The prestigious scientific journal The Lancet publishes a critical article by researchers Ruth Bonita and Robert Beaglehole (a former senior WHO official) about the World Health Organization’s (WHO) flawed approach to smoking cessation. The researchers say that in order to reduce the harmful effects of smoking on health, it is necessary to encourage alternatives to smoking and thus reduce the harm from it. And the current policy of banning smoking substitutes is misleading and harmful.
To date, the World Health Organization has recommended that nicotine-based alternatives to smoking be banned altogether or treated as equivalent to cigarettes. According to the researchers, “these are different products in terms of the damage they cause to health. It is cigarette smoke that causes smoking-related illnesses, not the nicotine found in substitutes.”
The problem of smoking is not new, it has existed for centuries. Many countries, including ours, are taking a variety of steps to reduce the number of smokers. There are countries that have been very successful in this, and there are countries that have had little success.
The problem of smoking is indeed a fundamental problem in Pakistan – according to the WHO, about 20% of the adult population in Pakistan smokes. Unlike many developed countries such as Sweden, New Zealand and the United Kingdom that have conducted their own research to lead their approaches, most low and middle-income countries instead join the policy of the World Health Organization (WHO) that recommends that alternatives to smoking be banned altogether or treated as equivalent to cigarettes.
“In order to reduce the harmful health effects of tobacco use,” the authors of the article argue, “it is necessary to adopt a harm reduction approach.” They explain that “tobacco harm reduction is the fastest and most effective way to reduce smoking prevalence and prevent smoking-related deaths. It is the burning of tobacco that is harmful, not the nicotine itself (which is found in smoking substitutes such as tobacco heating devices or nicotine liquid vaporizers).” Therefore, “a tobacco harm reduction approach should be the central WHO tobacco control strategy (FCTC), in addition to supply and demand reduction measures, which are necessary but not sufficient. The World Health Organization should adopt new products that provide smoke-free nicotine use.”
The article also states that in some countries it is possible to see a significant decrease in the prevalence of smoking, occurring at the same time as the introduction of smoking substitutes that contain nicotine but do not emit smoke. As an example, the researchers cite New Zealand, where smoking prevalence fell from 13.3% in 2017-2018 to 6.8% in 2022-2023, a 49% increase in five years. This came after e-cigarettes became widely available and the government supported their marketing and regulatory framework. At the same time, as the percentage of smokers decreased, the prevalence of smoking substitute use increased from 2.6% to 9.7%.
They also cite the example of Sweden, where there is a long tradition of using nicotine pads (“Snus”). Sweden boasts the lowest number of smokers in the world at 6%, as well as a low mortality rate from smoking-related diseases. Norway has had the same success as Sweden with an increase in the use of nicotine pads and e-cigarettes, which has led to a sharp decline in smoking prevalence in the country.
In England, too, it is believed that the use of substitutes helps smokers to give up cigarettes. There, the government encourages smokers to switch to alternative options and shows a sharp decline in the percentage of smokers from 30% to 13.5%. Japan has also seen a sharp decline in cigarette consumption, which is due to the rapid market penetration of alternative products based on heating tobacco instead of burning it.
Along with this progress in high-income countries, we can also look at low- and middle-income countries, where the political will to promote tobacco control measures is weaker and the potential for adopting a tobacco harm reduction approach has not been realized. It is important to say that 80% of smokers live in low- and middle-income countries, and this is where the greatest benefit can be gained from adopting a harm reduction approach.
The authors of the article argue that “there is no scientific basis for the World Health Organization’s position that e-cigarettes and new nicotine products based on heated tobacco should be treated as cigarettes.”
In conclusion, countries that have adopted a harm reduction approach and benefited from the promotion of smoking substitutes, such as New Zealand, Sweden, Norway, England and Japan, should continue to encourage other countries and WHO to support proposals that will rapidly reduce smoking rates. “The world’s 1.3 billion smokers, half of whom will die prematurely, deserve this help.”
