Notably absent from the discussion is careful consideration of how novel products, including heated tobacco products (HTPs), will impact the low- and middle-income countries (LMICs) where they are being aggressively introduced and marketed. In diverse nations like Ukraine, Yemen, Iraq, Papua New Guinea and Indonesia, these products will further stress already fragile health systems, now further constrained by COVID-19. Young people are particularly vulnerable.

We highlight these increasingly challenging issues amid the pandemic, in conjunction with World No Tobacco Day of May 31.

With the same tactics they deployed in the US, novel product producers are similarly encouraging youth uptake of e-cigarettes in LMICs, using social media, event sponsorship and flavors. Sound familiar? That’s because the products may be new, but the playbook and producers are not. E-cigarettes are increasingly dominated by the tobacco industry, and HTPs are exclusively tobacco industry owned.

Public health officials have good reason to be anxious. First and perhaps foremost, increasing evidence shows youth who use e-cigarettes, who have never smoked, and would have been considered low-risk for later taking up smoking, increase their chance of smoking traditional cigarettes later in life by two to four-fold.

In many LMICs — where bans on sales to minors are generally weak, where cigarettes are almost always insufficiently taxed and priced and where cigarettes are culturally ingrained and widely used — the potential for youth to transition from e-cigarettes to cigarette smoking is likely to be greater.

Next on the list of things to worry about is lack of enforcement. In LMICs, loopholes to circumvent tobacco control policies abound. Even before COVID-19, many LMICs had difficulty enforcing tobacco control policies, such as smoke-free areas, advertising bans, vendor licensing and measures to prevent youth sales.

In the Asia Pacific, tobacco use causes more than one in five cases of cardiovascular disease, like heart attack and stroke, and nearly a quarter of its population are smokers. This leads to the death of 1 million people in the region each year as a direct consequence of tobacco use.

And despite advances in countries like Indonesia, which has made progress in tobacco control in recent years, every year, more than 225,700 of its people are killed by tobacco-caused disease. Nearly 500,000 children aged 10 to 14 and 64 million people aged 15 and older use tobacco each day in Indonesia and the tobacco industry is actively pursuing new strategies to lure new and younger users. E-cigarettes and HTPs represent the next step in this aggressive campaign.

Additionally, regulating new products (whose devices and ingredients change rapidly) is expensive and will prove even more challenging amid the global pandemic. The nicotine and tobacco industries will exploit these weaknesses to promote their products and undermine tobacco control policies. Twin epidemics — of addiction to both novel products and traditional cigarettes — could emerge.

At least 24 countries/jurisdictions have banned e-cigarettes, and at least eight countries have banned heated tobacco products.

E-cigarette advocates often argue that vaping devices should be considered valuable tools in the harm reduction arsenal — and viewed as a new way to fight tobacco addiction. We are all for harm reduction, but vaping does not fall under this rubric. Harm reduction tools — clean needles, for example — are unique in that they do not do certain things: they do not appeal to new users, they do not exacerbate existing problems, and they do not catalyze new epidemics.

There may, of course, be individual instances of e-cigarettes enabling long-term smokers to cease using traditional tobacco products, but the net public health outcome of these products — which weighs the impact on both smokers and non-smokers (particularly youth) — should be the bottom line. Considering the enormous damage e-cigarettes and HTPs will cause youth in LMICs — and the insufficient evidence on reduced health damage to adult smokers — the net public health outcome of e-cigarettes and HTPs in LMICs is likely to be negative.

Novel products are really a distraction from the main game. The key to tobacco control lies not in flashy new ice cream flavored products but, rather, in the adoption and implementation of population-level, evidence-based policies.

These are outlined in the World Health Organization’s Framework Convention on Tobacco Control (FCTC) and MPOWER measures: monitoring tobacco use and prevention policies, protecting people from tobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco, enforcing bans on tobacco advertising, promotion and sponsorship and raising taxes on tobacco. Full adoption and implementation of these measures are clearly lacking in many LMICs.

Given the potential harms of e-cigarettes and HTPs — and as the long-term health effects are unknown — legislators must be guided by the precautionary principle and evidence-based approach to policy making where the science is inconclusive.

Safety must come first.

What we already know about e-cigarettes is highly disconcerting. Dual use of e-cigarettes and cigarettes, practiced by a considerable number of e-cigarette users, is increasingly found to be associated with critical health impacts. We cannot draw meaningful health impact conclusions on HTPs because few studies are independent of tobacco industry funding — and the evidence is ambiguous.

Far less ambiguous are big tobacco’s goals. The industry’s success depends on its ability to influence and dictate policy. The WHO FCTC, through Article 5.3, explicitly prohibits this practice, but the industry is desperately trying to transform its identity from a corporate pariah to a harm reduction producer of “safer” products; if the industry accomplishes this metamorphosis, it can reposition itself as a credible player, worthy of a seat at the table where novel product policy debates occur.

Governments must not fall for this blatant manipulation. They must be proactive.

The COVID-19 outbreak is not the only urgent public health challenge. Time is running out for many countries to dictate how their own novel product narratives will unfold.

At least 24 countries/jurisdictions have banned e-cigarettes, and at least eight countries have banned HTPs. We strongly encourage LMICs to act now, in abundance of caution, to ban the sale of novel tobacco products, as well as their manufacture, import and export.

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Megan Quitkin is the deputy director of tobacco control at The International Union Against Tuberculosis and Lung Disease. Tara Sing Bam is the union’s deputy director for the Asia Pacific region.

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