Leaving out science and innovation from nicotine regulation perpetuates smoking, warns Global Forum on Nicotine

By Nick Powell

“What if we found a parallel universe where people got their nicotine in non-combustion ways but they got their caffeine by smoking tea leaves? If somebody wanted to teach people to brew tea instead, would you say ‘oh my God, think of the children? What if a child is attracted to drinking tea? What if somebody who would have totally quit smoking tea leaves, starts drinking tea? What if there were flavours for those teas and people found that tea more acceptable? They might even drink more!’ We would laugh at that sort of thing and we should be laughing at the people who make that argument now about nicotine”.

That striking argument is an example of the original thinking and willingness to challenge convention that characterised the 2024 Global Forum on Nicotine, held in Warsaw. It came from Professor David Sweanor, the chair of the advisory board of the Centre for Public Health Law, Policy and Ethics at the University of Ottawa in Canada. He has been actively involved in tobacco and health policy issues since the early 1980s.

He is one of the many health and legal professionals and other experts who took part in the debates and discussions on how the scourge of cigarette smoking could be eradicated if only politicians and regulators were prepared to listen to science -and listen to adults who want to stop taking the appalling health risks associated with smoking tobacco.

The participants in the forum felt that too often they were left feeling that it’s most of the member states of the European Union, as well as other countries around the world, that have entered a parallel universe. Harm reduction products, developed to help smokers get their nicotine in much safer ways, are banned, taxed or restricted, leaving cigarettes as the one consistently available product.

But David Sweanor is encouraged by the way consumers are fighting back. “We will see the change in part because it can’t be stopped”, he told me. “Innovation, disruptive technology, there’s no ability to stop it now because the internet for getting information, social media for sharing it and international trade to get the product, you cannot stop consumers from moving. You can shape that market but you cannot stop it”.

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Nowhere is a desire to shape the market more strongly felt than in the European Union, one the first parts of the world to regulate tobacco harm reduction products, specifically electronic cigarettes as many other products were not available when the regulations were made in 2014. Now health ministers are discussing whether to restrict or ban newer tobacco and nicotine products, such as flavoured vapes, across the EU.

Konstantinos Farsalinos, who’s a physician and senior researcher specialising in public health at the University of Patras and West Attica in Greece, has conducted extensive research on smoking, tobacco harm reduction and vaping. He told me that many individual member states have been introducing further restrictions already, ignoring the evidence from the countries that have bucked that trend.

The most notable example is Sweden, which has seen cigarette smoking fall to 5.6% of male adults, according to the latest data. It is by far the EU country closest to meeting the World Health Organisation’s definition on ‘smoke-free’, which is to get below 5%.

For many Swedish ex-smokers, the solution has been snus, a traditional non-combustible tobacco product which is placed under the lip. “Snus is the only harm reduction product with undisputed long term, epidemiological evidence which shows that it is almost harmless”, Konstantinos Farsalinos said.

But it is banned in the European Union, with the exception of Sweden, although the EU “is a region where the sale of the most lethal product containing nicotine, tobacco cigarettes, is absolutely legal, they are available everywhere”. The ban on snus, from which Sweden secured an opt-out, was the result of a health scare campaign, alleging some scientific studies had found that the product was linked to mouth and gum cancers.

No such data exists but the regulators at DG SANTE of the European Commission have never withdrawn the allegation. Nor have they learnt from their mistake. “They are trying to add new restrictions, they think for example that if we ban flavours, kids will not use electronic cigarettes” said Konstantinos Farsalinos, who argued that the history and experience from all countries that introduced prohibitions has been a complete disaster.

He cited the remarkable example of India, where “e-cigarettes were so rare you couldn’t find them; you couldn’t see any people vaping. But they wanted to follow the World Health Organisation’s rules and recommendations, so they said ‘we’re banning them’.

“The market exploded. You now find products in every street, in every corner, in every major city. Everything is black market, illicit, illegally entering the country. No-one knows where they come from, what they contain… and of course the black market is going to attract the most vulnerable population, which is youth.

“That’s direct public health harm and now governments throughout Europe are becoming obsessed with flavours. There is so much research evidence that flavours are marketed to adults. Flavours improve the chance of quitting for adult smokers, yet authorities insist that flavours are there only to attract kids.

“Of course, ideally, all smokers should quit by themselves but we have 1.2 billion smokers worldwide and eight million deaths a year. We are avoiding the example of Sweden. Sometimes you’re so depressed by that, you feel that’s there’s no common sense. It’s not merely about science, it’s like there is no common sense prevailing. Anyway, let’s be optimistic!”

Optimism was plentiful at the Global Forum on Nicotine. David Sweanor argued that we are seeing a fundamental change. “Rather than be corralled by regulators, consumers are finding things for themselves… often using products that governments haven’t authorised, haven’t encouraged, certainly that anti-tobacco groups have discouraged.

“It’s not long ago that the only country you could point to was Sweden but now we can point to Norway, Iceland, Japan, New Zealand and even countries that have really worked hard to prevent this happening, like the United States which has banned virtually every alternative to cigarettes… non-combustion products have gone for 20% to 40% of the nicotine market in just five years.

“In Japan, cigarette sales have fallen by half in just seven years. In New Zealand, they’ve cut smoking rates by half in five years. So, we’re seeing this really major shift going on despite the opposition. How rapidly could we get rid of cigarette smoking if we really tried?”

The price of not trying is first and foremost paid by smokers who do not give up cigarettes, with disastrous consequences for themselves and their families. But David Sweanor also warns of “diminished trust in government, the diminished trust in authority which is a huge problem globally, being accentuated by this sort of action to prevent consumers from getting truthful information, to prevent them from getting access to the products, prevent them from being empowered to deal with their own health”.

Another speaker in Warsaw was Clive Bates, former Director of Action on Smoking and Health (ASH) in the UK. He identified a fundamental flaw in much of the current regulatory approach. “You can't assume -or you shouldn't assume- the regulation is inherently justified. It limits what people can do. It limits everything.

“Regulation has to be justified on its own merits. And those are sometimes simply illusion… children are used to create emotive campaigns, to create a sort of moral panic and to justify things that would not be justifiable if they were done to adults. There are 18 times as many adults using nicotine products as there are young people in the UK, but all of the political focus is on the small number of young people who are vaping”.

Michael Landl, from the World Vapers Alliance, said he also identified the same cause of much of the problem. “To exaggerate only slightly, I would say that if there was not a single child vaping in the entire world, we would still have a youth vaping issue because perception is more important than reality in the formulation of policy and regulation in this sector.

“We are living in this really weird time where it actually is the tobacco companies that are more positive towards helping people quit or switch to a less harmful product than the public health organisations and the WHO”.

It might seem weird but perhaps no-one should be surprised that the industry is best placed to transform how people use nicotine.  Over the last ten years, there has been a proliferation of new non-combustible products that are better alternatives to smoking.

It’s the market that’s delivering the solutions, as consumers seek out tobacco harm reduction products and companies invest in the innovation that gives hope of a world without cigarettes. Market-driven solutions can be hard for regulators to accept but politicians need to step up, avoid moral panic and insist that citizens have the right to choose solutions that work for them, especially when their health is at stake.

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