“Tobacco harm reduction is good public health and health promotion, starting with the people who matter: smokers and those who have chosen alternatives. It’s change driven from community level upwards—because it’s people who do harm reduction, not experts.”
Burning Issues: The Global State of Tobacco Harm Reduction 2020, the recently released second edition of a major biennial report produced by Knowledge-Action-Change*, is that rare report that passionately engages readers while supplying global data, powerful personal stories, common sense recommendations and a searing political analysis.
Author Harry Shapiro has penned a vital, cutting-edge document that isn’t afraid to name names, or to unapologetically defend tobacco harm reduction (THR) and the right to health.
The report (GSTHR) begins with a grim reality: “The World Health Organization (WHO) has not revised downwards its estimate that one billion lives could be lost to smoking-related disease by the end of the century. This is equivalent to the combined populations of Indonesia, Brazil, Nigeria, Bangladesh and the Philippines dying from COVID-19.”
“People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health.”
Smoking-related death and disease disproportionately impact poor and marginalized groups, especially in low- and middle-income countries. The author’s core argument is that this is preventable—but only if smokers have access to affordable safer nicotine products (SNP), in forms including snus, smokeless tobacco, heated tobacco products and vapes. The report emphatically states, “People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health.”
Shapiro employs some relatively new terminology which is desperately needed to clear up the confusion between vaping and smoking. The term “e-cigarette” is out because it’s too easily confused with the idea of smoking a cigarette. Instead, “SNP” is used as a collective, accurate descriptor for harm reduction products. No term has caused as much damage as the deceptive “EVALI” (E-cigarette or Vaping Lung Injury), which wrongly links the outbreak of deadly lung injuries in the US to vaping nicotine liquid. Instead, the precise words “Vitamin E-Related Lung Injury” (VITERLI) are used. These terms should be widely adopted.
GSTHR has collected never-before-reported data on SNP use:
* There are only nine SNP users for every 100 smokers globally; most live in high-income countries.
* Overall, 98 million people are estimated to use SNP worldwide.
* Of those, 68 million are vapers, with the largest vaping populations in the US, China, the Russian Federation, the UK, France, Japan, Germany and Mexico.
* 20 million are heated tobacco product users—most of whom live in Japan, where cigarette sales have dropped by 32 percent since 2016 when HTP were launched! This decrease is unprecedented.
* 10 million are users of snus or other forms of smokeless tobacco, concentrated in the US, Sweden, Norway and Iceland.
The numbers indicate an urgent need to scale up tobacco harm reduction around the world to help smokers make the switch.
A major barrier is philanthrocapitalist billionaires like Bill Gates and Michael Bloomberg.
GSTHR clearly identifies the obstacles to speeding up the transition to SNP in Chapter 5, titled “Project Fear: The War on Nicotine.” A major barrier is philanthrocapitalist billionaires like Bill Gates and Michael Bloomberg. Bloomberg Philanthropies (BP) is a vicious adversary of tobacco harm reduction and vaping in particular. The report notes that, “Since 2006, Bloomberg has donated close to $1 billion to promote anti-tobacco efforts, making BP the developing world’s biggest funder of tobacco-control initiatives. In 2013, it was reported that Bloomberg had donated 556 grants in 61 countries to campaigns against tobacco. In August 2016, the WHO appointed Bloomberg as its Global Ambassador for Noncommunicable Diseases.”
How is it that this rich, white man—who is neither scientist nor health professional, and isn’t elected or accountable to anyone—wields so much power and influence in the realm of global public health? It is fundamentally undemocratic and a disgrace. BP funds the Campaign for Tobacco-Free Kids, an organization that whipped up panic over the so-called teen vaping epidemic leading to bans on flavored e-liquids in states across the US—and disastrous international knock-ons like the national ban on vaping products in India. The GSTHR makes it clear that Bloomberg money is a direct threat to the widespread adoption of SNP.
A second, equally formidable barrier is a tsunami of junk science. Stanton Glantz, a nemesis of THR, is a leading researcher who publishes data about vaping that doesn’t stand up to scrutiny. GSTHR examines two of his studies that were severely criticized by leading tobacco experts and one study that was retracted. It compares Glantz to Harry Anslinger, the former head of the Federal Bureau of Narcotics who used fear-mongering and moral panics to enact cannabis prohibition. It’s an apt comparison: “He has been able to create an Anslinger-like cascade of misinformation through the publication of numerous papers and many conference and media appearances … Like Anslinger, he is an archetypal moral entrepreneur and is seen by many as the go-to expert on a subject around which swirls much ignorance.”
Anslinger, as the report should have mentioned, was also an unrepentant racist who targeted Black people in his war on marijuana, which kept cannabis illegal for over 50 years and criminalized millions who smoked it anyway. Glantz’s goal is simply the total prohibition of the sale and use of SNP by anyone. Incredibly, he argues that vaping is as dangerous as smoking. This calling out of Glantz is enormously satisfying for those of us who are sick of his ridiculous lies.
Tobacco shares in the US and India rose in response to news of proposed bans on SNP in those countries.
Ironically, the main beneficiary of SNP bans and anti-vaping panics is the combustible tobacco industry. Both reduce alternatives for smokers, so that they keep on smoking. In fact, tobacco shares in the US and India rose in response to news of proposed bans on SNP in those countries. This glaring contradiction doesn’t appear to bother the opponents of SNP, who charge that harm reduction products are a Big Tobacco Ruse—their tactics boost the profits and power of the very industry they loath and want to drive out of business.
Chapter 7 of GSTHR, “The Right to Health and the People Left Behind,” outlines the dire situation of groups with the highest rates of smoking. Few governments are making sustained efforts to address tobacco use among people with mental health and substance use issues, the LGBTQ community, Indigenous populations, or people experiencing homelessness or incarceration. These groups, among others, suffer high rates of anxiety, depression and suicide accompanied by high levels of smoking and other drug use. Those “left behind” disproportionately live in social and economic poverty and are highly stigmatized.
Despite serious challenges, there is some good news. GSTHR gives several examples of innovative attempts to reach vulnerable populations. The Vape2save program in New Zealand encourages Māori smokers to switch to vaping. Vaping shops are located in mental health hospitals in England and offer patients who smoke the opportunity to switch. British and some US prisons offer smokers modified vaping kits. Prison officials have said that allowing vaping reduces both smuggling of tobacco and levels of violence.
This chapter could have offered more explanation of the causes of high smoking rates among vulnerable populations, and why poor people constitute the vast majority of smokers in every country. How will tobacco harm reduction reach homeless people who live in encampments, or people who use other drugs chaotically? How will people with low or no income afford SNP? These are hard but essential questions.
The report could also have benefited from a chapter about vape shops. These small businesses play an invaluable role in normalizing vaping, educating smokers and helping them transition. In effect, they are smoking cessation clinics. Unfortunately, vape shops are under attack by anti-vaping forces. Many in the US, for example, have been forced to close due to flavor bans or a failure to recognize them as essential businesses during the pandemic. Will Big Vape put mom-and-pop shops out of business?
Cost and access will determine how many smokers can switch—and how many lives can be saved from smoking-related diseases.
A related issue is the price of SNP. How much do they cost in different countries where they are legal? Where is online purchasing permitted, or not? What are the taxes applied, and where are SNP cheaper than cigarettes—or vice versa? What do illicit markets look like in places where they’re forced to exist? Such critical questions deserve to be addressed by the next GSTHR, because cost and access will determine how many smokers can switch—and how many lives can be saved from smoking-related diseases.
Overall, this report is proof positive that tobacco harm reduction works and SNP are a life-saving, game changer for all groups of smokers. It summarizes:
“SNP is one of the most startling public health success stories of modern times … THR offers a global opportunity for one of the most dramatic public health innovations ever to tackle a non-communicable disease … In a time of COVID-19 when global health and public finance systems are stretched to breaking point and may not recover for some time, the imperative to drive forward with THR has never been more urgent.”
The following conclusions from GSTHR are a guide to ending the global war on nicotine users and liberating humanity from the scourge of burning tobacco.
* The immediate way to reduce smoking-related deaths is to focus on current smokers.
* The evidence for SNP demonstrates that they are substantially safer than combustible tobacco, both for smokers and by-standers, and contribute to helping those wishing to stop smoking.
* The adoption of SNP has been consumer-driven with nil, or minimal, cost to governments.
* SNP have the potential to substantially reduce the global toll of death and disease from smoking, and to effect a global public health revolution.
* Many US and US-funded organizations have manufactured panics about young people and vaping, about flavors and the outbreak of lung disease, overshadowing the real public health challenge, which is to persuade adult smokers to switch.
* The increasingly prohibitionist emphasis risks many consequences, including that current smokers may decide not to switch, current users of SNP may go back to smoking, and the growth of unregulated and potentially unsafe products.
* Those most affected by tobacco control policies have been stigmatized and excluded from the policy conversation. Good public health engages affected populations. The slogan “nothing about us without us” is central to THR, as it is to any field in public health.
*KAC has provided scholarships to The Influence Foundation, which operates Filter, to support tobacco harm reduction reporting. GSTHR was produced with the help of a grant from the Foundation for a Smoke-Free World (FSFW), although editorially independent. Filter Editor-in-Chief Will Godfrey was an unpaid editorial adviser to GSTHR. FSFW has also provided restricted and unrestricted grants to The Influence Foundation. Filter’s Editorial Independence Policy applies.