Letter from seventy-two specialists in nicotine science, policy and practice

Appel à l’OMS
signé par 72 experts internationaux en addictologie et en santé publique
en faveur des stratégies de réduction des risques dans la lutte contre le tabagisme

 

Letter from seventy-two specialists in nicotine science, policy and practice

Dear Dr. Adhanom Ghebreyesus

Innovation in tobacco control: developing the FCTC to embrace tobacco harm reduction

We write to express our hope that WHO will assume a leadership role in promoting effective and fast-acting policies for regulating tobacco and nicotine. In this letter, we propose that WHO and related stakeholders adopt a more positive approach to new technologies and innovations that have the potential to bring the epidemic of smoking-caused disease to a more rapid conclusion.

In the field of tobacco control and public health, the world has changed significantly since the Framework Convention on Tobacco Control was signed in 2003. It is impossible to ignore or dismiss the rise of Alternative Nicotine Delivery Systems (ANDS). These are established and new technologies that deliver nicotine to the user without combustion of tobacco leaf and inhalation of tobacco smoke. These technologies offer the prospect of significant and rapid public health gains through ‘tobacco harm reduction’. Users who cannot or choose not to quit using nicotine have the option to switch from the highest risk products (primarily cigarettes) to products that are, beyond reasonable doubt, much lower risk than smoking products (e.g. pure nicotine products, low-toxicity smokeless tobacco products, vaping or heated tobacco products). We believe this strategy could make a substantial contribution to the Sustainable Development Goal to reduce premature deaths through non-communicable diseases (SDG Target 3.4).

The concept of tobacco harm reduction is coded into the definition of ‘tobacco control’ set out in the FCTC (Article 1.d), and we believe it now needs to be fully expressed in the FCTC and by the Parties in their approach to implementation. To that end, we offer some guiding principles for your consideration for the development of the next phase of global tobacco control, starting from the next Conference of the Parties (COP-8, 1-6 October, Geneva).

• Tobacco harm reduction is integral to tobacco control. Harm reduction is a widely practiced strategy in public health (e.g. HIV, drug use, sexual health) and should become an integral component of tobacco control – helping smokers to quit smoking or diverting them from ever starting, and, in either case greatly reducing their risk.

• From a health perspective, the major distinction between nicotine products is whether they are combustible or non-combustible. It is not whether they are tobacco or non-tobacco products or whether they are established or novel. Given the principal focus of the FCTC is management of health risks, this distinction should be integral to the design and implementation of the FCTC (We recognise that poor production standards and the inclusion of slaked lime (calcium hydroxide), areca nut and other hazardous ingredients in some traditional tobacco-containing products such as gutka and paan can make these products much more hazardous than other smokeless tobacco products.).
Tobacco harm reduction is supportive and synergistic with the ‘MPOWER’ policies that underpin the FCTC. By providing more diverse options for users to respond to taxes or other measures, harm reduction can improve the effectiveness of conventional measures and mitigate the unintentional harmful consequences of such policies to continuing users, for example the impact of cigarette taxes on people who would otherwise continue to smoke.

• Stakeholders should give appropriate weight to the benefits and opportunities of tobacco harm reduction. They should not focus exclusively on unknown risks to health, especially when these are minor or improbable risks. A lost opportunity for a public health gain represents a real harm to public health, and should be recognised as such.

• Youth uptake of any tobacco or nicotine product demands a coherent and adaptable strategy focussed on reducing present and future harms to young people. Policies to address youth nicotine use should be based on an understanding of youth risk behaviours, the interactions between use of different products (for example, for some young smokers the potential displacement of smoking by low risk products may be beneficial), and due regard for the overall balance of harms and benefits to both adults and to youth arising from interventions.

• Uncertainty about long-term effects should not be a reason for paralysis. It is true we will not have complete information about the impacts of new products until they have been used exclusively for several decades – and given the complex patterns of use, we may never. But we already have sufficient knowledge based on the physical and chemical processes involved, the toxicology of emissions, and biomarkers of exposure to be confident these non-combustion products will be much less harmful than smoking. We also know with certainty that the incumbent product (cigarette) is extremely harmful.

• FCTC and its implementation should embrace “risk-proportionate regulation”. This means that the stringency of regulation or taxation applied to product categories should reflect risk to health. For example, there should be high taxes on cigarettes, but low or no taxes on vaping products. It is reasonable to ban all advertising of combustible products, but to place controls on advertising for non-combustible products (to protect never-smoking youth in particular) and so allow enough promotion so that smokers can still learn of alternatives and can be encouraged to switch. This risk-proportionate approach should be adopted throughout the FCTC.

• WHO and Parties to the FCTC should be aware of and careful to avoid the harmful unintended consequences of prohibitions or excessive regulation. If WHO-endorsed policies make noncombustible alternatives to smoking less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibit innovation and development of new and improved products, then these policies can cause harm by perpetuating smoking.

• The FCTC negotiations should become open to more stakeholders. There are many stakeholders, including consumers, the media and public health experts with pro-harm-reduction views, who should be part of the process. We are concerned that the FCTC has been excluding appropriately diverse perspectives and that its deliberations and decisions could be more robust and credible if its proceedings were more open.

We are concerned that WHO and the Convention Secretariat are not embracing these principles and in many cases are doing the opposite. We have seen the more detailed letter to you of 3 September by Abrams et al regarding prohibition and excessive regulation2. We recommend that this letter be read carefully by everyone with an interest in the future of tobacco control.

We believe that it is time for tobacco control to embrace tobacco harm reduction. We hope that WHO and Parties to the FCTC will advance this agenda at the Eighth Conference of the Parties of the FCTC, starting today. We will share this letter with relevant stakeholders.

The authors of this letter confirm no conflicts of interest with respect to the tobacco industry and that no issues arise with respect to Article 5.3 of the FCTC.

Yours sincerely,

 


 

David B. Abrams, PhD
Professor, Social and Behavioral Sciences, NYU
College of Global Public Health.
New York University.
United States

Marion Adler, PhD
Smoking Cessation Specialist
Hôpital Antoine Béclère
Clamart
France

Sanjay Agrawal, MD, MBChB
Consultant in Respiratory & Intensive Care
Medicine
Chair, Royal College of Physicians Tobacco
Advisory Group
United Kingdom

Jasjit S. Ahluwalia, MD, MPH, MS
Professor, Behavioral and Social Sciences and Professor, Medicine
Center for Alcohol and Addiction Studies
Brown University School of Public Health
and Alpert School of Medicine
United States

Philippe Arvers, MD, PhD
Addictologue et Tabacologue
membre de SOS Addictions
Observatoire Territorial des Conduites à Risques de l’Adolescent
Université Grenoble Alpes
France

Frank Baeyens, PhD
Professor
Faculty of Psychology and Educational Sciences
KU Leuven
Belgium

Shamsul Bahri Mohd Tamrin, PhD
Professor of Occupational Safety and Health/Ergonomics
Department of Environmental and Occupational Health
University Putra
Malaysia

Scott D. Ballin, JD
Health Policy Consultant
Former Vice President and Legislative Counsel
American Heart Association
Washington DC
United States

Clive Bates, MA, MSc
Director, Counterfactual Consulting
Former Director, Action on Smoking and Health UK
London
United Kingdom

Robert Beaglehole, MD, DSc, FRSNZ
Emeritus Professor
University of Auckland
Chair, ASH: Action for Smokefree 2025
New Zealand

Mihi Blair (Ngāti Whātua)
General Manager
National Tobacco Control Advocacy Service
Hapai Te Hauora
New Zealand

Anne Borgne, MD
Addictologist
CSAPA Victore Segalen
Villeneuve-la-Garenne
France

Ron Borland, PhD
Adjunct professor
Schools of Global and Population Health, and Psychological Sciences
University of Melbourne.
Australia

Thomas H. Brandon, PhD
Moffitt Distinguished Scholar
Chair, Department of Health Outcomes and Behavior
Director, Tobacco Research and Intervention Program
Moffitt Cancer Center
Professor, Departments of Oncologic Sciences and Psychology
University of South Florida
United States

John Britton, MD
Professor of Epidemiology
Director, UK Centre for Tobacco & Alcohol Studies
Faculty of Medicine & Health Sciences
University of Nottingham
United Kingdom

Jamie Brown, PhD CPsychol Deputy Director
Tobacco and Alcohol Research Group
University College London
United Kingdom

Jean-Pierre Couteron
Psychologist, Addictologist CSAPA Ophélia Boulogne-Billancourt
CNAM
Paris France

Sharon Cox, PhD
Research Fellow
Centre for Addictive Behaviours Research
Division of Psychology
School of Applied Sciences
London South Bank University
United Kingdom

Kenneth Michael Cummings, PhD
Professor Co-leader Tobacco Research Program
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston
South Carolina United States

Lynne Dawkins, PhD
Associate Professor
Centre for Addictive Behaviours Research
London South Bank University
United Kingdom

Jean-Michel Delile, MD
President of Fédération Addiction, Paris
Director General of CEID, Bordeaux
France

Allan C. Erickson
Former Vice President for Public Education and Tobacco Control, American Cancer Society;
Former Staff Director, Latin American Coordinating Committee on Tobacco Control
National Tobacco Reform Initiative
United States

Jean-François Etter, PhD
Professor of Public Health
University of Geneva
Switzerland

Konstantinos Farsalinos, MD, MPH
Onassis Cardiac Surgery Centre
University of Patras
National School of Public Health
Greece

Antoine Flahault, MD, PhD
Professor
Directeur de l’Institut de Santé Globale
Faculté de Médecine, Université de Genève, Suisse/ Institute of Global Health,
University of Geneva,
Switzerland

Jonathan Foulds, PhD
Professor of Public Health Sciences & Psychiatry
Penn State University, College of Medicine
Hershey
United States

Thomas J. Glynn, PhD
Adjunct Lecturer
School of Medicine
Stanford University
Palo Alto, California
United States

Peter Hajek, PhD
Professor of Clinical Psychology
Director, Tobacco Dependence Research Unit
Wolfson Institute of Preventive Medicine,
Queen Mary University of London
United Kingdom

Wayne Hall, PhD
Professor Centre for Youth Substance Abuse Research The University of Queensland Mental Health Centre Royal Brisbane and Women’s Hospital Australia

Natasha A. Herrera, PhD
Clinical Psychology
Centro Medico Docente la Trinidad
Servicio de Psiquiatría
Consulta de Cesación de Fumar
Caracas
Venezuela

Martin J Jarvis, DSc OBE
Emeritus Professor of Health Psychology
Department of Behavioural Science and Health
University College London United Kingdom

Martin Juneau , MPs, MD, FRCPC
Medical Director
Montreal Heart Institute
Full Clinical Professor of Medicine
Faculty of Medicine
University of Montreal
Montreal
Canada

Aparajeet Kar, MD
Consultant Pulmonologist Narayana Hruduayalaya, Bangalore,
India

Leon Kosmider, PhD, PharmD
Research Assistant Professor
Technical Director, Bioanalytical Shared Resource Laboratory
School of Pharmacy
Department of Pharmaceutics
Virginia Commonwealth University
Richmond
United States

Lynn T. Kozlowski, PhD
Professor of Community Health and Health Behavior
Former Dean
School of Public Health and Health Professions
University at Buffalo,
State University of New York
New York
United States

Hiroya Kumamaru, MD, PhD
Vice Director AOI International Hospital
Kawasaki
Japan

Christopher E. Lalonde, PhD Professor of Psychology
University of Victoria
British Columbia
Canada

Murray Laugesen QSO
Adjunct Professor, Department of Psychology, University of Canterbury,
Christchurch,
New Zealand

Jacques Le Houezec, PhD
Honorary Clinical Associate Professor, School of Medicine, University of Nottingham, UK.
Independent consultant in Public Health – Smoking Cessation Specialist
Rennes
France

Arvind Krishnamurthy MS (Gen Surg), MCh (Surg Onco) DNB (Surg Onco)
Professor and Head, Surgical Oncology
Cancer Institute (WIA) Adyar, Chennai
India

William Lowenstein, MD
Addictologist
President
SOS Addictions
Paris, France

Karl E Lund, PhD
Senior Researcher
Norwegian Institute of Public Health
Oslo,
Norway

Bernhard-Michael Mayer, PhD
Professor of Pharmacology and Toxicology
Institute of Pharmaceutical Sciences
Karl-Franzens-Universität
Graz
Austria

Olivia Maynard, PhD
MRC Integrative Epidemiology Unit,
Lecturer in the School of Psychological Science,
University of Bristol
United Kingdom

Andy McEwen, PhD
Chief Executive
National Centre for Smoking Cessation and Training (NCSCT)
Honorary Reader
CRUK Health Behaviour Research Centre
University College London
United Kingdom

Ann McNeill, PhD
Professor of Tobacco Addiction
Head of the Nicotine Research Group (NRG) National Addiction Centre,
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
United Kingdom

Klim McPherson, PhD, FMedSci, Hon FRCP
Emeritus Professor of Public Health Epidemiology
Dept Primary Care Science
Fellow of New College
Oxford
United Kingdom

Colin Mendelsohn, MB
Chairman, Australian Tobacco Harm Reduction Association
Associate Professor, School of Public Health and Community Medicine,
University of New South Wales,
Sydney
Australia

Robin Mermelstein, PhD
Distinguished Professor, Psychology Department
Director, Institute for Health Research and Policy
University of Illinois at Chicago
United States

Fares Mili, MD, CTTS
Addictologyst & Pulmonologyst
Chairman
Tunisian Society of Tobacology and Addictive Behaviours (STTACA)
Tunisia

Thomas J. Miller
Attorney General of Iowa
Des Moines
Iowa United States

Marcus Munafò, PhD
Professor of Biological Psychology
University of Bristol
United Kingdom

Raymond Niaura, PhD
Professor, Social and Behavioral Sciences
College of Global Public Health
New York University
United States

Caitlin Notley, PhD
Senior Lecturer in Mental Health
Addictions Research Group
Norwich Medical School
University of East Anglia
Norwich
United Kingdom

David Nutt, DM, FRCP, FRCPsych, FMedSci, DLaws
Professor of Neuropsychopharmacology
Imperial College
Hammersmith Hospital
London
United Kingdom

Konstantinos Poulas, PhD
Associate Professor of Biochemistry Laboratory of Mol. Biology and Immunology Department of Pharmacy,
University of Patras
Greece

Philippe Presles, MD
Smoking Cessation Specialist and BCT Psychologist
SOS Addictions member
Paris
France

Lars M. Ramström, PhD
Principal Investigator
Institute for Tobacco Studies
Täby
Sweden

Vaughan Rees, PhD
Lecturer on Social and Behavioral Sciences Director, Center for Global Tobacco Control Department of Social and Behavioral Sciences Harvard T.H. Chan School of Public Health
United States

Steven A. Schroeder, MD
Distinguished Professor of Health and Healthcare
Department of Medicine,
University of California, San Francisco
United States

John R. Seffrin , PhD
Member, National Tobacco Reform Initiative
United States

Lion Shahab, PhD
Associate Professor
Department of Behavioural Science and Health
University College London
United Kingdom
Rajesh N. Sharan, Ph. D.
Professor of Biochemistry and Molecular Biology
Department of Biochemistry
North-Eastern Hill University
India

Michael Siegel, MD, MPH
Professor
Department of Community Health Sciences
Boston University School of Public Health
United States

Roberto A Sussman, PhD
Department of Gravitation and Field Theories
Institute for Nuclear Research,
National Autonomous University of Mexico, ICN-UNAM
Representing Pro-Vapeo Mexico AC
Mexico

David Sweanor, JD
Chair of Advisory Board of the
Center for Health Law, Policy and Ethics
University of Ottawa
Canada

Umberto Tirelli MD
Professor
Director, Cancer Center Clinica Mede Sacile
Italy

Natalie Walker, PhD
Associate Professor in Population Health,
NIHI Programme Leader – Tobacco and Addictions,
Associate Director, Centre for Addiction Research, Faculty of Medicine and Health Sciences
The National Institute for Health Innovation (NIHI), School of Population Health,
The University of Auckland,
New Zealand

Kenneth Warner, PhD
Avedis Donabedian Distinguished University Professor Emeritus of Public Health and Dean Emeritus,
University of Michigan School of Public Health United States

Alex Wodak
Emeritus Consultant,
Alcohol and Drug Service
St Vincent’s Hospital, Sydney
New South Wales
Australia

Naohito Yamaguchi, MD
Research Division Chief,
Saiseikai Research Institute of Healthcare and Welfare
Japan

Ben Youdan
ASH New Zealand
Auckland
New Zealand

 

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