Harm Reduction

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In recent years a large number of newer consumer tobacco and nicotine products have emerged on the market, including electronic nicotine delivery systems (ENDS), commonly  known as e-cigarettes, and heated tobacco products. The tobacco control community is engaged in an ongoing discussion about the terminology used to describe these ‘new’, ‘novel’, or ‘alternative’ products.1 See the product terminology page for details, including terms used by the tobacco industry.

Meanwhile the range of products available continues to grow. TobaccoTactics focuses mainly on the products in which the large transnational tobacco companies (TTCs) have developed an interest since the early 2000s. We refer to them collectively as ‘newer nicotine and tobacco products’.

There is an ongoing scientific and policy debate about the role of these products in tobacco control, and whether they can help reduce the harms of tobacco. This page explores the concepts and issues around the topic and links to relevant pages on TobaccoTactics, research by the Tobacco Control Research Group (TCRG), and resources for further reading.

What is Harm Reduction?

The concept of harm reduction, first used in relation to illicit drugs, refers to policies and programmes which aim to reduce the harm from addictive behaviours for individuals, and the community and society in which they live.2345 Harm reduction recognises that, while the preferred goal is abstinence, this is not always achievable. Helping people change to less harmful alternatives may be a more effective approach.34 It therefore primarily aims to reduce drug-related harm rather than drug use.5

Tobacco Harm Reduction

The concept of tobacco harm reduction (THR) refers to reducing the levels of disease (morbidity) and death (mortality) from tobacco use among smokers. While eliminating exposure to nicotine altogether would result in the greatest reduction of harm, THR recognises that this is not always achievable, and users may not always be able or willing to quit. So THR advocates, as its primary goal, that users switch to using nicotine in its less harmful forms.

People smoke primarily because they are addicted to nicotine, but it is the other toxins in tobacco smoke that cause most of the harm. Nicotine can be obtained from a range of products, which vary in their level of harm and addictiveness. This “spectrum of harm” ranges from conventional smoked tobacco (cigarettes) at the top, to medicinal nicotine (nicotine replacement therapy, or NRT) at the bottom.67

It is hard to determine the exact position of other products in this spectrum, especially their long-term effects on health. With a longer history of use in Scandinavia and the US, there has been research into the relative harms of snus for a number of years. It would generally be placed at the lower end of the spectrum.8

More recently there has been considerable research around the potential role of e-cigarettes, and some evidence that they might help individual smokers quit cigarettes. However,  they are not harm free and there are concerns around youth uptake and dual use with with new and conventional tobacco products.91011121314

The research around newer heated tobacco products (HTPs) is much less developed.111516 While there is some independent evidence of reduced exposure to harmful chemicals from these products, there is currently no independent evidence that HTPs are less harmful than cigarettes, in terms of reduced disease or mortality. There is also no reliable evidence that they help people stop smoking cigarettes. The UK Cochrane review, published in January 2022, found that to date all randomised control trials (RCTs) assessing safety had been funded by tobacco companies. Of the eleven trials eight were “at unclear risk of bias and three at high risk.”17 The reviewers concluded that: “Independently funded research on the effectiveness and safety of HTPs is needed.”17

For individual smokers, quitting entirely is the best option for reducing harm. If smokers are not able to quit, the risk of disease from tobacco use can be reduced by switching completely to a genuinely less harmful product. Continuing to smoke cigarettes alongside other tobacco or nicotine products would not lead to the same health benefits.

Reducing Harm at Population Level

Although there is no single definition of harm reduction, it is generally acknowledged that it needs to reduce harm not only for the individual user but for the community and society in which they live.1819 In tobacco harm reduction, therefore, it is necessary to consider the impacts on the whole population rather than just those who currently smoke.20

A product might enable some smokers to quit or reduce their risk of disease. But if it still increases population level of harm, it cannot be considered as harm-reducing; for example if a large numbers of non-smokers took up the use of tobacco products; continued to smoke rather than quit; or continued to smoke cigarettes and use other products at the same time (dual or poly/multi use).2122232425

Although individual smokers who switch fully to less harmful products can reduce their health risks, that does not mean that the introduction of one or more newer products in a country will lead to reduced harm at a population level.26272829 This would depend on which products are available, whether they enable smokers to quit, and if they are genuinely lower risk than combustibles. It also depends on how they are used. If they are primarily taken up by smokers to quit, or by those who would otherwise have started smoking, this would help reduce overall levels of smoking and therefore reduce harm in the population. However, if they are taken up by people who have not used the products before (sometimes called “nicotine naïve” consumers), including children, this could lead to an increase in smoking, and increase harm.303132333435

A summary of these issues is provided by the National Academies of Sciences.13

Particular concerns about the potential for population benefit have been expressed by healthcare professionals, policy makers and tobacco control advocates low and middle-income countries (LMICs).363738

The impact at population (or country) level also depends on other inter-related factors, including:

  • the strength and enforcement of regulation controlling the product itself (e.g. its nicotine content and formulation as well as its price, promotion and availability)
  • the behaviour of the companies selling tobacco and newer products: for example whether and how they market to youth, or circumvent regulation, such as smoke-free policies
  • the strength and enforcement of tobacco control regulation more generally (i.e. FCTC measures)
  • the degree of tobacco company interference, and the ability to counter it

Overall, quitting smoking entirely remains the best option both for individual smokers and from a public health perspective.

  • For up to date information on tobacco regulation, see the Tobacco Control Laws website, published by the Campaign for Tobacco Free Kids (CTFK).
  • Information on the regulation of specific products can be found on the pages linked below.
  • For information on tobacco companies’ interference in tobacco control, see the Global Tobacco Industry Interference Index.

The Role of the Tobacco Industry

Tobacco harm reduction has become controversial and, some feel, divisive in public health, in particular where the debate has focussed on the potential role for other nicotine and tobacco products such as e-cigarettes and snus.8394041

  • See the list of TobaccoTactics Resources below for links to pages on the various products made and sold by tobacco companies.

One of the reasons harm reduction is a sensitive topic is that it can involve engagement with the tobacco industry, which has a history of manipulating public debate and health policy.

A History of Misinformation and Manipulation

In the 1960s and 1970s, public health scientists and officials in the US and UK encouraged smokers to switch to low-tar and low-nicotine cigarette brands.  They had been persuaded by an apparent commitment by tobacco companies to develop a “less hazardous cigarette”.4243 However, the tobacco industry concealed its own research which showed that these modified products would lead to ‘compensatory’ smoking behaviours (such as inhaling more strongly or taking more frequent puffs) and not in fact reduce the harms of smoking.424445

In the 1990s harm reduction claims were also made for early ‘heat not burn’ tobacco products, although these were not commercially successful at the time.44

Historians of public health have warned that, given the tobacco industry’s past misleading use of harm reduction claims to further its commercial and policy goals, THR strategies need to be approached with care and be supported by robust scientific evidence.45464748

The Industry’s Real Motive

In one word: profit. While tobacco companies continue to sell and promote their conventional products, global cigarette sales are decreasing.49

Tobacco companies have invested in, developed and promoted newer nicotine and tobacco products in the hope that this will prevent smokers from quitting entirely and attract new users. Ultimately, the aim is to offset the diminishing profits from conventional tobacco products. However, the main driver for tobacco company growth is still cigarettes; and this is likely to continue to be the case for the foreseeable future.394950

Evidence shows that the tobacco industry has never been genuinely interested in reducing harm. Its activities are primarily designed to serve its commercial objectives, in a variety of ways:

  • by claiming a commitment to harm reduction, and attempt to improve its reputation. This can be seen as an attempt to “‘renormalise’ an industry that wants to be seen as a responsible business with a legitimate product”.39495051
  • by using newer products as tools to initiate dialogue with scientists, public health experts, politicians and policy makers, re-framing the industry as ‘part of the solution’ rather than being responsible for the problem. It continues to try to re-enter the policy arena from which it has increasingly, and successfully, been excluded (see below), to gain a ‘seat at the table’.4950
  • by attempting to weaken and undermine tobacco control regulations. Nearly a decade after the promotion of snus as a dual use product, tobacco companies are following the same strategy. British American Tobacco (BAT) has referred to the “additive opportunity” of newer products ; a way to gain both new nicotine users and give smokers “new consumption moments”, including in restaurants and other places where smoking is banned.3952 Philip Morris International (PMI) has promoted “IQOS friendly places” including hotels, clubs and other public spaces, where people can use HTPs despite smoking bans.53 The tobacco industry’s fundamental conflict of interest should prevent it from influencing the regulation of newer products.
  • as a tactic to divide the public health community.464954

Research shows that the industry uses different public narratives in its investor-facing and public-facing materials, which serve to mislead and distract from the harms of its products.5556 Companies emphasise individual factors like consumer choice, and downplay the addictiveness of their products, and both individual and population level harms.5556 Large transnational companies:

“seek to normalize their role in public discussions of health policy, to cast themselves as instrumental in the redress of tobacco-related inequalities and shift responsibility for the continuation of tobacco-product use onto individual consumers.” 56

Meanwhile conventional cigarettes remain key to tobacco companies’ business models.

The main barrier to achieving public health benefits from harm reduction approaches is the behaviour of the tobacco industry. There is a fundamental conflict of interest between tobacco companies’ interests and public health. This is enshrined in the World Health Organization’s (WHO) Framework Convention for Tobacco Control (FCTC).  FCTC Article 5.3 requires the exclusion of the tobacco industry and its front groups from policy making. As the tobacco industry manipulates debates over harm reduction for policy advantage, Article 5.3 applies to those producers of newer products who are part of the tobacco industry, and the third party organisations lobbying on its behalf.4950

Industry-Funded Research

The tobacco industry attempts to influence the scientific debates around newer products and harm reduction. Research into these products and their impacts, at both individual and population level, is essential. The tobacco industry has a clear vested interest in showing that their products are safe, but it has a  history of manipulating the science around cigarettes.575859 It has also done this via third parties.6061

Evidence is beginning to emerge indicating that we should also be concerned about the industry’s newer products science,6263 particularly its heavy involvement in heated tobacco product science.11151662

Researchers from the Center for Tobacco Control Research at UCSF found that articles funded by the tobacco industry favoured harm reduction, while non-industry-funded articles, were “evenly divided in stance”.64 They also found a lack of empirical research, with more of the debate conducted in ‘opinion pieces’.65

A number of scientists influencing the debate on harm reduction or newer products are funded by the tobacco industry. Examples on TobaccoTactics include:

It has been argued that the best way to ensure independent science in this area is through a tax on tobacco companies.66 Until that happens, care must be taken when interpreting research funded directly – or indirectly – by the tobacco industry.

Implications for Global Tobacco Control

The WHO has published guidelines on newer products and their regulation. An information sheet on HTPs was released in July 2018, recommending that “HTPs should be subject to the same policy and regulatory measures applied to all other tobacco products” in line with the FCTC.67

In March 2019, the Secretariat of the WHO FCTC issued an information note, which compiled all Conference of the Parties (COP) decisions related to e-cigarettes. A few months later, the Secretariat released a statement urging governments to remain vigilant, stating that:

“novel and emerging nicotine and tobacco products…are creating another layer of interference by the tobacco industry and related industries, which is still reported by Parties as the most serious barrier to progress in implementing the WHO FCTC”. 68 It also reminded Parties of their obligations under Article 5.3 to protect tobacco control policies and activities from all commercial and vested interests.68

According to the editor of the journal Tobacco Control, tobacco companies:

“continue to work to interject themselves into activities promoted under the WHO Framework Convention on Tobacco Control (FCTC), particularly criticising Article 5.3, which seeks to protect public health policy-making from their commercial interests, and why their allies seek to pressure and undermine the WHO.”69

The global tobacco control priority remains the implementation of comprehensive, evidence-based, well-enforced population level policies. As outlined in the FCTC these aim to reduce the uptake of smoking by young people and prompt smokers to quit. They include policies such as tobacco tax increases, bans on promotion, restrictions on availability, and the implementation of WHO FCTC Article 5.3. Any harm reduction approaches should be implemented as part of a broader strategy, including a comprehensive range of well enforced tobacco control policies.

The Tobacco Control Research Group states that:

“The tobacco industry, and its front groups, should not be treated as legitimate partners in any discussions on tobacco control policies and approaches, including harm reduction, or in research on NNTPs [novel nicotine and tobacco products].”54

For more information on how the tobacco industry works through its front groups and other allies see the page: Third Party Techniques.

Tobacco Endgame

In some countries (such as New Zealand and Canada) ‘endgame’ approaches to creating a tobacco- and nicotine-free future are increasingly being discussed, for example de-nicotinising tobacco products. Endgame approaches are diverse.7071 They may include a role for genuinely reduced risk products to be used as quitting aids and/or alternative products to cigarettes.72737475

TobaccoTactics Resources

The Newer Nicotine and Tobacco Products page gives an overview of transnational tobacco companies’ interests and products, and links to more detailed pages for each company. The page contains a graphic overview of key tobacco company brands.

The following pages give more detail on the product types, and link back to tobacco company product pages:

See also Product Innovation as a tobacco company strategy.

List of pages in the category Harm Reduction.

Tobacco Industry Product Terminology page – also covers conventional and traditional products.

Read more about Tobacco Industry Tactics

Relevant Links

TCRG Research

Identifying misleading corporate narratives: The application of linguistic and qualitative methods to commercial determinants of health research, I. Fitzpatrick , A. Bertscher, A.B. Gilmore, PLOS Global Public Health, 16 November 2022, doi:10.1371/journal.pgph.0000379

Tobacco industry messaging around harm: Narrative framing in PMI and BAT press releases and annual reports 2011 to 2021, I. Fitzpatrick, S. Dance, K. Silver, M. Violini, T.R. Hird, Frontiers in Public Health, 18 October 2022, doi:10.3389/fpubh.2022.958354

Understanding the emergence of the tobacco industry’s use of the term tobacco harm reduction in order to inform public health policy, S. Peeters, A.B. Gilmore, Tobacco Control, 2015;24:182-189

E-cigarettes: threat or opportunity?, A.B. Gilmore, G.E. Hartwell, European Journal of Public Health, 2014, 24(4):532-3. doi:10.1093/eurpub/cku085

For a comprehensive list of all TCRG publications, including TCRG research that evaluates the impact of public health policy, go to the Bath TCRG’s list of publications.

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References

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