Harm Reduction

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In recent years a large number of new consumer tobacco and nicotine products have emerged on the market, including e-cigarettes and heated tobacco products. These are collectively referred to as new, novel, or alternative tobacco and nicotine products and the range of products available continues to grow. The tobacco control community is engaged in an ongoing discussion about the terminology used to describe these products.1 TobaccoTactics focuses mainly on the products in which the large transnational tobacco companies have an interest, and currently refers to them as “next generation products” (abbreviated as NGPs).

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 smoked tobacco (cigarettes) at the top, to medicinal nicotine (nicotine replacement therapy products, or NRT) at the bottom.67

It is hard to determine the exact position of other, newer 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 tobacco products.91011121314

The research around newer heated tobacco products (HTPs) is much less developed with as yet no randomised control trials (RCTs).111516 There is currently no evidence that HTPs are less harmful than cigarettes.

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.1718 In tobacco harm reduction, therefore, it is necessary to consider the impacts on the whole population rather than just those who currently smoke.19

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 use).2021222324

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 NGPs in a country will lead to reduced harm at a population level.25262728 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.293031323334

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.353637

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

  • the strength and enforcement of regulation controlling the NGP itself (e.g. its nicotine content and formulation as well as its price, promotion and availability)
  • the behaviour of the companies selling tobacco and NGPs: 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.83839

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”.4041 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.404243

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.42

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.43444546

The Industry’s Real Motive

In one word: profit. While tobacco companies continue to sell and promote their combustible products, global cigarette sales are decreasing.47

Tobacco companies have invested in, developed and promoted NGPs 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.384748

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”.38474849
  • by using NGPs 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’.4748
  • 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 NGPs; a way to gain both new nicotine users and give smokers “new consumption moments”, including in restaurants and other places where smoking is banned.3850 Philip Morris International (PMI) has promoted “IQOS friendly places” including hotels, clubs and other public spaces, where people can use Heated Tobacco Products (HTPs) despite smoking bans.51 The tobacco industry’s fundamental conflict of interest should prevent it from influencing the regulation of NGPs.
  • as a tactic to divide the public health community.444752

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 NGPs who are part of the tobacco industry, and the third party organisations lobbying on its behalf.4748

Industry-Funded Research

The tobacco industry attempts to influence the scientific debates around NGPs and harm reduction. Research into new 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 they have an  history of manipulating the science around cigarettes.535455

They have also done this via third parties.5657

Evidence is beginning to emerge indicating that we should also be concerned about their NGP science,5859 particularly their heavy involvement in heated tobacco product science.11151658

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”.60 They also found a lack of empirical research, with more of the debate conducted in ‘opinion pieces’.61

A number of scientists influencing the debate on harm reduction or NGPs, are funded by the tobacco industry. Examples covered 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.62 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 NGPs 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.63

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”. 64 It also reminded Parties of their obligations under Article 5.3 to protect tobacco control policies and activities from all commercial and vested interests.64

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.”65

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].”52

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.6667 They may include a role for genuinely reduced risk products to be used as quitting aids and/or alternative products to cigarettes.68697071

TobaccoTactics Resources

The Next Generation 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.

Relevant Links

TCRG Research

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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