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Jakarta Post

Ethical, moral tobacco harm reduction

Jakarta   /   Tue, May 14, 2019   /   09:30 am
Ethical, moral tobacco harm reduction In a report released ahead of World No Tobacco Day, WHO warned that the annual death toll of seven million people had jumped from four million at the turn of the century, making tobacco the world's single biggest cause of preventable death. (Shutterstock/File)

According to the World Health Organization (WHO), there were 61 million smokers in Indonesia in 2018. Tobacco kills an estimated 230,000 people each year, mainly through cardiovascular diseases, representing a whopping 15 percent of all deaths.

Clearly, this represents a major public health problem. Therefore, interventions that can mitigate the smoking epidemic need careful consideration.

To this end, a review of recent evidence on vaping and electronic nicotine delivery systems (ENDS) suggests that these products have potential in reducing the harm caused by smoking.

Given the right to health of every human being, it is an ethical and moral responsibility to take a fresh look at the potential benefits of these interventions for those who want to quit smoking.

What is the state of the current evidence on ENDS? First, and based on comprehensive analyses of the evidence by credible, independent and impartial organizations, ENDS has been shown to be safe and contain 60-95 percent fewer toxic chemicals compared to combustible cigarettes.

Second, there are strong indications that ENDS can help those who want to quit smoking. In the United Kingdom, it is estimated that electronic cigarettes (ECs) have helped 15,000-22,000 people quit smoking every year.

Third, ECs have been shown to be twice as effective as standard nicotine replacement therapies such as gum, patches and lozenges in helping people quit smoking.

Fourth, evidence for the “gateway” effect — the increased risk of youths using ENDS eventually becoming smokers — has been overstated and riddled with conjecture and assumptions. For example, the association between early use of vaping products and subsequent smoking does not necessarily mean that these youth would not have smoked even in the absence of ECs.

Fifth, the use of ECs and heat-not-burn products, has resulted in dramatic reductions in cigarette consumption and sales in the United States and Japan.


Part of the problem is [...] the unwillingness of policymakers to consider evidence [...]


Two recent policy developments representing progress in the debate surrounding harm reduction are worth highlighting. First, the United States Food and Drug Administration recently authorized the sale of a leading heat-not-burn device in the country.

Second, and based on human rights considerations, the Superior Court of Quebec, Canada, endorsed the factual foundation of establishing vaping as a harm reduction measure and overturned laws that seek to limit access to such lower risk products.

But there are arguments challenging the use of ENDS. First, ENDS are as dangerous as combustible cigarettes, which is misleading as stated above. Second is the gateway effect, which as stated above, has not been conclusively proven. Fears of hypothesized harm due to gateway effects among youths should not undermine the much larger benefits of reducing smoking prevalence in the whole population.

The third argument is that there is insufficient evidence and that more research is needed to ensure both the efficacy and safety of ENDS products.

While ENDS are not without health risks and there is still uncertainty about their longer-term benefits and risks, they are likely to be far less harmful than combustible cigarettes, and it is arguably better to vape than to smoke even if nicotine and dependence remain. At least for now there are strong indications that ENDS looks like a useful innovation in public health.

The current state of evidence, while incomplete, would seem sufficient to guide policy development. The scale of harm from smoking globally requires bold but defensible decisions to be made on ENDS, even if such decisions are based on imperfect information.

There are, however, some factors that block the acceptance of ENDS. First, the lack of robust local research on ENDS. This is important as many policy-and decisionmakers give a lot of consideration and weight to research done in the local context.

Second, the position of WHO on harm reduction and ENDS remains rigid and uncompromising. Such a stance reflects the historic legacy of bad behavior on the part of multinational tobacco companies that actively sought to undermine WHO’s efforts to develop the Framework Convention on Tobacco Control.

Third, the difficulty in communicating the concept of “evidence” and the inherent uncertainty that is integral to the process of scientific discovery. It is a reality that experts often differ in their views and this can create confusion among policymakers and the public.

Finally, there is a natural human tendency to defend a particular position and to cherry pick only the evidence that supports that position. Therefore, a major part of the problem is not so much the lack of scientific evidence, but the unwillingness of policymakers to consider evidence of such benefits.

We can expect some implications of the evidence on ENDS for the development of rational policies and regulations. First, policies and regulations for ENDS should be “risk proportionate” in nature and ENDS should not be considered in the same category as combustible cigarettes. This includes proportional tax rates, labelling requirements and space separation for users.

Second, to allay fears about the so-called gateway effect, regulations must be put in place to limit access to those younger than 18 years old, including restrictions on the use of attractive images in advertisements to attract the attention of youth.

Third, regulations and standards are needed to ensure the safety and quality of ENDS.

Fourth, policies and resources are needed to promote and support more high-quality local research to evaluate the efficacy and safety of ENDS. Fifth, more open and inclusive consultation and dialogue is needed to inform policy, including hearing the views of smokers and producers of ENDS.

The dialogue goes hand-in-hand with the need for more effective and balanced communication strategies to convey the potential benefits of ENDS and in overcoming misinformation and fake news on its harms.

Policies must take into account the ethical, moral, human rights and equity dimensions. Smokers who want to quit must surely have the right to access information and products that can enable them to have a healthier life.

Let us remember how many smokers try repeatedly to get rid of the scourge of tobacco without success. While trying ECs and heat-not-burns is no guarantee of anything, it can play a role in facilitating quitting tobacco and its harms.

Denying them access to such interventions constitutes a human rights violation.


The writer is a visiting professor at Lee Kuan Yew School of Public Policy, National University of Singapore. The views expressed are his own.

Disclaimer: The opinions expressed in this article are those of the author and do not reflect the official stance of The Jakarta Post.