summary
Introduction
Tobacco Harm Reduction 101
The “industry”
The medical debate
The regulation of e-cigarettes
A few key ethical questions
..........Do consumers get the right information?
..........Will vaping lead to smoking?
.......... Is the tobacco industry inadvertently being
protected from competition?
..........Is mimicry acceptable?
..........Is there a second hand eect?
..........What is the impact on youth?
Recommendations
..........A human-centric health ecosystem
..........What should employers do?
Conclusion
References
About the author
i
ii
1
3
5
7
13
16
17
18
18
19
19
19
20
20
22
23
24
26
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
i
There are vastly opposing views within the medical profession about tobacco harm
reduction. The author of this report is not a physician and is not in a position to
comment on the medical validity of the different views and the scientific data which
inform them. Similarly, no legal opinions are expressed in terms of the regulatory
environment.
However, beyond the medical and the legal arguments there is a fundamental ethical
premise: the behaviour of companies, as well as the products or services they provide,
can be – and should be – subjected to moral scrutiny. This premise also applies to
companies that are involved in tobacco harm reduction, and will be explored in this
report.
The views presented are those of the author and do not necessarily reflect the views
of the Africa Harm Reduction Alliance.
DISCLAIMER
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting ii
EXECUTIVE
Tobacco smoking is harmful in many ways. Globally,
more than 1 billion people smoke tobacco and 5
million people die each year as a direct result of
tobacco use. One quarter of all lifelong smokers
will succumb in middle age, and smoking costs
the global economy more than $1 trillion per year,
almost four times the amount generated through
tobacco excise duties.
The Framework Convention on Tobacco Control
(FCTC) by the World Health Organization (WHO) is
the conventional reference point for all stakeholders
who agree that tobacco is harmful. The FCTC
came into eect in 2005 and is legally binding in
180 countries. It focuses on the production, sale,
distribution, advertisement, and taxation of tobacco.
There is no doubt that these measures are
important and that the FCTC has had a positive
impact, but only up to a point. Long term
projections are that current measures will reduce
smoking gradually. Globally, the WHO projects that
smoking prevalence will reduce from 22.1% in 2010
to 18.9% in 2025, a reduction of only 3.5%.
A concept that deserves serious attention is
tobacco harm reduction, which can make a
contribution to a much more comprehensive
approach to tobacco control. This topic is
controversial and includes both scientic and legal
components, but ultimately is based on a simple
objective – the reduction of harm.
The concept hinges on the logic that was neatly
articulated more than 40 years ago by Professor
Michael Russell, the South African born pioneer
in the eld of smoking behaviour, namely that
smokers smoke for nicotine but are killed by tar.
Simply put, tobacco harm reduction is dened as
any measure that decreases the risk attached to
using tobacco or nicotine. Cigarette substitutes
such as vaping products and smokeless tobacco
are examples. Vaping is the act of inhaling and
exhaling the vapour produced by an electronic
cigarette (e-cigarette).
It is more harmful than quitting
smoking altogether;
Anything that is associated with the
tobacco industry cannot be trusted;
There is not enough long-term data
available to make informed decisions;
There is a conict of interest – it is not
possible to sell the problem and the
solution (although this is true only for
tobacco companies);
It re-normalises smoking; and
It is a gateway to smoking, especially
amongst youth.
It is 95% less harmful than smoking;
It can be eective as a smoking
cessation tool; and
It is more popular than other nicotine
replacement therapy (NRT) products
because it mimics the smoking ritual.
SUMMARY
THE MAIN ARGUMENTS
IN FAVOUR OF
E-CIGARETTES
AGAINST
E-CIGARETTES
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
iii
The overall nding of a study by the Royal
College of Physicians in the United Kingdom
(UK) has been quoted extensively in this debate:
“Large-scale substitution of
e-cigarettes, or other non-
tobacco nicotine products,
for tobacco smoking has
the potential to prevent
almost all the harm
from smoking in society.
Promoting e-cigarettes,
NRT and other non-tobacco
nicotine products as widely
as possible, as a substitute
for smoking, is therefore
likely to generate significant
health gains in the UK.”
Not everybody shares the positive assessment
of e-cigarettes and other reduced-risk products.
The WHO acknowledges that these products are
less toxic than cigarette smoke, but continues
to argue that these products are “unlikely to
be harmless, and long-term use is expected
to increase the risk of chronic obstructive
pulmonary disease, lung cancer, and possibly
cardiovascular disease as well as some other
diseases also associated with smoking”. The
views of the WHO have been questioned in a
report published by the UK-based Centre for
Tobacco & Alcohol Studies.
The regulatory approach has been inconsistent
worldwide, ranging from exible measures
that allow e-cigarettes to be brought to
market as either medicines or as consumer
products (France), to outright bans on the sale,
advertisement, distribution and importation
of e-cigarettes (Brazil). At the moment, the
legal position in South Africa seems to be
that e-cigarettes are covered neither by the
Tobacco Products Control Act (because there
is no combustion or smoke involved), nor by
the Medicines and Related Substances Control
Act if they are marketed and sold purely for
recreational purposes without any medical
claims.
From a consumer perspective it seems to be
reasonable to expect regulation to address the
following as priorities:
Protecting children by preventing marketing and
prohibiting sales to minors;
Ensuring rigid safety standards in terms of
production;
Ensuring accurate labelling;
Regulating the mimicry eect, for example by
banning e-cigarettes in aeroplanes and regulating
vaping in public spaces; and
Ensuring accurate denitions of dierent
products that are based on scientically
accepted data.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting iv
Beyond the medical and the legal arguments
there is a fundamental ethical premise: the
behaviour of companies, as well as the products
or services they provide, can be – and should be
– subjected to moral scrutiny.
Normative theory is concerned with ethical
behaviour, and the distinction between right and
wrong. Simply because something is the way
it is, does not mean that therefore it ought to
be the way it is. Philosopher G.E. Moore framed
the “open question argument” in the early 20th
century. According to this argument, any state
of aairs in the world is logically subject to the
open question: “Is it good?”.
The tobacco industry has indeed been subjected
to moral scrutiny over many years. From a
business ethics perspective this has involved
views on the industry itself (usually clustered
with other controversial industries like arms
manufacturing, liquor and gambling) as well as
on individual companies (speculating whether
company A is more responsible or ethical than
company B).
It is possible to apply Moore’s argument and to
expand it slightly when we investigate tobacco
harm reduction. In order to answer the question
“is it good?”, we have to look at a range of other
ethical issues, for example:
Honesty and transparency (do producers,
physicians and regulators communicate
honestly, understandably and transparently to
all stakeholders,
most importantly to
consumers?);
Accountability (are
corporations held accountable
for their actions, including compliance
with regulations as well as adherence to
the public commitments they make?);
Human rights (are the human rights of
consumers, including the human right to health,
respected?);
Fairness (are producers of reduced risk products
treated fairly, for example do regulations address
risks in an objective way, and is the distinction
between smoking and vaping addressed in a fair
manner?); and
Empathy (does the health of consumers, and the
fact that many people are addicted to nicotine,
generate sucient empathy in society in order
not to put forward unrealistic and unhelpful
recommendations?).
Linked to these ethical issues, some of the
questions addressed in this report are:
Do consumers get the right information?
Will vaping lead to smoking?
Is the tobacco industry inadvertently being
protected from competition?
Is mimicry acceptable?
Is there a second hand eect from vaping?
Will the youth suer?
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
v
In the interest of advancing the overall
debate, some general recommendations are
made. These relate to a proposed broad-
based approach to advance the debate, as
well as how employers should regulate in this
area. The broad based approach follows the
World Economic Forum recommendation of a
human-centric health ecosystem (HCHE). It is
suggested that a harm-reduction HCHE would
address the following:
Acceptance of the fundamental ethical values
of honesty, transparency, accountability,
fairness and empathy;
The need for a more sophisticated denition
of the “industry”;
Agreement on marketing ground rules (no
youth marketing, no glamorizing of smoking);
The need for base level scientic common
ground;
A strategy to develop reliable, long-term data
in a fast-changing industry;
The need for fair and consistent government
regulation; and
Eective measures to be taken by employers.
In terms of employer measures the following
principles recommended by the UK government
are endorsed:
Make clear the distinction between vaping
and smoking;
Ensure policies are informed by the evidence
on health risks to bystanders;
Identify and manage risks of uptake by
children and young people;
Support smokers to stop smoking and stay
smoke free; and
Support compliance with smoke free law and
policies.
Support for e-cigarettes does not equate to
support for tobacco companies, but many
opponents of tobacco refuse to accept the
distinction. The reasons are unclear. Perhaps
governments are addicted to excise duties, or
perhaps some sections of the anti-smoking lobby
have become an industry in themselves and need
tobacco in order to survive. Clearly the debate
is more nuanced, and there is a big dierence
between tobacco companies that sell both
cigarettes and e-cigarettes and other producers
who are only in the nicotine business.
It is perfectly understandable that – given the
tainted history of the tobacco industry – any
product that includes the word “cigarette” will
be treated with disdain at worst and suspicion
at best. The WHO points out – correctly – that
there is limited empirical evidence available on
the long-term impact of e-cigarettes. As was
the case with mobile phones, this evidence will
emerge over the long term, but is complicated
by the fact that rapid technological advancement
results in new and improved products all the
time. The evidence that is currently available
from very credible sources seems to be rather
convincing, and one should question why this
information is not more widely known.
For the sake of more than one billion smokers
in the world, most of whom are addicted to
nicotine and unable or unwilling to quit, a more
pragmatic approach to e-cigarettes is required.
Technically, it is correct to argue that it is better
to quit altogether than to reduce harm by 95%,
but such a puritan approach will do more harm
than good.
Vigilant watchdogs are required for both
cigarettes and e-cigarettes, but the two products
should not be conated by regulators, life
insurance companies or other stakeholders. The
overriding criterion should always be to make
decisions that will save lives. Both smokers and
non-smokers deserve that and should demand it.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 1
DEMAND
REDUCTION
Tobacco smoking is harmful in many ways. This
fact has been well-documented and will not be
discussed in any detail in this report. We know
that, globally, more than 1 billion people smoke
tobacco and that 5 million people die each year
as a direct result of tobacco use. 1 One quarter of
all lifelong smokers will die in middle age (Meier
& Shelley, 2006: 494), and according to a study
by the World Health Organization (WHO) and the
US National Cancer Institute published earlier this
year, smoking costs the global economy more
than $1 trillion per year, almost four times the
amount generated through tobacco excise duties
(U.S. National Cancer Institute and World Health
Organization, 2016: 99).
The Framework Convention on Tobacco Control
(FCTC) by the World Health Organization is the
conventional reference point for all stakeholders
who agree that tobacco is harmful. The FCTC
came into eect in 2005 and is legally binding in
180 countries. It focuses on the production, sale,
distribution, advertisement, and taxation of tobacco.
The objective of the FCTC is “to protect present
and future generations from the devastating health,
social, environmental and economic consequences
of tobacco consumption and exposure to tobacco
smoke by providing a framework for tobacco control
measures to be implemented by the Parties 2 at the
national, regional and international levels in order to
reduce continually and substantially the prevalence of
tobacco use and exposure to tobacco smoke” (WHO,
2005: Article 3).
The core measures proposed by the FCTC to reduce both the demand for and the supply of tobacco
comprise articles 6 to 17 of the FCTC and are summarised in the table below:
Table 1: FCTC measures to reduce demand for tobacco (WHO, 2005)
SUPPLY
REDUCTION
Article 15: Elimination of all forms of illicit trade in tobacco
products, including smuggling, illicit manufacturing and
counterfeiting
Article 16: Sales to and by minors: prohibit the sales
of tobacco products to persons under the age set by
domestic law, national law or eighteen
Article 17: Promotion of economically viable alternatives
for tobacco workers, growers and, as the case may be,
individual sellers
Article 6: Price and
tax measures
Article 7:
Non-price measures
Article 8: Protection from
exposure to tobacco smoke
Article 9: Regulation of the
contents of tobacco products
Article 10: Regulation of
tobacco product disclosures
Article 11: Packaging and
labelling of tobacco products
Article 12: Education,
communication, training and
public awareness
Article 13: Tobacco
advertising, promotion and
sponsorship
Article 14: Demand reduction
measures concerning tobacco
dependence and cessation
INTRODUCTION
1 http://www.who.int/mediacentre/factsheets/fs339/en/; accessed 31 January 2017.
2 States that have either signed or ratified the FCTC in order to become a Party to the Convention.
There are currently 180 Parties to the Convention.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
2
There is no doubt that these measures are
important and that the FCTC has had a positive
impact, but only up to a point. Long term
projections are that current measures will
reduce smoking gradually. Globally, the WHO
projects that smoking prevalence will reduce
from 22.1% in 2010 to 18.9% in 2025, a reduction
of only 3.5% (WHO, 2015). In the United States,
it is estimated that smoking prevalence will be
reduced from the current 20% to 10% of the
population in 2030 (Yach, 2015: 9). Although
this constitutes progress, more should be done.
Something that deserves serious attention is
tobacco harm reduction, which can make a
contribution to a much more comprehensive
approach to tobacco control. This topic is
controversial and includes both scientic and
legal components, but ultimately is based on a
simple objective – the reduction of harm.
Dr Scott Gottlieb, recently appointed as head
of the US Food and Drug Administration (FDA),
used the opportunity of his rst address to sta
to make very strong remarks about smoking and
– very signicantly – about harm reduction:3
“We need to redouble
eorts to help more smokers
become tobacco-free. And,
we need to have the science
base to explore the potential
to move current smokers –
unable or unwilling to quit
– to less harmful products,
if they can’t quit altogether.
At all times, we must protect
kids from the dangers of
tobacco use.”
The next section introduces the concept of
tobacco harm reduction and – in particular –
e-cigarettes. This is followed by a discussion of
medical opinions and regulatory approaches, as
well as a discussion of some of the core ethical
issues that are involved in the debate. The report
concludes with some recommendations on
how dierent stakeholders could make a more
meaningful contribution to health promotion.
3 https://www.fda.gov/NewsEvents/Speeches/ucm558566.htm?utm_source=TMA+Publications&utm_campaign=a1f57b63fd-EMAIL_
CAMPAIGN_2017_05_17&utm_medium=email&utm_term=0_f85a4ca640-a1f57b63fd-88377377, accessed 23 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 3
TOBACCO HARM
REDUCTION 101
Tobacco harm reduction has divided the medical
profession and deserves more airtime and column
inches, also in non-medical circles. This division
will be discussed in the next section. The concept
hinges on the logic that was neatly articulated
more than 40 years ago by Professor Michael
Russell, the South African born pioneer in the eld
of smoking behaviour: smokers smoke for nicotine
but are killed by tar. 4
Simply put, tobacco harm reduction is dened as
any measure that decreases the risk attached to
using tobacco or nicotine. Cigarette substitutes
such as vaping products and smokeless tobacco
are examples. Vaping is the act of inhaling and
exhaling the vapour produced by an electronic
cigarette (e-cigarette).
There are many other nicotine replacement
therapy products on the market, e.g. nicotine
gum or patches. But although they help some
people to quit smoking, they have had limited
success. A recent New Zealand study 5 found that
e-cigarettes were more eective than nicotine
patches for those looking to quit smoking.
Tobacco Harm Reduction forms part of a more
general approach to harm reduction that is
based on the assumption that certain unhealthy
behaviours cannot be eliminated, and that the
focus should therefore rather be on reducing
the harm caused by these behaviours. Examples
include the provision of needles to drug users and
the distribution of condoms to prevent the spread
of sexually transmitted diseases.
Clive Bates, former director-general of sustainable
futures for the Welsh government, has developed
a model that clearly describes the dierent
components of the reduced-risk consumer
nicotine market, based on distinctions between
heated and unheated substances, as well as
nicotine or tobacco based products. The model is
displayed below.
Figure 1: The Bates model 6
Reduced-risk consumer nicotine market
UNHEATED HEATED AEROSOL
Vaping products
Unheated nicotine products
Heated tobacco products
“Heat-not-burn”
Smokeless tobacco
PURE NICOTINE BASED TOBACCO BASED
4 https://www.theguardian.com/science/2009/aug/04/obituary-michael-russell. Accessed 24 May 2017.
5 https://www.northernstar.com.au/news/e-cigarettes-more-effective-patches-says-study/2015715/, accessed 22 May 2017.
6 The Bates model is available at , available at https://www.clivebates.com/reshaping-american-tobacco-policy-eight-proposals-for-
the-trump-administration/, accessed 23 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
4
E-cigarettes and other vaping products form
part of the heated aerosol / pure nicotine based
quadrant. One of the reasons it has attracted
attention is because it has proved popular with
smokers, something that cannot be said for
many other nicotine products on the market.
Undoubtedly one of the major reasons for the
popularity is that smokers who switch can follow
the same ritual. According to the Royal College
of Physicians (RCP), vaping replicates the
delivery, sensory and behavioural characteristics
of smoking (RCP: 2016, 64).
In a report that was published in November
2016 the WHO makes a distinction between
Electronic Nicotine Delivery Systems and
Electronic Non-Nicotine Delivery Systems
(ENDS/ENNDS). E-cigarettes would therefore
be classied as a member of the ENDS group,
while a further distinction is made between the
following products: rst-generation (cigalikes),
second-generation tank systems and larger third-
generation or personal vaporizers (WHO, 2016:
1). Although the main focus of this report is on
e-cigarettes, the more generic term of “reduced
risk products” is applicable throughout.
Tobacco harm reduction has been referred
to as the third option for smokers, who have
traditionally been confronted with the binary
choice: continue smoking or quit altogether
(Polosa et al, 2013: 1). Norway presents an
excellent case study of how reduced risk
products can change the market. In less than 30
years cigarettes lost 27% market share to snus
(smokeless moist tobacco powder that is placed
under the lip) and medicinal nicotine. Although
this example does not include e-cigarettes,
the impact of reduced risk products is clearly
demonstrated.
Figure 2: The changing nicotine market in Norway (Lundt, 2017).
Cigarettes
95%
Snus
5%
Snus
30%
Cigarettes
68%
Medical
nicotine
2%
1645g per capita
2012
2070g per capita
1985
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 5
It is important to distinguish between the
tobacco industry and those involved in harm
reduction. This is not an easy task, because there
is substantial overlap and it is a uid environment
with frequent mergers and acquisitions.
Not all manufacturers of e-cigarettes are
associated with the tobacco industry. And
not all tobacco companies are responding to
e-cigarettes in a similar way. All the big tobacco
companies are involved in harm reduction, some
more extensively than others. Of course, they
all face a huge legacy, and one cannot expect all
stakeholders to embrace their commitments to
harm reduction enthusiastically and uncritically.
This view has been articulated by Dr Neil Schluger,
professor in Epidemiology, Environmental Health
Sciences and Medicine at the Columbia University
Medical Center (2014):
“If there were ever an industry
that does not deserve the
benet of the doubt when
it comes to protecting or
promoting the public’s health,
it is the tobacco industry, and
one notes with alarm that Big
Tobacco has moved quickly
into the e-cigarette market
… However, just because
e-cigarette manufacturers are
primarily interested in selling
nicotine addiction does not
mean that careful use of their
product might not have some
benet for smokers, and that
is the question before us.”
It is interesting to note that a company like Twisp,
which does not have any links to tobacco and
only sells vaping products, does not include
any health-related information on its web site.
There is only one brief reference to their product
as a “safer alternative”.7 This probably has to
do withcaution over the South African health
department’srather confusing scheduling of
e-cigarettes within the South African market,
where a classication related to smoking
cessation will attract scheduling as an S3
substance with the implication that the product
can only be sold at pharmacies (Motala & Judin,
n.d.). This also presents an ironical twist, and is
probably what irks so many from the traditional
anti-smoking lobby groups: a product that mimics
the very thing that they oppose could potentially
be more eective than anything that has been
tried before.
THE “INDUSTRY”
7 https://www.twisp.co.za/about-us, accessed 22 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
6
Figure 3: Advertisement for Blu 8
Twisp’s approach seems to be in line with
the general approach globally, which is not
to market e-cigarettes as products with
health benets, but rather as a consumer
product positioned as an alternative to
smoking. Schluger (2014) has noted that some
companies position e-cigarettes as “glamorous,
sophisticated, sexually attractive, or macho”.
This has created a challenge for the vaping
industry, because it is perceived to be (and has
mostly decided to present itself as) a new market in
nicotine as opposed to a new product to reduce the
harm from smoking tobacco. Dierent companies
use very dierent marketing and messaging
strategies. One can understand the negative
response from those opposed to smoking
tobacco when they see an advertisement like
the one displayed in Figure 3.
It is sometimes dicult to keep the ways
in which nicotine is sold separate from the
potential benets, but – as articulated by Dr
Schluger above – that should be done. The role
of big players in the industry should also be
acknowledged – if there is really going to be
a fundamental shift in the market, what Wells
Fargo has referred to as the global “arms” race in
reduced risk products,9 it cannot be done without
major companies playing a substantial role.
We can talk about big tobacco and small tobacco,
about “good” tobacco and “bad” tobacco, about
smokeless tobacco or no tobacco, but ultimately
the health of individuals should be the overriding
factor. This brings us to the medical debate.
8 http://tobacco.stanford.edu/tobacco_web/images/ecig_ads/a_free/break/large/break_1.jpg, accessed 22 May 2017.
9 http://www.cspdailynews.com/category-news/tobacco/articles/big-tobacco-arms-race, accessed 24 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 7
THE MEDICAL
DEBATE
It is understandable that the medical profession
will be somewhat cautious about making
pronouncements in this area, since only a few
decades ago they were much more closely
associated with the tobacco industry than they
would like to acknowledge, as illustrated by the
Camel advertisement from the 1950s displayed in
Figure 4.
Figure 4: Camel advertisement from 1950s 10
Today, the medical profession seems to be united
against smoking but it is safe to say that it is
divided about e-cigarettes. According to Schluger
(2014): “e-cigarettes have managed to split the
public health community in two: those who view
them as a potentially valuable harm reduction tool
to reduce the morbidity and mortality associated
with smoking tobacco on the one side, and those
who view them as a Trojan horse designed to
renormalise smoking behaviour, addict a new
generation of young people to nicotine, and
to slow the anti-tobacco momentum that has
gathered slowly but powerfully across the globe”.
As was mentioned in the disclaimer, the author of
this report is not a physician and can therefore not
express an opinion about the reliability of scientic
information. However, the important point here
is to highlight the existence of opposing views,
seemingly all from credible parts of the profession.
10 http://tobacco.stanford.edu/tobacco_web/images/tobacco_ads/doctors_smoking/more_doctors_smoke_camels/large/camels_
doctors_whiteshirt.jpg, accessed 24 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
8
The main arguments in favour of e-cigarettes are:
It is 95% less harmful than smoking;
It can be eective as a smoking cessation
tool; and
It is more popular than other nicotine
replacement therapy (NRT) products because it
mimics the smoking ritual.
The main arguments against e-cigarettes are:
It is more harmful than quitting smoking;
Anything that is associated with the tobacco
industry cannot be trusted;
There is not enough long-term data available to
make informed decisions;
There is a conict of interest – you cannot sell
the problem and the solution (although this
applies only for tobacco companies);
It re-normalises smoking; and
It is a gateway to smoking, especially amongst
youth.
Information about opposing views is important,
because the denition of harm reduction also
includes education about the risks associated
with dierent sources of nicotine in order to help
people make decisions. If information is available,
people should know about it. For example (and
discussed in more detail below), expert opinion
estimates that e-cigarettes are 95% safer than
smoking cigarettes (Public Health England, 2016:
80). However, in the United Kingdom (UK), nearly
half of the population is not aware of this.
The potential benets of a switch from cigarettes
to e-cigarettes have been conrmed by a report
of the Royal College of Physicians (RCP) in the
UK. Although the RCP acknowledged that some
of the carcinogens and toxins from cigarettes
have been detected in e-cigarette vapour, it is
stated that the magnitude of risks of developing
lung cancer or other smoking-related diseases is
“extremely low in absolute terms” (RCP, 2016: 87).
They conclude that: “Although it is not possible
to precisely quantify the long-term health risks
associated with e-cigarettes, the available data
suggest that they are unlikely to exceed 5% of
those associated with smoked tobacco products,
and may well be substantially lower than this
gure” (RCP, 2016: 87).
The overall nding of the RCP study has been
quoted extensively (2016: 189):
“Large-scale substitution of
e-cigarettes, or other non-
tobacco nicotine products,
for tobacco smoking has the
potential to prevent almost
all the harm from smoking in
society. Promoting e-cigarettes,
NRT and other non-tobacco
nicotine products as widely as
possible, as a substitute for
smoking, is therefore likely
to generate signicant health
gains in the UK.”
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 9
Dr Derek Yach, who formerly headed tobacco control at the WHO, shares the skepticism about tobacco
companies, and argues that their intention to change should be stated publicly and backed up by
action. But he is clear about the potential benet of e-cigarettes and how other market sectors should
respond (Yach, 2015: 10):
“Other market sectors need to adapt to the reality of e-cigs as a
force for good. Retailers should voluntarily withdraw cigarettes
from stores, or at least reduce their prominence, in favour of
e-cigs and NRTs. CVS Health has yet to oer e-cigs, despite the
fact that they work better than pharmaceutical products. Life
insurers still treat e-cig users as regular smokers when they
calculate premiums. This is shortsighted and misses a golden
opportunity to spell out the benets of quitting smoking and the
positive impact of switching to e-cigs on people’s longevity.”
Key Recommendations of “Nicotine Without Smoke: Tobacco Harm Reduction”
Smoking is thebiggest avoidable causeof
death and disability, and socialinequality in
health, in the UK.
Provision of the nicotine that smokers are
addicted to without the harmful components of
tobacco smoke can prevent most of the harm
from smoking.
Nicotine replacementtherapy (NRT)is most
eective in helping people to stop smoking
when used togetherwith health professional
input and support, but much less so when used
onits own.
E-cigarettes are marketed as consumer
products and are proving much morepopular
than NRT as a substitute and competitor for
tobacco cigarettes.
E-cigarettes appear to be eective when used
by smokers asan aid toquitting smoking.
E-cigarettes are not currently made to
medicines standards and are probablymore
hazardous than NRT.
However, the hazard to health arising from long-
term vapour inhalationfrom the e-cigarettes
available today is unlikely to exceed5% of the
harmfrom smoking tobacco.
Technological developments and improved
production standards couldreduce the long-
term hazard of e-cigarettes.
There are concerns that e-cigarettes will
increase tobacco smoking byrenormalising the
act of smoking, acting as a gateway to smoking
in youngpeople, and being used for temporary,
not permanent, abstinence fromsmoking.
However, the available evidence to date
indicates that e-cigarettes are beingused
almost exclusively as safer alternatives to
smoked tobacco, by conrmedsmokers who
are trying to reduce harm to themselves or
others fromsmoking, or to quit smoking
completely.
There is a need for regulation to reduce direct
and indirect adverse eects ofe-cigarette
use, but this regulation should not be allowed
signicantly toinhibit the development and use
of harm-reduction products by smokers.
However,in the interests of public health it is
important to promote the useof e-cigarettes,
NRT and other non-tobacco nicotine
productsas widely aspossible as a substitute
for smoking in the UK.
The above is a direct extract from the web site. The full report is available at:
https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
10
Professor Ann McNeil from King’s College in London has called e-cigarettes a “game changer for public health”.11
McNeil was one of the independent authors of a study by Public Health England (PHE). 12
According to the PHE study it is not known whether e-cigarettes are more eective than licensed stop smoking
medications, “but they are much more popular, thereby providing an opportunity to expand the number of
smokers stopping successfully” (PHE, 2016: 10).
PHE is also concerned about inaccurate perceptions about e-cigarettes: “Although the majority of adults and
youth still correctly perceive [e-cigarettes] to be less harmful than tobacco cigarettes, there has been an overall
shift towards the inaccurate perception of [e-cigarettes] being at least as harmful as cigarettes over the last
year” (PHE, 2016: 11). Based on this shift they state an urgent need for clear and accurate information as well as
additional research.
The overall message of the PHE report is (2016:12):
“While vaping may not be 100% safe, most of the chemicals causing
smoking-related disease are absent and the chemicals which are
present pose limited danger. It has been previously estimated that
[electronic cigarettes] are around 95% safer than smoking. This
appears to remain a reasonable estimate.”
This view is corroborated by a scale that was developed by an international expert panel convened by the
Independent Scientic Committee on Drugs.13 The panel developed a multi-criteria decision analysis model
of the relative importance of dierent types of harm related to the use of nicotine-containing products.
Twelve products and fourteen harm criteria were used (seven each for harm to the user and harm to
others). A score of 100 denes the most harmful product and a score of zero denes no harm. The results
are displayed below:
Cigarettes
Small cigars
Pipes
Cigars
Water pipe
Smokeless
unrened
Smokeless
rened
Snus
ENDS
Nasal
Sprays
Oral
Products
Patch
Figure 3: The products ordered by their overall harm scores, with the stacked bar graphs showing the contribution to the overall score of
harms to users and harm to others. The numbers in the legend show the sums of the normalized weights at each node. 14
100
90
80
70
60
50
40
30
20
10
0
To users 67 To others 33
11 https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review,
accessed 22 May 2017.
12 Public Health England is an operationally autonomous executive agency of the Department of Health in the United Kingdom.
13 https://www.truthinadvertising.org/wp-content/uploads/2015/09/European-Addiction-Research-Study-PHE.pdf,
accessed 23 May 2017.
14 Available at https://www.truthinadvertising.org/wp-content/uploads/2015/09/European-Addiction-Research-Study-PHE.pdf,
accessed 24 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 11
Not everybody shares the positive assessment
of e-cigarettes and other reduced risk products.
The WHO acknowledges that ENDS/ENNDS
are less toxic than cigarette smoke (2016: 2),
but continues to argue that these products
are “unlikely to be harmless, and long-term
use is expected to increase the risk of chronic
obstructive pulmonary disease, lung cancer, and
possibly cardiovascular disease as well as some
other diseases also associated with smoking”.
Of course, harm reduction does not claim to be
harmless, but it is problematic that the WHO does
not quantify the risk compared to smoking, other
than stating that it is likely to be smaller than from
tobacco smoke. This concern was also raised by
the UK Centre for Tobacco and Alcohol Studies
(2016), discussed below.
It is important to note that the WHO does include
harm reduction in their denition of tobacco
control: “a range of supply, demand and harm
reduction strategies that aim to improve the
health of a population by eliminating or reducing
their consumption of tobacco products and
exposure to tobacco smoke” (WHO, 2005: 4).
However, that is the only time that the words
“harm reduction” appear in the entire FCTC!
In terms of the role of e-cigarettes to help
smokers to quit, the WHO states the following:
“given the scarcity and low quality of scientic
evidence, it cannot be determined whether ENDS
may help most smokers to quit or prevent them
from doing so” (2016: 4).
The WHO is also concerned about the commercial
interests of traditional tobacco transnational
companies (TTCs), and view their involvement as
a major threat to tobacco control (WHO, 2016: 5).
The concerns are that TTCs will promote ENDS
as a complement rather than an alternative to
tobacco, will control technological innovations in
order to prevent ecacy as an aid to cessation,
will promote smoking to both adults and children
through ENDS advertising, and will assert
potential benets as an excuse to engage with
and inuence policymakers and scientists in
order to undermine the FCTC, and in this way
build credibility in corporate social responsibility
initiatives (WHO, 2016: 5).
The WHO (2016) puts forward a range of
regulatory options, all aimed at “parties that have
not banned the importation, sale, and distribution
of ENDS/ENNDS”, which seem to be the implicit
recommendation. Almost thirty regulatory options
are listed, which include the following:
Banning the possession of ENDS/ENNDS by
minors;
Banning or restricting the use of avours that
appeal to minors;
Prohibiting by law the use of ENDS/ENNDS in
indoor spaces or at least where smoking is not
permitted;
Prohibiting implicit or explicit claims about the
comparative safety or addictiveness of ENDS/
ENNDS with respect to any product unless
these have been approved by a specialized
governmental agency;
Establishing measures to limit interactions with
the industry and to ensure transparency in
those interactions that do take place;
Rejecting partnerships with the industry; and
Banning activities described as “socially
responsible” by the industry, including but not
limited to activities described as “corporate
social responsibility”.
Certainly many of the regulatory options make
sense, including some of the above, specically
with regards to minors as well as the regulation
of where the products may be used (this is
only fair given the mimicry that is involved).
However, one of the biggest problems with
the recommendations is that they refer to “the
industry” as if it were completely homogenous
and synonymous with the tobacco industry.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
12
In their extensive commentary on the WHO report,
the UK-based Centre for Tobacco & Alcohol
Studies provided a lengthy list of concerns. Their
main points are summarised below (UK Centre for
Tobacco & Alcohol Studies, 2016):
Because ENDS are primarily positioned as an
alternative to smoking, the opportunities, rather
than the threats should be emphasized;
Risk should be quantied according to
materiality in terms of the level of exposure (this
also applies to second hand vapour);
Because almost all users of e-cigarettes are
smokers, ex-smokers or would-be smokers, the
most relevant comparison for health policy is
with smoking;
There is condence that ENDS are helping many
smokers to quit smoking and not having negative
eects like renormalising smoking, reducing quit
rates or creating gateway eects;
ENDS marketing is promoting an alternative
to smoking and may therefore be promoting
desirable changes in smoking behavior;
Flavours are essential to the appeal of ENDS as
an alternative to smoking;
The WHO report fails to acknowledge the threat
of disruptive technology such as ENDS to the
commercial viability of the traditional cigarette
business and in this way it is actually supporting
the very part of the industry that it is opposing;
and
By addressing their recommendations only to
parties that have not banned the importation,
sale, and distribution of ENDS/ENNDS, the WHO
suggests implicitly that prohibition should be the
default position.
In summary, the main concern of the Centre
for Tobacco & Alcohol Studies is that the
implementation of the WHO recommendations
will have unintended consequences that will result
in the “reduction of harm reduction”, thereby
increasing harm.
It is acceptable to have strong negative views
about e-cigarettes. But refusing to even talk to the
other side is not helpful but harmful. According to
Armando Peruga from the WHO: “By appearing to
oer a solution with one hand, while continuing to
create mass destruction with the other, the tobacco
industry is trying to regain the respectability it lost
long ago. The manufacturers of cigarettes and other
tobacco products cannot be legitimate partners in
any public health discussion” (WHO, 2014: 857).
Contrary to the WHO’s position to limit interaction
and reject partnerships with the industry, David
Nutt, Professor of Neuropsychopharmacology at
Imperial College, London and former government
chief drugs adviser in the UK, (2016) has argued:
“If we believe vaping saves lives, then we should be
encouraging the tobacco industry to pay attention”.
Benjamin Meier and Donna Shelley from Columbia
University have argued that international law
supports a harm reduction approach to tobacco
control: “Addressing the needs of those addicted to
nicotine … requires a new paradigm for international
tobacco control: the human right to health” (Meier
& Shelley, 2006). With reference to the FCTC, they
state the following: “To address those unwilling or
unable to overcome their nicotine dependence,
it is vital that nations promulgate a similar
protocol specic to harm reduction, arming
their commitment to health and human rights
by analyzing the prospective benets of harm-
reduction products” (Meier & Shelley, 2006).
To be fair, the WHO (2016: 2) admits the following:
“If the great majority of tobacco smokers who are
unable or unwilling to quit would switch without
delay to using an alternative source of nicotine with
lower health risks, and eventually stop using it, this
would represent a signicant contemporary public
health achievement”. It is further argued that this
will only be the case if “the recruitment of minors
and non-smokers into the nicotine-dependent
population is no higher than it is for smoking, and
eventually decreases to zero” (WHO, 2016: 2).
To summarise: there seems to be overwhelming
evidence that e-cigarettes are much safer than
cigarettes. The “95% less harmful” metric is
accepted with condence by many credible
institutions like the Royal College of Physicians.
The counter-argument seems to rely on two main
objections: rstly that more time is required to
study the long-term impact of e-cigarettes, and
secondly that the “industry” cannot be trusted.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 13
THE REGULATION
OF E-CIGARETTES
There have been frequent court cases about patent violations,15 while dierent countries have approached
the regulation of e-cigarettes in many dierent ways. Combined, this does not bode well for the general
advancement of health, as pointed out by The Economist: 16
“The e-cigarette business, then, will probably end up much like
the smartphone industry (whose miniature-battery technology
helped make modern e-cigarettes possible): awash in patent-
related lawsuits and counter-lawsuits.Taken together with
restrictive and ill-conceived e-cigarette regulations proposed
on both sides of the Atlantic, all this may slow growth and
innovation in an industry that could greatly reduce the number
of smoking-related deaths worldwide. Not exactly a win for
anyone involved.”
As a result of the absence of consensus from the medical profession, it is to be expected that the regulatory
environment might be inconsistent. That is indeed the case.
15 The original patent for a smokeless non-tobacco cigarette dates back to 1965 and can be viewed here: https://www.google.com/
patents/US3200819.
16 http://www.economist.com/blogs/schumpeter/2014/03/e-cigarette-patent-wars, accessed 22 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
14
The table below presents a variety of regulations from selected countries:
Table 2: Regulation in selected countries. http://globaltobaccocontrol.org/e-cigarette/country-comparison-database
With reference to South Africa, Van Aartsen (2016)
discusses the diculty of regulating e-cigarettes and
proposes that e-cigarettes should be regulated on two
levels: rstly as medicinal treatment and secondly all
other consumption to be included under the tobacco
products regulation legislation. According to Van
Aartsen: “The reality is, that all tobacco and tobacco-
related product consumption contain [sic] risks to
develop cancer and other health issues. Simply put, it
causes the same harm as regular tobacco cigarettes
and should be regulated accordingly”. This seems
to be a non-sensical position and highlights the risk
of making pronouncements without the necessary
scientic knowledge. At the moment the legal position
in South Africa seems to be that e-cigarettes are
neither covered by the Tobacco Products Control Act
(because there is no combustion or smoke involved),
nor by the Medicines and Related Substances
Control Act if they are marketed and sold purely for
recreational purposes without any medical claims.
A major shift from the US Foods and Drugs
Administration (FDA) seems to be on the cards, given
the comments from the newly appointed head of the
FDA, quoted earlier.
COUNTRY
Argentina
Australia
Belgium
Brazil
Canada
Equador
France
Greece
Norway
United Kingdom
United States
REGULATION
A ruling bans the sale, advertisement, distribution and importation of e-cigarettes. A decree classied
these as tobacco products, thus use is inherently prohibited in enclosed public spaces/transport by
the national tobacco control law.
A law classies nicotine as a restricted poison if it is not used for therapeutic purposes. Non-nicotine
e-cigarettes are classied as legal consumer products.
According to a science policy advisory report nicotine-containing e-cigarettes are regulated
as medicinal products and have not received marketing authorization to date, hence their sale,
distribution, importation and manufacturing are illegal.
Classied as tobacco products. A resolution prohibits the sale, advertisement, distribution and
importation of e-cigarettes. As tobacco products, their use in public places and public transportation
is prohibited by a decree.
A notice by Health Canada classies nicotine-containing e-cigarettes as new drugs under the
Food and Drug Regulations. As such, there are restrictions on their sale, advertisement, promotion,
sponsorship, importation and manufacturing.
Classied as ENDS per a decree. Minimum age of purchase is 18 years. Advertising is restricted to
venues accessed solely by adults. The tobacco control law bans use in public spaces/transport.
E-cigarettes maybe be brought to market either as medicines or as consumer products.
A law bans the sale, display, manufacture and commercialization of e- cigarettes. Use of all types of
e-cigarettes in enclosed public places is prohibited.
E-cigarettes can be classied either as medicinal products or as tobacco surrogates.
E-cigarettes may be brought to market either as medicines or as consumer products. Those seeking
medicines approval undergo the standard licensing process.
The US Food and Drug Administration (FDA) classies e-cigarettes and other electronic nicotine
delivery systems (ENDS) as tobacco products, except in cases when they are marketed as drugs,
devices or combination products.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 15
At the risk of making the same mistake by making
pronouncements about regulation without legal
knowledge, it seems to be reasonable to expect
regulation to address the following as priorities:
Protecting children by preventing marketing
and prohibiting sales to minors;
Ensuring rigid safety standards in terms of
production;
Ensuring accurate labelling;
Regulating the mimicry eect, for example
by banning e-cigarettes in aeroplanes and
regulating vaping in public spaces; and
Ensuring accurate denitions of dierent
products that are based on scientically
accepted data.
IF YOU SNUS,
YOU DON’T LOSE
Much of the current debate
about the impact of e-cigarettes
must sound very familiar to
those in the snus industry.
Snus is a smokeless form of
tobacco that is very popular in
Nordic countries. It comprises
moist tobacco in a teabag-like
container which users place
against their gums for nicotine
absorption. The product has
had a positive health impact in
countries where it is popular,
yet it remains banned in the
European Union. According to
Swedish Match, a producer of
snus, “the evidence available
demonstrates that snus is
significantly less harmful to
health than was previously
thought when it was banned by
the European Union in 1991 and
that snus can play a constructive
role in a tobacco related harm
reduction strategy”.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
16
A FEW ETHICAL
QUESTIONS
Beyond the medical and the legal arguments
there is a fundamental ethical premise: the
behaviour of companies, as well as the products
or services they provide, can be – and should
be – subjected to moral scrutiny. This premise
has not always been accepted, demonstrated by
philosopher John Ladd’s views from 1970:
“We cannot and must not
expect formal organizations,
or their representatives acting
in their ocial capacities,
to be honest, courageous,
considerate, sympathetic,
or to have any kind of moral
integrity. Such concepts are
not in the vocabulary, so to
speak, of the organizational
language game.”
Normative theory is concerned with ethical
behaviour, and the distinction between right and
wrong. Simply because something is the way
it is, does not mean that therefore it ought to
be the way it is. Philosopher G.E. Moore framed
the “open question argument” in the early 20th
century. According to this argument, any state
of aairs in the world is logically subject to the
open question: “Is it good?”.
The tobacco industry has indeed been subjected
to moral scrutiny over many years. From a
business ethics perspective this has involved
views on the industry itself (usually clustered
with other controversial industries like arms
manufacturing, liquor and gambling) as well as
on individual companies (speculating whether
company A is more responsible or ethical than
company B).
It is possible to apply Moore’s argument and to
expand it slightly when we investigate tobacco
harm reduction. In order to answer the question
“is it good?”, we have to look at a range of other
ethical issues, for example:
Honesty and transparency (do producers,
physicians and regulators communicate
honestly, understandably and transparently
to all stakeholders, most importantly to
consumers?);
Accountability (are corporations held
accountable for their actions, including
compliance with regulations as well as
adherence to the public commitments they
make?);
Human rights (are the human rights of
consumers, including the human right to
health, respected?);
Fairness (are producers of reduced risk
products treated fairly, for example do
regulations address risks in an objective way,
and is the distinction between smoking and
vaping addressed in a fair manner?); and
Empathy (does the health of consumers,
and the fact that many people are addicted
to nicotine, generate sucient empathy in
society in order not to put forward unrealistic
and unhelpful recommendations?).
Based on the above, a few key issues that
have ethical implications for both producers
and regulators are discussed below. These are
complex issues and this report cannot begin
to do justice to any one of them, but they will
ultimately have a big impact on consumers.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 17
The issues can be framed as follows:
Do consumers get the right information?
Will vaping lead to smoking?
Is the tobacco industry inadvertently being
protected from competition?
Is mimicry acceptable?
Is there a second hand eect?
What is the impact on youth?
DO CONSUMERS GET THE
RIGHT INFORMATION?
What is important for consumers to understand
about harm reduction is that it is not harm
prevention. It is important for consumers to
get accurate information in a format that is
accessible to those who do not have medical
degrees, and that it is presented in an honest
and transparent way. For example, the evidence
that smoking is bad is highly scientic and
therefore dicult to understand for many
consumers. Consider the following extract from
an article that was published in the Journal
of Occupational and Environmental Medicine
(Whitsel et al, 2015: 334):
Smoking conventional cigarettes involves the
combustion of tobacco, which generates more
than 5000 distinct chemicals dispersed in both
the particulate and gas phase of the smoke.
These include reactive and toxic carbonyls
such as acrolein, acetaldehyde, butyraldehyde,
formaldehyde, propionaldehyde, and butadiene,
metals such as cadmium, lead, arsenic, and
nickel, as well as carbon disulde, hydrogen
cyanide, benzene, nitrosamines, and polycyclic
aromatic hydrocarbons (PAHs). Cigarette
smoke also contains high levels of carbon
monoxide (CO), which increases the levels
of carboxyhemoglobin and reduces oxygen
delivery from red blood cells in smokers. The
particulate phase of mainstream smoke contains
more than 5 Å~ 10 particles per cubic cm that
range in particle size from 0.1 to 1 μm. Recurrent
exposure to this complex mixture of chemicals
has been shown to result in the development of
cancer, as well as cardiovascular and respiratory
diseases, including an increased risk and
severity of respiratory tract infections.
For most consumers, an abbreviated extract
would be more than sucient to get the
message across (Whitsel et al, 2015: 334):
Smoking conventional cigarettes involves the
combustion of tobacco, which generates more
than 5000 distinct chemicals … Recurrent
exposure to this complex mixture of chemicals
has been shown to result in the development of
cancer, as well as cardiovascular and respiratory
diseases.
This message can be further reduced to
“smoking causes cancer” which is seen as
a health warning on many cigarette packs.
Despite the clear message, millions of smokers
prefer to ignore the warning. They would argue,
correctly, that it is their right to choose to
smoke and that cigarettes are a legal product
available in an open market. As will be discussed
further below, the average human being does
not always make decisions in the way that
scientists would like them to. Rather, they focus
on what seems most valuable today and tend
to be less inuenced by logic and statistics. But
there is a moral responsibility on governments
and producers to provide information that
is accurate and accessible. With regards to
e-cigarettes, possibly it is enough for consumers
to understand Professor Russell’s dictum that
smokers smoke for nicotine but are killed by tar.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
18
WILL VAPING LEAD TO
SMOKING?
This is the gateway argument, and unsubstantiated
claims in this regard do not stand the test of either
honesty, transparency or fairness. According to
Prof Linda Bauld, Cancer Research UK’s expert in
cancer prevention: “Fears that e-cigarettes have
made smoking seem normal again or even led to
people taking up tobacco smoking are not so far
being realised … In fact, the overall evidence points
to e-cigarettes actually helping people to give up
smoking tobacco”.17 Although some scholars dispute
whether e-cigarettes should be recommended as
part of a smoking-cessation strategy (Van Zyl Smit
et al, 2013: 873), the more pragmatic approach
seems to be that e-cigarettes (and other reduced
risk products) should be viewed as alternatives
for smoking, and not employed necessarily as a
cessation tool.
According to the RCP report (2016: 186):
All the UK evidence, and almost all the international
evidence, on the use of e-cigarettes by children and
young people to date indicates that concerns about
e-cigarettes helping to recruit a new generation
of tobacco smokers through a gateway eect
are, at least to date, unfounded, although vigilant
surveillance is required to ensure that the emergence
of any such eect is detected and reversed promptly.
According to Public Health England (2016: 38):
Since [e-cigarettes] were introduced to the market,
smoking prevalence among adults and youth has
declined. Hence there is no evidence to date that
[e-cigarettes] are renormalising smoking, instead
it’s possible that their presence has contributed to
further declines in smoking, or denormalisation of
smoking. The gateway theory is ill dened and we
suggest its use be abandoned until it is clear how it
can be tested in this eld.
IS THE TOBACCO INDUSTRY
INADVERTENTLY BEING
PROTECTED FROM
COMPETITION?
This is an area for investigation in terms of both
intended and unintended consequences. Yach
(2015: 10) has argued that “governments have
become addicted to tobacco excise tax and
may fear that, as e-cigs take o, they will lose a
valuable source of income”. However, as we have
seen, the overall costs to the global economy
are almost four times the size of income from
excise duties. The conspiracy argument is that
governments don’t care about the health of their
citizens, but that they are more interested in the
revenue. A more nuanced approach is probably
more realistic. Even if we give governments the
full benet of the doubt, there are some serious
problems with both high excise duties as well
as inconsistent regulation. High excise duties
hurt the poor more than the rich and drive many
people to illicit trade, with serious consequences
both in terms of health and corruption. At the
same time, there is no doubt that higher prices
act as a deterrent. It has been argued that it
would make more sense for increases to be less
frequent but steeper, because small increases
are more likely to be absorbed by consumers
without complaint.
Inconsistent regulation, specically with regards
to e-cigarettes, will prevent the disruption of
the tobacco industry and strengthen the status
quo. As was mentioned earlier, the disruption (or
transformation) of the tobacco industry will have
to involve the big players, and currently there
is divided opinion about their commitment and
intentions. Holding all role players accountable
to their commitments will ensure transparency,
while ensuring that human rights are respected
will improve accountability.
17 https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review, accessed
22 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 19
IS MIMICRY ACCEPTABLE?
It looks like a cigarette, feels like a cigarette in your
hand, you inhale and exhale, but there is no smoke.
This is potentially one of the biggest advantages
of e-cigarettes, because it mimics the ritual of
smoking but excludes the smoke. The counter-
argument is that this is a way of renormalising
smoking, and that it would lead people to graduate
from e-cigarettes to cigarettes (discussed above).
Current statistical information seems to counter
these claims. It is true that many non-smokers
could be oended by e-cigarettes, but only if they
are allowed to be used in areas where smoking
is banned. This is a small price to pay for vapers
– by holding on to the smoking ritual they will
sometimes be treated as real smokers. But fair
treatment based on the actual risks should be the
guiding principle in this regard.
IS THERE A SECOND HAND
EFFECT?
Another reason for banning vaping in public places
is to protect others from second hand eects.
Rodu et al (n.d.) have argued that this is an unfair
way of public shaming (linked to the mimicry
eect), with no convincing evidence that there is
any material risk, because second hand vapour
disperses almost immediately. Public Health
England states categorically that e-cigarettes
“release negligible levels of nicotine into ambient
air with no identied health risks to bystanders”
(PHE, 2016: 65). Again, fair treatment based on
empirical evidence and the principle of fairness
should inform regulation in this area.
WHAT IS THE IMPACT ON
YOUTH?
In a report by the American Academy of
Pediatrics (2017), it is argued that both avoured
tobacco products and avoured e-cigarettes
are ways to lure children to try a product and
eventually become addicted. Evidence in this
area is lacking, but it goes without saying that
any attempt to market nicotine products
to children are unacceptable. Whitsel et al
(2015: 336) have argued that it is important to
prevent young people from obtaining and using
e-cigarettes, because experimentation might
lead to later or concurrent use of conventional
cigarettes.
According to Public Health England (2016: 87)
most estimates indicate that less than 3% of
youth currently or recently used e-cigarettes.
They acknowledge that experimentation is
increasing, but state that regular or current
use of e-cigarettes appears to be largely
concentrated in those already smoking
conventional cigarettes (PHE, 2016: 87). Honest
communication based on reliable empirical
evidence, respect for human rights (and in
this case children’s rights) as well as proper
accountability structures will ensure fair
treatment of young people.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
20
It is very dicult to make recommendations in a
eld that has been well-researched and contains
a wealth of scientic data with often conicting
interpretations. A simple Google search on
tobacco harm reduction yielded almost 4 million
results, and for electronic cigarettes almost 10
million results! This study does not purport to
be familiar with all the data, and as was pointed
out in the disclaimer, does not attempt to
assess the scientic validity of medical opinions.
However, in the interest of advancing the overall
debate, some general recommendations are
made here. These relate to a proposed broad-
based approach to advance the debate amongst
all key stakeholders, as well as how employers
should regulate in this area.
A HUMAN-CENTRIC
HEALTH ECOSYSTEM
The World Economic Forum has proposed the
concept of a human-centric health ecosystem
(HCHE) in order to cooperate to achieve
shared health goals: “An HCHE is a complex
environment in which an array of organizations
interacts to yield health-related outcomes for
individuals and populations. Fundamental to
the HCHE concept is its focus on the individual
and his or her perceptions, intentions and
behaviour as those inuence personal health
results. Personal health, in turn, ultimately drives
population health” (World Economic Forum,
2017: 3).
The focus on individual behaviour is very
important in the context of e-cigarettes,
because ultimately – despite the best eorts of
governments and other organisations – the choice
to smoke or not is an individual choice. The World
Economic Forum identied prominent behaviours
that aect people’s health choices (World
Economic Forum, 2017:3). These behaviours are:
People choose what seems most valuable
today and heavily discount future benets;
People place far greater psychological weight
on detrimental outcomes than on benecial
ones;
People base their interpretation of
possibilities on the way information is
presented;
People respond more strongly to compelling
stories than to logic and statistics;
People are inuenced by what others in
family or peer groups are doing or choosing;
People make decisions based on how, and
how many, options are presented and on
which options are easiest to select;
People’s decisions are inuenced by feelings
of low energy or low attention levels; and
People believe unrealistically in their personal
ability to eect change and avoid adverse
outcomes.
It should be possible to introduce the concept
of a topic-specic HCHE on harm reduction. If
this is accepted, it would challenge stakeholders
to interact with each other with a focus on
individual behaviour, in this case the potential
use of e-cigarettes. It would have to be
positioned within the broader HCHE concept
that looks at more risk factors (tobacco, diet,
alcohol, air pollution and physical inactivity)
and a broader range of non-communicable
diseases (e.g. cardiovascular disease, mental
illness, cancer, chronic respiratory disease and
diabetes).
RECOMMENDATIONS
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 21
The rst challenge would be to get all stakeholders
around the table. In this regard it is useful to be
reminded that the WHO actually included harm
reduction as part of its denition of tobacco
control. In fact, Article 14.2(a) of the FCTC
recommends the “design and implement[ation
of] eective programmes aimed at promoting the
cessation of tobacco use” (WHO, 2005: 13). It could
therefore be argued that an attempt to create an
HCHE on harm reduction is perfectly aligned with
the FCTC. Meier and Shelley have argued exactly
this point: “working under the FCTC framework,
countries should create international mechanisms
to research and regulate harm-reduction products
and programs” (Meier & Shelley, 2006). The recent
comments by Dr Scott Gottlieb, referred to earlier,
also support this type of dialogue.
The creation of a harm reduction HCHE does
not have to be the result of a single event, but
can rather be an umbrella term for a series of
events, discussions and research publications
on harm reduction. Of course, all these activities
are happening already. But there would be
two major dierences with anything that has
happened so far:
There will be a wider group of stakeholders
around the table; and
The focus will be on individual behavior, with
the understanding that this ultimately shapes
population health.
On the agenda will be:
Acceptance of the fundamental ethical values
of honesty, transparency, accountability,
fairness and empathy;
The need for a more sophisticated denition
of the “industry”;
Agreement on marketing ground rules (no
youth marketing, no glamorizing of smoking);
The need for base level scientic common
ground;
A strategy to develop reliable, long-term data
in a fast-changing industry;
The need for fair and consistent regulation;
and
Eective measures to be taken by employers.
The last point is particularly important and
deserves more attention. Individuals spend a
substantial amount of time at the workplace.
Contrary to a home environment that is very
dicult to regulate, corporate measures can
have a big inuence on how individuals behave.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
22
WHAT SHOULD
EMPLOYERS DO?
The UK government has recommended that
employers should adhere to the following
principles when regulating the use of e-cigarettes
in the workplace:18
Make clear the distinction between vaping and
smoking;
Ensure policies are informed by the evidence on
health risks to bystanders;
Identify and manage risks of uptake by children
and young people;
Support smokers to stop smoking and stay
smoke free; and
Support compliance with smoke free law and
policies.
Whitsel et al (2015) have proposed the following
guidelines:
Employers should include e-cigarettes in their
tobacco-free policies and should ban e-cigarette
use in their smoke-free work areas;
Employers should oer comprehensive tobacco
cessation services within their employee health
care plans and wellness programmes and
e-cigarette users should be eligible for these
programmes;
Employers should screen for e-cigarette use
in their health screenings and in their health
insurance plan design and wellness programmes
to be able to tailor their wellness programmes
and worksite policies optimally; and
Employers should target tobacco use instead
of nicotine use if they elect to administer health
contingent incentives in coordination with their
wellness programmes.
18 https://www.gov.uk/government/news/vaping-in-public-places-advice-for-employers-and-organisations, accessed 24 May 2017.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 23
Support for e-cigarettes does not equate to support
for tobacco companies, but many opponents
of tobacco refuse to accept the distinction. The
reasons are unclear. Perhaps governments are
addicted to excise duties, or perhaps some sections
of the anti-smoking lobby have become an industry
in themselves and need tobacco in order to survive.
Clearly the debate is more nuanced, and there is
a big dierence between tobacco companies that
sell both cigarettes and e-cigarettes and other
producers who are only in the nicotine business.
It is perfectly understandable that – given the
tainted history of the tobacco industry – any
product that includes the word “cigarette” will be
treated with disdain at worst and suspicion at best.
The WHO points out – correctly – that there is
limited empirical evidence available on the long-
term impact of e-cigarettes. As was the case with
mobile phones, this evidence will emerge over the
long term, but is complicated by the fact that rapid
technological advancement results in new and
improved products all the time. The evidence that is
currently available from very credible sources seems
to be rather convincing, and one should question
why this information is not more widely known.
For the sake of more than one billion smokers in
the world, most of whom are addicted to nicotine
and unable or unwilling to quit, a more pragmatic
approach to e-cigarettes is required. Technically, it
is correct to argue that it is better to quit altogether
than to reduce harm by 95%, but such a puritan
approach will do more harm than good.
Vigilant watchdogs are required for both cigarettes
and e-cigarettes, but the two products should not
be conated by regulators, life insurance companies
or other stakeholders. The overriding criterion
should always be to make decisions that will save
lives. Both smokers and non-smokers deserve that
and should demand it.
CONCLUSION
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
24
American Academy of Pediatrics. 2017. The Flavor Trap.
Bates, C., Lehrer, E. & Sweanor, D. 2017. Reshaping American Tobacco Policy. Available at
https://www.clivebates.com/documents/ReshapingUSpolicy.pdf. Accessed 23 May 2017.
Food and Drug Administration, United States. 2016. FDA takes signicant steps to protect Americans
from dangers of tobacco through new regulation. Press release: May 5th, 2016.
Ladd, J. 1970. Morality and the Ideal of Rationality in Formal Organizations. The Monist. Issue 54.
Lund, K. 2014. Future research questions in harm reduction. 2014. Global Forum on Nicotine; 2014-06-27
- 2014-06-28
Lund, K. 2017. State of play in Harm Reduction and the Scandinavian Experience. 2017. Presented at the
Swedish Embassy in Prague, 21 March 2017.
Lund, K. & Vedøy, T. 2015. Evidence for the impact of snus on smoking –the Norwegian experience.
PowerPoint presentation to Global Forum on Nicotine.
Meier, B. & Shelley, D. 2006. The Fourth Pillar of the Framework Convention on Tobacco Control:Harm
Reduction and the International Human Right to Health. Public Health Rep. 2006 Sep-Oct;
121(5): 494–500
Motala, I. & Judin, M. n.d. Legal status of e-cigarettes in South Africa.
Naqvi, J. n.d. Health leaders call for immediate action to curb smoking in the U.S. Washington Post.
Nutt, D. 2016. Vaping saves lives. It’d be madness to ban it. The Guardian. 14 October 2016.
Polosa, R., Rodu, B., Caponetto, P., Maglia, M. and Raciti, C. 2013. A fresh look at tobacco harm reduction:
the case for the electronic cigarette. Harm Reduction Journal 2013, 10:19.
Public Health England. 2016. E-cigarettes: an evidence update. Available at
https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update.
Accessed: 24 May 2017.
Rodu, B., Glans, M. & Stroud, L. n.d. Vaping, E-Cigarettes, and Public Policy Toward Alternatives to
Smoking. The Heartland Institute.
Royal College of Physicians. 2016. Nicotine without smoke: Tobacco harm reduction. London: RCP.
Available at https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-
harm-reduction-0. Accessed 24 May 2017.
Schluger, N. 2014. The electronic cigarette: a knight in shining armour or a Trojan horse? The Psychiatric
Bulletin. October 2014, 38(5): 201 – 203.
Terry, M., Serin, J., Cummings, K., Erickson, A. & Shopland, D. 2017. Ending cigarette use by adults in a
generation is possible. Core Team on Tobacco Control.
REFERENCES
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting 25
UK Centre for Tobacco & Alcohol Studies. 2016. Commentary on WHO Report on Electronic Nicotine
Delivery Systems and Electronic Non-Nicotine Delivery Systems. Available at
http://ukctas.net/news/commentary-on-WHO-report-on-ENDS&ENNDS.html.
U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A
Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Oce on Smoking and Health, 2016.
U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco
Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-
8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of
Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016.
Van Aartsen, Yda. 2016. A smokey issue – the law relating to the distribution of e-cigarettes. De Rebus,
December 2016.
Van Zyl-Smit, R., Allwood, B., Stickells, D., Symons, G., Abdool-Gaar, S., Murphy, K., Lalloo, U., VAnker,
A., Dheda, K. and Richards, G. 2013. South African tobacco smoking cessation clinical practice
guideline. South African Medical Journal, 2013;103(11):869-876.
Wells Fargo Securities. 2017. 2017 “Watershed Year” For E-Cigs/Vapor? May 9, 2017.
Whitsel, L., Benowitz, N., Bhatnagar, A., Bullen, C., Goldstein, F., Matthias-Gray, L., Grossmeier, J., Harris,
J., Isaac, F., Loeppke, R., Manley, M., Moseley, K., Niemiec, T., O’Brien, V., Palma-Davis, L., Pronk,
N., Pshock, J., Stave. G. and Terry, P. 2015. Guidance to Employers on Integrating E-Cigarettes/
Electronic Nicotine Delivery Systems Into Tobacco Worksite Policy. Journal of Occupational and
Environmental Medicine, Volume 57, Number 3, March 2015
World Economic Forum. 2016. Future of Healthy: How to Realize Returns on Health.
World Economic Forum. 2017. Human-Centric Health: Behaviour Change and the Prevention of Non-
Communicable Diseases.
World Health Organization. 2005. WHO Framework Convention on Tobacco Control.
Available at http://apps.who.int/iris/bitstream/10665/42811/1/9241591013.pdf?ua=1.
Accessed 24 May 2017.
World Health Organization. 2015. WHO global report on trends in prevalence of tobacco smoking 2015.
World Health Organization. 2016. Electronic Nicotine Delivery Systems and Electronic Non-Nicotine
Delivery Systems. Conference of the Parties to the WHO Framework Convention on Tobacco
Control.
World Health Organization. 2014. Countries vindicate cautious stance on e-cigarettes. Bulletin
of the World Health Organization. 2014; 92:856–857. Available at http://www.who.int/bulletin/
volumes/92/12/14-031214.pdf.
Yach, D. 2015. E-cigarettes save lives. Spectator Health. 21 February 2015.
AFRICA HARM REDUCTION ALLIANCE Just Managing Consulting
26
This report was prepared for the Africa Harm Reduction Alliance by Daniel Malan from Just Managing Consulting.
Dr Daniel Malan is the director of the Centre for
Corporate Governance in Africa at the University of
Stellenbosch Business School in South Africa. His
focus areas are corporate governance, business ethics
and corporate responsibility. He is a member of the
following initiatives: the World Economic Forum’s
Expert Network and the International Corporate
Governance Network’s Integrated Business Reporting
Committee. He is currently an honorary visiting fellow
in the faculty Legal Studies and Business Ethics
department of the Wharton School, University of
Pennsylvania (September 2016 to July 2017), an
honorary visiting fellow in the faculty of management
at Cass Business School and a portfolio partner at the
International Center for Corporate Governance in St
Gallen. Previously he was an associate director with
KPMG Forensic, where he was responsible for ethics
and integrity services. His educational qualications
include a PhD in Business Administration, a Masters
degree in Philosophy as well as a Masters degree in
Business Administration (MBA), all from the University
of Stellenbosch in South Africa.
Daniel Malan
Telephone: +27 82 902 0269
Email: daniel.malan@usb.ac.za
ABOUT THE
AUTHOR
AFRICA HARM REDUCTION ALLIANCE
Registration Number: 2017 / 064966 / 08
Co-Founders: Dr. Kgosi Letlape, Dr. Delon Human
E-Mail Address: info@ahra.co.za / delon@ahra.co.za
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Electronic cigarettes have caused a sharp debate in the public health community, with some promoting them as a means of harm reduction for tobacco users and some taking a strong stand against them because of fear of renormalising smoking behaviour and interrupting tobacco control progress. People with mental health problems smoke at high rates and e-cigarettes seem a potentially attractive method of cessation in this population, and their use should be studied carefully.
Article
Full-text available
Tobacco smoking (i.e. cigarettes, rolled tobacco, pipes, etc.) is associated with significant health risks, reduced life expectancy and negative personal and societal economic impact. Smokers have an increased risk of cancer (i.e. lung, throat, bladder), chronic obstructive pulmonary disease (COPD), tuberculosis and cardiovascular disease (i.e. stroke, heart attack). Smoking affects unborn babies, children and others exposed to second hand smoke. Stopping or 'quitting' is not easy. Nicotine is highly addictive and smoking is frequently associated with social activities (e.g. drinking, eating) or psychological factors (e.g. work pressure, concerns about body weight, anxiety or depressed mood). The benefits of quitting, however, are almost immediate, with a rapid lowering of blood pressure and heart rate, improved taste and smell, and a longer-term reduction in risk of cancer, heart attack and COPD. Successful quitting requires attention to both the factors surrounding why an individual smokes (e.g. stress, depression, habit, etc.) and the symptoms associated with nicotine withdrawal. Many smokers are not ready or willing to quit and require frequent motivational input outlining the benefits that would accrue. In addition to an evaluation of nicotine dependence, co-existent medical or psychiatric conditions and barriers to quitting should be identified. A tailored approach encompassing psychological and social support, in addition to appropriate medication to reduce nicotine withdrawal, is likely to provide the best chance of success. Relapse is not uncommon and reasons for failure should be addressed in a positive manner and further attempts initiated when the individual is ready.Key steps in smoking cessation include: (i) identifying all smokers, alerting them to the harms of smoking and benefits of quitting; (ii) assessing readiness to initiate an attempt to quit; (iii) assessing the physical and psychological dependence to nicotine and smoking; (iv) determining the best combination of counselling/support and pharmacological therapy; (v) setting a quit date and provide suitable resources and support; (vi) frequent follow-up as often as possible via text/telephone or in person; (vii) monitoring for side-effects, relapse and on-going cessation; and (viii) if relapse occurs, providing the necessary support and encourage a further attempt when appropriate.
Article
Full-text available
Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable -- or at least unwilling -- to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking's damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.
Article
Full-text available
By applying the right to health to tobacco control, this article advocates for research in and evaluation of these purportedly less hazardous tobacco products through the FCTC framework. Only by acknowledging these tobacco harm-reduction products and appraising them as part of national comprehensive tobacco control strategies can governments realize their obligations under the right to health. Casting success as the reduction in exposure to toxins, these less hazardous nicotine-delivery products, while not offering the preferred health and economic benefits of abstaining from tobacco entirely, might nevertheless become a viable component of a nation’s comprehensive tobacco policy.
Chapter
There are many unanswered questions related to the development of optimal neuroprotection of the drowning victim. Eight key questions that emerged from the areas in this chapter are presented below.
Reshaping American Tobacco Policy
  • C Bates
  • E Lehrer
  • D Sweanor
Bates, C., Lehrer, E. & Sweanor, D. 2017. Reshaping American Tobacco Policy. Available at https://www.clivebates.com/documents/ReshapingUSpolicy.pdf. Accessed 23 May 2017.
United States. 2016. FDA takes significant steps to protect Americans from dangers of tobacco through new regulation. Press release
  • Drug Food
  • Administration
Food and Drug Administration, United States. 2016. FDA takes significant steps to protect Americans from dangers of tobacco through new regulation. Press release: May 5th, 2016.
State of play in Harm Reduction and the Scandinavian Experience
  • K Lund
Lund, K. 2017. State of play in Harm Reduction and the Scandinavian Experience. 2017. Presented at the Swedish Embassy in Prague, 21 March 2017.
Evidence for the impact of snus on smoking -the Norwegian experience
  • K Lund
  • T Vedøy
Lund, K. & Vedøy, T. 2015. Evidence for the impact of snus on smoking -the Norwegian experience. PowerPoint presentation to Global Forum on Nicotine.