Tobacco Harm Reduction and the right to health

Tobacco harm reduction and the right to health 17 From its inception, the FCTC – the WHO’s cornerstone document on tackling the tobacco crisis – has acknowledged that ‘tobacco control’ should include harm reduction strategies. The WHO must shift the balance to incorporate a strategy that it already – apparently – endorses. When ‘better safe than sorry’ isn’t better The ‘precautionary principle’ codifies the adage ‘better safe than sorry’ for policymakers of all kinds: it advocates for the adoption of precautionary measures when evidence is uncertain, and the stakes are high. The global public health world is divided on tobacco harm reduction and for many, the ‘precautionary principle’ wins out. Citing uncertainty over a range of issues, such as short- and long-term health harms of safer nicotine products, the risk of gateway progression to smoking or nicotine dependency in young people, or continued smoking through dual use, many in public health would rather apply the precautionary principle than adopt tobacco harm reduction measures. Rational application of the precautionary principle is right and proper in many areas of human activity. In tobacco harm reduction, however, application of the precautionary principle is not rational. It ignores the extraordinarily high and well-documented stakes of the status quo – seven million lives lost to tobacco- related disease every year. It also dismisses a significant and constantly growing international evidence base addressing many of the concerns. Being extremely cautious about potential risks, while ignoring huge and likely potential benefits, is not an appropriate way to implement the precautionary principle. in tobacco harm reduction, application of the precautionary principle is not rational Just because we don’t know everything, does not mean that we don’t know anything about safer nicotine products. A rational approach to ‘Big Tobacco’ Reasoned suspicion of the tobacco industry and its motives mean that many understandably find it difficult to accept that the market – and the industry which caused so many problems – could be part of the solution. But as the market for their products wanes in higher income countries, due in no small part to the implementation of tobacco control measures, the industry has recognised the disruptive power of innovative products to reduce their profits. They still manufacture and sell cigarettes, but many are also investing in new risk- reduced products. Product research and development in order to support innovation of this type requires sustained, significant investment. That investment is not currently forthcoming from philanthropy or public health. Perhaps a more rational approach accepts that “businesses can adopt business practices and market products that are either health harming or innovative products that are health-improving or displace health-harming products. Sometimes the same companies can do both.” 55 A rational approach to nicotine Public health thinking has been dominated by the tobacco control narrative for decades so that all tobacco use is seen as a problem. The lens through which professionals have viewed the issue has been ‘anti-tobacco’ for so long that it is understandably challenging to abandon this view to move towards a ‘neutral’ stance on nicotine use without tobacco combustion. But is objection to the use of nicotine rooted in moral or ideological constructs rather than clinically-based health concerns? 56 Global public health has made enormous strides in combatting infectious diseases; two have been eradicated, smallpox and rinderpest, with programmes now tackling polio, yaws and malaria. Five more infectious diseases have been identified as potentially eradicable. One of them is measles. Yet the proliferation of fake news communicated by lay anti-vaccine 55 Joint consultation submission to the WHO High Level Commission on NCDs by David Abrams, Clive Bates, Ray Niaura and David Sweanor (2018) https://www.who.int/ncds/governance/high-level-commission/Ottawa-University.pdf?ua=1 56 Knowledge-Action-Change (KAC) (2018). No Fire, No Smoke: The Global State of Tobacco Harm Reduction 2018 , p.70. https://gsthr.org/report/full-report.