May 6, 2020
by Luthfi Mardiansyah

The world urgently needs innovative solutions to pressing public-health issues, and science-based policies to support their rapid dissemination. In that regard, the World Health Organization’s guidance in the fight against COVID-19 provides a beacon for policymakers to follow. Innovative solutions and science-based policy are equally important in the fight against smoking, the world’s leading cause of preventable death and disease. Unfortunately, the WHO has ignored innovative approaches to tobacco control, failed to develop science-based recommendations, and is jeopardizing hundreds of millions of lives.

There are more than one billion smokers in the world, and most of them are in Asia. Most of the roughly seven million annual smoking-related illnesses are in low- and lower-middle income countries (LMICs). Scientists agree that products that do not burn tobacco, such as electronic cigarettes and heated tobacco products, are significantly less harmful than continuing to smoke. Allowing smokers to have access to safer alternatives to cigarettes could complement other tobacco control measures and save millions of lives.

Countries that have allowed these products have seen historic reductions in cigarette sales and smoking rates. For example, in Japan, heated tobacco products led to a 31% reduction in the cigarette market over 4 years. And the latest figures from the UK show that more than 2 million people have switched from cigarettes to e-cigarettes, driving the UK’s smoking rates to historic lows. This progress should not be limited to wealthy countries.

Scientists acknowledge that vaping and e-cigarettes are not harmless. The longer-term health risks of vaping remain unknown, and nicotine is still an addictive substance. There are concerns that youths who vape could eventually become smokers, although evidence suggests this ‘gateway effect’ is not happening. Continued research should be pursued. But there is sufficient evidence today that the public health benefits of e-cigarettes and heated tobacco products far outweigh the harms.

Despite using this same evidence base, policymakers around the world have adopted very different policies to regulate these products. The Philippine Congress, before which I testified last year, has recognized the potential value of less harmful alternatives to cigarettes and is considering legislative and regulatory options. The UK and New Zealand actively encourages e-cigarette use, while countries such as Australia, Singapore, Thailand, and India have banned them. Many countries are somewhere in the middle and would welcome science-based guidance to develop risk-proportionate policies.

Unfortunately, the WHO’s positions on e-cigarettes have compounded governmental confusion. The WHO Framework Convention on Tobacco Control (FCTC), the first global public health treaty under the auspices of the WHO, includes tobacco harm reduction in its definition of tobacco control, and FCTC expert bodies acknowledge e-cigarettes could benefit public health. Despite that, the FCTC secretariat and a vocal handful of countries advocate banning e-cigarettes. Worse, FCTC bodies have resisted science-based regulation of e-cigarettes and avoided transparent deliberations and broad participation. In contrast with the strong science-based guidance provided to countries during the COVID-19 crisis, this is unprecedented in my experience with WHO, represents a significant policy failure, and threatens the institution’s credibility at a time it is most needed.

While it was appropriate to treat all tobacco as equally harmful in 2005, when the FCTC entered into force, things have changed significantly since then. While smoking is still “Deadly in Any Form or Disguise,” in the words of a 2006 WHO campaign, a wide range of tobacco and nicotine products now occupy very different places on the risk continuum. They should be treated differently and seen as tools to reduce harm.

John Maynard Keynes once stated, “There is nothing a government hates more than to be well-informed; for it makes the process of arriving at decisions much more complicated and difficult.” Some have suggested that FCTC’s approach on e-cigarettes typifies that maxim. I am more positive: WHO institutions are resilient and dynamic, as the fight against COVID-19 shows. I would prefer that the FCTC’s policy recommendations on tobacco harm follow another adage frequently attributed to Professor Keynes: “When events change, I change my mind. What do you do?”

Fortunately, the FCTC is designed to accommodate and embrace change: Expert working groups can be established, allowing science rather than dogma to inform policy recommendations. Guidelines can require inclusion and transparent deliberation, rather than exclusion and policymaking within an echo-chamber. Finally, Article 33 of allows parties to adopt protocols, allowing recommendations to be developed by interested countries and experts without diverting attention from the supply- and demand-measures at the heart of the Treaty.

The FCTC’s objective is compelling – reducing the harm caused by tobacco. Its strategies are sound – reducing demand, reducing supply, and reducing the harmfulness of tobacco products. However, the principle of tobacco harm reduction embedded in the Treaty has lain dormant for too long, and the FCTC’s ways of working on e-cigarettes are beneath the dignity of the WHO and inconsistent with its stated mission of ‘the attainment by all peoples of the highest possible level of health’.

Tikki Pangestu is a Visiting Professor at the Lee Kuan Yew School of Public Policy after 13 years at the World Health Organization (WHO) in Geneva, Switzerland as Director of its Research Policy & Cooperation department.

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