In an open letter, "one hundred specialists" on nicotine raise the question of risk reduction

A group of "one hundred experts on nicotine science and policy" from the FCTC addressed an open letter to the heads of delegation of the 9^th session of the Conference of the Parties (COP9) of the Framework Convention on Tobacco Control in November 2021 to ask them to integrate tobacco harm reduction into their deliberations. An initiative that is not without interest, but on which some troubling elements cast a shadow.

Adopted in 2003 and now ratified by 181 countries and the European Union, the Framework Convention on Tobacco Control (FCTC), supported by the World Health Organization (WHO), sets out the basic principles of tobacco control policies and brings together numerous provisions that each country undertakes to apply.[1]. Every two years, the Conference of the Parties brings together all the Parties to this treaty to evaluate and complete the initial treaty with, between sessions, the implementation of the measures adopted and the preparation of the work decided by the countries. In 2021, the 9th Conference will be held from 8 to 13 November^th session of the Conference of the Parties (COP) virtually due to the health situation.

The open letter is available in several languages, including French, on the website The Counterfactual hosted by Clive Bates, a former director of Action on Smoking and Health (London) from 1997 to 2003. It appears under the title "One hundred experts call on WHO to change its hostile position on tobacco harm reduction". The signatories accuse WHO of "turning its back on a public health strategy that could prevent millions of tobacco-related deaths." They "urge Parties to the FCTC to encourage WHO to support and promote the inclusion of tobacco harm reduction in the WHO Framework Convention on Tobacco Control."

WHO challenged

The signatories of the open letter criticize the WHO for opposing the aggressive promotion of new tobacco products. This criticism of the WHO forgets that it thinks globally, while the majority of the examples and studies cited in the open letter relate to the United States, Great Britain and the richest countries in the world. If a country like Chad decided to regulate access to these products, what right could the WHO have to dissuade it from doing so?[2]?

It may not have been the intention of the letter's signatories, but this attack on the WHO echoes a similar attack by Philip Morris against the UN organization, which the tobacco company accuses of "failing to recognize the sound science and innovation that underpins alternatives to cigarettes" (here, Philip Morris is referring to its own studies).[3]It also echoes, by taking up the same arguments, an open letter addressed in January 2019 to the members of the WHO Executive Board by the president of the Foundation for a World Without Tobacco, which is notoriously a front organization for Philip Morris.[4].

It is understandable that the WHO is the bête noire of Philip Morris and other tobacco multinationals, because the defense of public health on a global scale is an obstacle to their ambitions to conquer emerging tobacco markets (notably the huge potential market that is the African continent) and their new products. As for the public health advocates, it is permissible to wonder whether such a frontal attack on the WHO is the best method to obtain the desired change from it.

Amalgamation of “reduced risk” products

The signatories to the open letter lump together all “nicotine products that do not involve burning tobacco leaves and inhaling smoke” under one label: “reduced-risk products” (with “smokeless products” as a synonym). This is a very broad range of products that includes “vaping products, new oral nicotine pouches, heated tobacco products, and smokeless tobacco (…), such as snus.” Having made this amalgamation, the signatories declare without transition that “there is compelling evidence” that these smokeless products “are much less harmful than cigarettes and that they can displace smoking at the individual and population levels.” And this comes less than two months after the U.S. Food and Drug Administration (FDA) announced refuse "applications to place on the market approximately 55,000 flavored electronic cigarette products, for lack of being able to prove that they adequately protect public health" and to demand that they be withdrawn from the market[5].

A free interpretation of FDA opinions

The signatories are unconditional defenders of heated tobacco products (whose market is dominated by Philip Morris' IQOS) by relying on the FDA's decision to grant IQOS the status of "modified exposure product". They neglect, however, to specify that this agreement is only temporary. Moreover, their statement that these products "may constitute a more acceptable and reduced-risk alternative to conventional cigarettes for some smokers" is contradicted by the FDA, which states in its report that such claims are "unfounded".[6]. The FDA is very explicit on this issue:

“With respect to the applications for a risk modification order, the applicant [Philip Morris] has failed to demonstrate that, as actually used by consumers, the products sold or distributed with the proposed modified risk information will meaningfully reduce the harm and risk of tobacco-related disease to individual tobacco users and benefit the health of the population as a whole […].”[7]

The open letter therefore presents a truncated and highly selective version of the FDA's decision regarding IQOS that makes it say the opposite of what it says. It cites the example of Japan, where the introduction of heated tobacco products was accompanied by a sharp decline in cigarette consumption. But the signatories could just as well have taken the example of the Republic of Korea, where the introduction of IQOS was accompanied, over the same period (2015-2020), by only a very small decline in the consumption of conventional cigarettes, of only 4% and resulted in an increase in the consumption of tobacco products, of 4%. They could also have cited as a counter-example the case of the Philippines, a market in which heated tobacco products were absent during the period 2015-2020 and which nevertheless saw its cigarette consumption decrease by 32%.[8]. Here again, the open letter gives a truncated and selective version of reality.

A component of the CCLAT to be strengthened

Despite the limitations and the lack of rigor of their argument, the signatories of the open letter nevertheless raise a real problem. To be balanced and complete, the fight against smoking and nicotine addiction must be based on three pillars, which are prevention, assistance to quit, and harm reduction, as recognized by Article 1.d of the Framework Convention (which uses a slightly different but similar taxonomy): "Tobacco control means a range of strategies to reduce supply, demand and harm, aimed at improving the health of a population by eliminating or reducing their consumption of tobacco products and their exposure to tobacco smoke." The guidelines developed by the Parties to the Framework Convention concern almost exclusively the first two pillars, prevention and assistance to quit (or demand reduction and supply reduction). It is clear that harm reduction has been neglected by the FCTC and by the WHO.

Several reasons can be given to explain this lack of interest: there is perhaps the mistaken impression that by having a good prevention and cessation assistance policy, risk reduction becomes superfluous; there is also the fear of tackling a complex subject, characterised by a high level of noise, and getting bogged down in it; finally, there is the desire to avoid a subject that could potentially divide and for which the consensus decision-making mechanisms practised by the Conference of the Parties risk being unsuitable.

However, by avoiding addressing the issue of harm reduction, the FCTC has created a vacuum into which the tobacco industry has rushed to exploit the concept, distort it, and turn it into a tool for propaganda and marketing. In such a context, it seems not only desirable, but urgent, that the FCTC and WHO re-appropriate the concept of harm reduction and work together to develop guidelines on this important public health issue.

Keywords: CCLAT, COP, WHO, Nicotine, harm reduction

©Tobacco Free Generation

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[1] World Health Organization, Framework Convention on Tobacco Control, accessed October 19, 2021.

[2] Adam, D. Tobacco and electronic cigarette - The electronic cigarette seen from elsewhere: the example of Chad, AFIS Science, consulted on October 28, 2021

[3] World Health Organization fails to put science at the core of public policy. Our Science. Philip Morris International, July 28, 2019, https://www.pmi.com/our-science/world-health-organization-fails-to-put-science-at-the-core-of-public-policy (accessed October 27, 2021)

[4] Yach, D. An open letter to the WHO Executive Board, January 24, 2019. https://www.ft.com/brandsuite/smoke-free-world/an-open-letter-to-who-executive-board.html (accessed October 27, 2021)

[5] US Food and Drug Administration. FDA Denies Marketing Applications for About 55,000 Flavored E-Cigarette Products for Failing to Provide Evidence They Appropriately Protect Public Health, August 26, 2021, https://www.fda.gov/news-events/press-announcements/fda-denies-marketing-applications-about-55000-flavored-e-cigarette-products-failing-provide-evidence (accessed October 27, 2021)

[6] “…the claims “Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system can reduce the risks of tobacco‐related diseases.” and “Switching completely to IQOS presents less risk of harm than continuing to smoke cigarettes.” are not substantiated.” In US Food and Drug Administration. Scientific Review of Modified Risk Tobacco Product Application (MRTPA) Under Section 911(d) of the FD&C Act -Technical Project Lead, June 29, 2020, https://www.fda.gov/media/139796/download

[7] Ibid. The translation is by the editors.

[8] The tobacco product consumption statistics used in this paragraph are derived from data on major tobacco markets presented in PMI quarterly reports.

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