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Where there is no smoke, is there still fire?
Dated: Thursday, June 15, 2017
​The harm caused by tobacco has been well-documented and only a few of the most ghastly statistics are presented here. On this day alone, more than 13 000 people will die worldwide as a direct result of tobacco, writes USB’s Dr Daniel Malan in this article. Read it here.

The harm caused by tobacco has been well-documented and only a few of the most ghastly statistics are presented here. On this day alone, more than 13 000 people will die worldwide as a direct result of tobacco. One quarter of all lifelong smokers will succumb in middle age, and, according to a study by the World Health Organization (WHO) and the United States 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.


The typical response to a day like today is to reinforce the importance of the WHO's Framework Convention on Tobacco Control (FCTC). 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 measures to decrease demand for and distribution of tobacco are important and that the FCTC has had a positive impact, but only up to a point. The people who will die today because of tobacco are a grim reminder of this fact.


One additional strategy in terms of tobacco control is harm reduction. This strategy has divided the medical community and deserves more airtime and column inches. It 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). 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 study in New Zealand found that e-cigarettes were more effective than nicotine patches for those looking to quit smoking.


The potential benefits of a switch from cigarettes to e-cigarettes have been confirmed by a report of the Royal College of Physicians in the UK, which states: "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 … as a substitute for smoking, is therefore likely to generate significant health gains in the UK".


Other experts agree. According to a study by Public Health England e-cigarettes are 95% safer than smoking, yet nearly half of the population is not aware of this. Dr Derek Yach, who formerly headed tobacco control at the WHO, has referred to e-cigarettes as a "force for good". Professor Ann McNeil from King's College in London has called e-cigarettes a "game changer for public health".  Dr Scott Gottlieb, the new head of the US Food and Drug Administration (FDA), used the opportunity of his first address to staff last week to make very strong remarks about smoking and – very significantly – about harm reduction: "We need to redouble efforts 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".


Supporting 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 an ethical difference between tobacco companies that sell both cigarettes and e-cigarettes and other producers who are only in the nicotine business.


It is interesting to note that a company like Twisp, which sells only vaping products, does not include any health-related information on its web site. This probably has to do with caution over the Health Department's rather confusing scheduling of e-cigarettes within the South African market, where a classification related to smoking cessation will attract scheduling as an S3 substance with the implication that the product can only be sold at pharmacies. This also presents an ironical twist, and is probably what irks so many from the traditional anti-smoking lobby groups – namely that a product that mimics the very thing that they oppose could potentially be more effective than anything that has been tried before.


It is perfectly understandable – given the tainted history of the tobacco industry – that 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 the launch of new 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.


It is to be expected that there will be strong views against e-cigarettes. But refusing even to talk to the other side is not acceptable. The WHO's official report on "Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems" proposes to limit interaction and reject partnerships with the industry, as if the companies that produce these devices are all part of tobacco. This approach is not helpful. Benjamin Meier and Donna Shelley from Columbia University have argued that international law supports a harm reduction approach to tobacco control. They insist that "[a]ddressing the needs of those addicted to nicotine … requires a new paradigm for international tobacco control: the human right to health".


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 ultimately do more harm than good.


Vigilant watchdogs are required for both cigarettes and e-cigarettes, but the two products should not be conflated by regulators, life insurance companies or other stakeholders. Where appropriate, similarities should be acknowledged. Vaping in a theater or on a plane should not be permitted on the grounds that there is no combustion. Advertising related to smoking should never target children and when this occurs there should be severe sanctions. The integrity of those companies that aggressively market both cigarettes and e-cigarettes should be questioned. The medical profession should continue empirical research and one should never expect a consensus opinion. But the overriding criterion should be to make decisions that will save lives. Both smokers and non-smokers deserve that – and should demand it.


Dr Daniel Malan is currently doing research for the Africa Harm Reduction Alliance.