Tobacco harm reduction is here for good

Malawi: Most people have probably internalised HIV and AIDS messaging that promotes total abstinence, being faithful to one partner, or using a condom-'Condomise' (A-B-C).

A record of massive condom sales suggests that, in contrast to being faithful to one partner and abstaining, most people may have chosen the 'Condomise' option.

A similar approach to 'enjoying' sex without contracting a Sexually Transmitted Infection has been researched and proven that people who are addicted to smoking (Nicotine) can still enjoy the pleasure of smoking without being harmed by the tobacco.

Tobacco threat

According to the World Health Organization (WHO), the tobacco epidemic is one of the most serious public health threats the world has ever faced, killing more than eight million people each year, including approximately 1.2 million deaths from second-hand smoke exposure.

In a message on World no Tobacco day commemorated on May 31, 2022, the WHO Regional Director for Africa, Dr. Matshidiso Moeti said despite 24 African countries instituting bans on smoking in public places, and 35 banning tobacco advertising, promotion and sponsorship, “our estimates are that one in every 10 African adolescents use tobacco. The emergence of new products, such as electronic nicotine and tobacco products, are also proving attractive to youths, compounding the concerns.”

According to the WHO, there are over 4000 chemicals in tobacco smoke, and there is no safe level of exposure to second-hand tobacco smoke.

The WHO strongly encourages smokers to quit, “When tobacco users become aware of the dangers of tobacco, most want to quit. However, the nicotine contained in tobacco products is highly addictive and without cessation support, only 4 per cent of users who attempt to quit tobacco use will succeed. Professional support and proven cessation medications can more than double a tobacco user's chance of successful quitting.”

Quitting smoking

Nonetheless, international stakeholders believe that quitting smoking is more difficult than anticipated, and there is an urgent need to consider the adoption of technologies that would satisfy' smokers' addiction without exposing them to the 4000 chemicals in tobacco smoke.

According to the WHO website, the MPOWER strategy has been implemented to address the tobacco disease challenge. MPOWER is an acronym that stands for Monitor tobacco use and prevention policies.

MPOWER stands for Monitor tobacco use and prevention policies, Protect people from tobacco use, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship and Raise taxes on tobacco. The WHO does not subscribe to harm reduction products.

Tobacco harm reduction, according to Consumer Advocates for Smoke-free Alternatives Association Tobacco (CASAA), is an evidence-based public health approach consisting of pragmatic policies, regulations, and actions to reduce health risks by, among other things, providing access to safer forms of products or substances.

“Instead of trying to convince or force people to stop doing something, harm reduction promotes education and gives people safer ways of doing it,” reads the website information in part.

According to the website of the Australian Tobacco Harm Reduction Association (THR), THR is no different from other widely used harm reduction strategies in public health, such as condom use by sex workers, clean needles, syringes, and medically supervised injecting centres for injecting drug users, and Methadone for heroin users.

“Smoke-free products deliver nicotine to satisfy nicotine cravings. Electronic cigarettes and Heat-not-burn (HnB products) have the added advantage of replicating the familiar hand-to-mouth ritual and sensations of smoking which smokers can find very hard to stop.”

“While not risk-free, the overwhelming scientific consensus is that these products deliver far lower levels of toxic and harmful compounds than combustible cigarettes. If a smoker switches completely from smoking s/he is likely to have substantial improvements in health,” reads the website information in part.

Dr. Lars Ramström, Principal Investigator at the Institute for Tobacco Studies (a Swedish independent research agency), claims that WHO's tobacco control measures are failing - and that harm reduction works.

His new study findings, which will be presented at the 9th Global Forum on Nicotine (GFN22) in Warsaw, Poland, from June 16 to 18, 2022, indicate that incorporating tobacco harm reduction into existing tobacco control measures holds the key to hastening the end of smoking.

“The key to reducing tobacco-related mortality is tobacco harm reduction through the transition from combustible cigarettes to safer nicotine products, which must be made easier for people who smoke. These include not just Swedish-style snus but also vapes, tobacco-free nicotine pouches and heated tobacco products,” he said.

Dr. Ramström called on the WHO and governments to heed modern science.

He said: “They need to move from rejecting tobacco harm reduction to promoting it. Governments can also play their part by adopting rates of taxation that make low-risk products cheaper than cigarettes and the ban of snus in the European Union must be overturned.”

Harm reduction frontier

The GFN 22 is an international conference focusing on the role of safer nicotine products in assisting people to quit smoking. E-cigarettes (vapes), nicotine pouches, oral tobacco such as Swedish snus, and heated tobacco products are all safer nicotine products.

The conference was attended by consumer and consumer advocacy organisations, manufacturers, public health experts, harm reduction advocates, medical doctors, researchers, scientists, policymakers, former smokers, and academia, among others, under the theme "Tobacco Harm Reduction-Here for Good."

Despite playing a critical role in informing and shaping debates about safer nicotine products and tobacco harm reduction, these groups are frequently excluded from other international meetings and events.

“The rapid development and use of safer nicotine products raise a number of challenging scientific questions about their safety, who uses them and why, and the impact on smoking. These products also raise challenges for governments who seek to understand what kind of policy and regulation is appropriate. The GFN examines the rapidly developing science in relation to nicotine and its use, including policy and regulatory responses,” reads the GFN media information package document.

It further says smoking tobacco is the most harmful way of using nicotine since it is the tars and gases in cigarette smoke that are harmful to health, “Many people find it hard to stop smoking because they find it hard to go without nicotine. Making available lower-risk products helps people to switch from smoking and avoid the associated risks.”

What it means for Malawi

Tobacco is Malawi's main foreign exchange earner and the backbone of the country's agrarian economy. This could imply that WHO's anti-smoking lobby and harm reduction products are a threat to the organization's green gold economy.

However, Malawi harm reduction consumer advocates believe Malawi could capitalise on this by investigating the possibility of producing safer nicotine products such as snus for local and export use.

According to Harm Reduction Journal on BioMed Central (BMC) website, Snus is a moist oral tobacco product which is placed behind the upper lip, either loose or in portioned sachets, which resemble miniature tea bags, “Air-cured tobacco is ground, mixed with salt and water and then processed under strict quality and regulatory controls using a technique similar to pasteurisation”

Chimwemwe Ngoma, a Harm Reduction Consumer Advocate, claims that the tobacco leaf is not the problem, but smoking is, and that there are safer nicotine products, such as snus, made from the same tobacco.

“Countries like Sweden are enjoying the health benefits of Snus such that Sweden has the lowest smoking prevalence and lowest disease and death profile in the whole of Europe,” he notes.

“Malawi is part of the global community and equally affected by adverse effects of tobacco smoking. Statistics show that close to a million people are active daily tobacco users in Malawi and approximately 5,700 people die from tobacco-related infections annually.”

Ngoma adds: “The GNF therefore discussed some of the ground-breaking consumer-centric tobacco harm-reduction interventions and strategies that can help to mitigate the effects of smoking-related harms. Our participation in the conference also meant that we could contribute towards the discussion and learn from others.”

However, Malawian smokers have their own concerns and opinions about tobacco harm reduction technologies.

Robert, a Blantyre (semi-urban) resident, says he is aware that combustive cigarettes are harmful to one's health, but he is perplexed to hear of other modern types of cigarettes.

"An ordinary smoker like me may not be able to afford this," he fears of the harm reduction cigarettes.

“Another concern I have is that the new products may not provide me with the ‘vibe’ that I associate with smoke."

Daniel, another ‘smoker', says he would like to use the products but is unaware of their benefits and drawbacks.

"It's a good idea, yes," says Daniel, who claims to have been smoking combustible cigarettes for over 21 years. He claims to smoke no less than 50 combustible cigarettes per week on average.

Sahan Lungu, another harm reduction consumer advocate at Tobacco Harm Reduction Malawi, acknowledges that lack of awareness, availability, accessibility, and affordability of safer nicotine products continue to be major barriers to adoption by Malawian smokers who are unable or unwilling to quit smoking.

He claims that THR, an information dissemination initiative run by a group of volunteers in Malawi, is assisting in raising awareness of safer nicotine products and dispelling myths about nicotine.

“The group has previously engaged various stakeholders through workshops and has spread the word through a website, social media platforms, documentary films and television/radio appearances,” he says.

Lungu claims that despite the fact that THR is still a relatively new concept in developing countries such as Malawi, safer nicotine products such as nicotine patches and gum are being used in some of the country's smoking cessation centres.

“We hope that the government and smoking cessation centres in Malawi will continue taking a pragmatic approach by adopting and formulating science-based policies on novel lower-risk products just like the United Kingdom has done by incorporating electronic cigarettes in the country’s healthcare system,” he says.

Similar to HIV prevention

Harm reduction is thought to work and save lives after learning from the effectiveness of A-B-C- HIV infection prevention and other related preventive methods in reducing new HIV infections.

GFN22 is an annual opportunity for open discussion, debate, and engagement on how to best prevent tobacco-related illnesses and deaths and achieve the third United Nations Sustainable Development Goal (SDG).

The goal's goal is to make it possible for everyone to live in good health and to promote the well-being of people of all ages.

Tobacco use reduction is critical to global efforts to meet the SDG target of reducing premature deaths from noncommunicable diseases (NCDs) by one-third by 2030.

Hopefully, there will be more harm reduction progressive updates about Malawi at the GFN23.