The panel discussion that closed the first day of this Summit, was moderated by Mr David Sweanor, focused on the ongoing debate between prohibition and regulation in public health, particularly regarding tobacco control. Mr Sweanor highlighted the historical ineffectiveness of prohibition and its adverse outcomes, setting the stage for experts from various countries to present the actual results of the bans on the low-risk alternatives to cigarettes and to share their perspectives about effective strategies for reducing smoking.
As was said by Lisa McGirr in her wonderful book “The War on Alcohol”, Mr Sweanor said, there is an ongoing tendency of people to want to use the power of the state to impose their moral views on the behaviour of others. But history has shown us that bans are not only almost always ineffective, but they are almost always a disaster. And yet they keep happening, he underlined.
Spain: Proposals for the new Tobacco Control Plan
Dr Fernando Fernandez-Bueno from Spain introduced the country’s new tobacco control plan, advocating for science-based strategies and harm reduction.
The Minister of Health of Spain, he said, has recently announced the development of a comprehensive tobacco control plan, and has committed to listening to the proposals of civil society and ensuring that her decisions are based on scientific criteria. Therefore, with the aim of contributing to reducing the number of smokers in Spain, which is currently over 9 million, Tobacco Harm Reduction Platform has prepared a document with 10 recommendations based on objective and scientific criteria.
These recommendations include increasing taxes on combustible cigarettes which is the most toxic form of nicotine consumption and the cause of nearly 63,000 deaths each year in Spain. Proposed measures will enhance protection for minors and young people, expanding the smoke-free spaces for combustible cigarettes to include terraces, stadiums, cars and other places since science has demonstrated the effects of second-hand smoking. Among other measures that are recommended is plain packaging for combustible cigarettes. It is also suggested developing realistic scientifically based solutions and incorporating new tools that are adapted to modern times for smokers who cannot quit with traditional methods or are unwilling to stop using nicotine; as well as learning from international partners and offering specialized training for healthcare professionals to effectively tackle smoking-related issues.
Dr Bueno affirmed that the Platform he represents supports the idea that the future tobacco control plan must be based on science and empirical data, avoiding personal judgments or preconceived ideas. There is a vast amount of scientific literature demonstrating the potential of harm-reducing alternatives, such as electronic cigarettes, nicotine pouches, snus, or heated tobacco, in helping people quit smoking. Of course, prevention and cessation have been and continue to be the key pillars in the fight against smoking, he said, but harm reduction can be extremely useful as a complementary strategy for those who are unable to quit smoking using the usual tools.
In recent years, Dr Bueno concluded, Spain has lost the leadership in fight against smoking that the country had earned nearly two decades ago with the approval of the ambitious anti-tobacco law. This is why the new Ministry of Health has the opportunity to once again position Spain as a reference country in the fight against smoking. To achieve this, the Tobacco Control Plan must focus on three key pillars. Science, building on international experience and societal stories, and strengthening prevention and cessation strategies with harm reduction.
Advocacy for Safer Nicotine Products in Canada
The second speaker, Mrs Maria Papaioannoy, addressed the need for a fresh approach to tobacco control in Canada, advocating for inclusivity and innovation in regulations for safer nicotine products, and pointed out the challenges faced by advocates and the detrimental effects of existing laws on harm reduction efforts.
Unfortunately, Mrs Papaioannoy said, North America’s current tobacco control model is based in the past. Policymakers are not looking in the future, and they want to stop innovation. Describing the regulatory situation currently in Canada, she said “is a patchwork,” and explained that one hand there is Health Canada and the Minister of Addictions and Health that support flavour should not be banned. On the other hand, however, the rest of the government is being influenced by misguided people, she said, who don’t understand the difference between nicotine and combustion and delivery methods. So, what harm reduction advocates currently are doing, is fighting different battles across the country. “It is very sad that today it costs more to buy a bottle of e-liquid than it does to buy a pack of cigarettes,” she said characteristically and commented that the current laws in Canada are biased. Moreover, Canada’s Minister of Health has stopped nicotine pouches from being available at corner stores where alcohol is available.
Mrs Papaioannoy announced her goal to create a new act, the Safer Nicotine Act, and talked about the importance of collective action in achieving this goal. Tobacco control needs to change, she explained, needs to be more inclusive and embrace the innovation. “Rights 4 Vapors” movement is about safer nicotine because the whole point of vaping and innovation is to create a safer product.
Canada needs to learn from New Zealand and Sweden, needs to learn about how to make better regulations and go to the next level, because at the end of the day people are going to die, Mrs Papaioannoy concluded. 48,000 Canadians die every year from tobacco-related illness. There is deep stigmatization and systemic beliefs about what happens when people smoke, and people who smoke are treated worse than any other population. It is therefore crucial for us that we continue to speak up and out, to educate and participate in conferences, she underlined.
Mr David Sweanor thanked the speaker and referenced the book “Innovation and Its Enemies” written by Calestus Juma, to discuss the long-standing resistance of societies to innovative products. “The promise of new technology is often greeted with scepticism, vilification, or outright opposition, often dominated by slander, scare tactics, conspiracy theories, and misinformation,” he said. The assumption that new technologies carry unknown risks guides much of the debate, and this is often amplified to levels that overshadow the dangers of known risks.
Understanding consumer needs
Dr Sudhanshu Patwardhan stressed the necessity of using scientific literature to guide policymaking and the importance of understanding consumer needs, especially in low and middle-income countries where tobacco use poses significant challenges.
Answering the rhetorical question of the title of the session, Dr Patwardhan said that obviously the public health frontier needs to be where the consumers are.
It is true that regulation and policymaking is hard work, he continued, and it needs local regulatory science and enforcement capabilities, which are often lacking in most of the world. That means that policymakers and regulators in those countries are very vulnerable to be influenced by policies sent from a handful of ideologically driven countries or folks with no assessment, with no oversight. And in such a context, prohibition is seen as an easy way out due to lack of local expertise.
Dr Patwardhan shared the negative outcomes of prohibition in Bhutan, where the ban on tobacco sales had fuelled a thriving black market, emphasizing the need for locally relevant cessation tools and the role of healthcare professionals in addressing nicotine misinformation and supporting quit attempts.
Misinformation drives a lot of policymaking and decision making around tobacco control policies, explained Dr Patwardhan. Nearly 80% of healthcare professionals around the world think wrongly that nicotine and tobacco products cause cancer.
Smoking causes and increases the inequity in the society not only in low and middle-income countries but even in the western world, the speaker stressed. For example, disadvantaged populations such as those with mental health conditions suffer disproportionately due to the harms of smoking and yet the policies are often absolutist and impractical. For example, in 2018 the UK government required and mandated smoke-free hospital sites but not enough was done to empower clinicians to actually help patients who are smokers who are admitted to sustainably quit smoking.
If we are not acknowledging the smokers’ need to be able to quit a habit which is addictive in a sustainable, meaningful way, I think we’re missing the point. By focusing on the consumers, I think in a generation with all the right efforts, we can make the world free of risky forms of tobacco products, Dr Patwardhan said.
People can only make as good a decision as the information available to them allows, Mr Sweanor commented. And it is simply unfair to fail to give people adequate information to make an informed decision and then hold them responsible for the harm that is caused to them by having made a poor decision. We clearly need to allow people to be empowered to make decisions about their health. We’ve got a long way to go, and it is shocking to have so many who are working against consumers getting that information and therefore supporting the status quo. And the status quo is 8 million global deaths a year from cigarette smoking!
Tobacco Harm Reduction in Moldova
The last speaker Dr Eugeniu Cotelea, highlighted the difficulties and the obstacles encountered in advocating for tobacco harm reduction in Moldova due to restrictive laws and opposition from the medical community.
He spoke about the resistance from the medical establishment and government, citing examples of rejected research projects and the proposed restrictive laws that limit the free speech of medical practitioners. In Moldova, Dr Cotelea explained, a very tough medical establishment is in place, opposing the ideas of tobacco harm reduction, supporting the harm reduction ideas only for illegal drugs. “In fact, when they hear the word tobacco, you become a public enemy,” he said.
Moldova has one of the strictest laws regarding tobacco smoking with a lot of prohibitions. For example, it is not allowed to smoke on the street and to advertise tobacco products. Also, now the parliament is debating a new law that will be more restrictive than before, prohibiting the free speech of medical doctors.
Dr Cotelea expressed the need for providing realistic and qualitative information to individuals seeking less harmful tobacco products, and said that the Moldovan government, instead of promoting healthy lifestyle through harm reduction, accepts harm reduction only in the case of illegal drugs. But the government has a totally different approach for alcohol and tobacco that are not illegal, he added. In this case, they do not prohibit the products, and they do not prohibit smoking or using, they prohibit the medical doctors’ free speech. Moldovan Ministry of Health wants to be the best in WHO recommendations, so they decided to stop the medical doctors’ free speech, the speaker said. “In my opinion, he concluded, if a patient asks and wants to be informed, you should provide him realistic and qualitative information about all products that can benefit his health.”
Discussion
The sad reality is that these bans on free speech are promoted globally and are incredibly protective of the cigarette industry, Mr Sweanor commented. These laws are present even in countries like the United States. It is not allowed to promote a reduced risk product—even though that’s absolutely true—unless the FDA allows it; however, FDA’s process makes approval virtually impossible. The result is that some people in the United States are misinformed because they are not getting information.
Canada has a constitution that gives a right to life, a right to free speech. Yet the government several years ago passed a law on vaping that made it illegal for a company to inform consumers about the difference in risk between products. “Anti-tobacco advocates think it is a good idea that consumers cannot make an informed decision, that they’re not empowered to make decisions about their own health. But people need to know that there’s a product that’s less hazardous than a cigarette. They need to know how much less hazardous, where can they get it, if it is available readily and what are the policies on it,” Mr Sweanor said.
There are politicians that are also medical doctors that are extremely aggressive against any kind of idea of THR, Dr Cotelea added. They are supporting the pharmaceutical industry lobby, but they address Tobacco Harm Reduction as something bad.
Dr Patwardhan talked about the complex situation in India following the ban on Safer Tobacco Products five years ago, emphasizing how this ban has led to the products being sold underground, increasing the risks for consumers. He expressed empathy for the 300 million tobacco users in India who are deprived of safer alternatives and criticized the idea for restrictions on access to nicotine replacement therapy, which is hindering efforts to reduce tobacco use.
In India, the government has also sent a note to media saying that it is not accepted to criticize their policies, Mr Sweanor added. But how can you develop better policy if you can’t criticize the faults of current policy, he wondered.
Persistence and finding amplifiers within the system can make the change, Mrs Papaioannoy said, emphasizing the power of connecting with people. We must never give up, she stressed, we just have to believe that it will happen and stop focusing on all the times it didn’t happen.
Health institutions, doctors, nurses, scientists should provide objective and scientifically validated public information, Dr Bueno commented. Today, a lot of people still think nicotine is the problem. But the problem is not nicotine, the problem is the smoke. First, we need to avoid the smoke. If population doesn’t understand this, we cannot win this war, he said.