The crisis in Ukraine offers an opportunity to transform tobacco use across eastern and central Europe.
By Derek Yach
Vladimir Vorotnikov, writing Vapor Voice‘s sister publication in Tobacco Reporter’s August 2022 issue, outlined how Russia’s invasion of Ukraine has upended well-established supply chain and business relationships that have been in effect for decades. In fact, a careful read of Balkan Smoke by Mary C. Neuberger traces the roots of these relationships way back to Bulgaria in the 1920s. Vorotnikov discussed the impact of sanctions on Russian tobacco production, the emergence of illicit trade in the region, and more recently, the reestablishment of cigarette production in Ukraine.
He does not discuss the massive growth over the past few years in new reduced-risk nicotine products—led by IQOS—across eastern and central Europe. The editor makes the point that Russia is (was) one the largest markets for IQOS. My own observations during a visit to Kyiv in late October 2021 were that a range of vape products and heated-tobacco products were readily available across the city despite posters funded by Bloomberg Philanthropies near the Parliament proclaiming that they were dangerous.
An anti-vaping poster in Kyiv (Photo courtesy of Derek Yach)
This is a time of profound transition for the region. Amid the horrors of war and the human tragedies it continues to bring to the people of Ukraine are opportunities to reduce future deaths from the single largest cause of premature death in the region—and especially among men—combustible tobacco products. As rebuilding begins—as it inevitably will—government, business and health professionals need to grasp the chance to avoid rebuilding the tobacco industry in the image of the past and rather take the high ground of health and make reduced-risk products the easily available option while phasing out combustible sales.
For governments, this means adopting risk-proportionate regulations that build on the approaches proposed by the recent Javed Khan report for the United Kingdom, and on the authorizations of a range of reduced-risk products by the U.S. Food and Drug Administration. Ukraine and the neighboring countries relied on FDA guidance in relation to Covid vaccine advice—now is the time to draw upon their guidance to accelerate access to reduced-risk products, citing the FDA’s comments that they are deemed “appropriate for the protection of public health.”
Tax and other regulatory approaches could be applied to accelerate the transition. Further, governments of the region need to step up investments in customs and excise oversight to stop large-scale illicit trade taking hold—as it has in the occupied territories of Georgia following Russian invasion in 2008.
The Russian government also has an obligation to protect the health of its people and take regulatory steps to ensure that the progress made by Philip Morris International, Japan Tobacco International and BAT is increasing their revenue from heated-tobacco products at the cost of combustibles. Slippage with regard to these gains will translate into a return to the very high smoking rates, and associated death rates, of the past.
Government actions will be limited, though, unless the three leading tobacco companies (PMI, JTI and BAT) active in the region commit to take concerted efforts to accelerate their transition out of combustibles and publicly clarify what “withdrawing from Russia” means. Are they continuing to profit from Russian cigarette sales albeit through local companies? Are those companies obliged to push ahead with reduced-risk products, or will they revert to cigarettes?
Outside of Russia, leading tobacco companies could communicate the benefits of switching, take measures to clamp down on illicit trade and tighten youth access to all nicotine products, through joint action. Such bold actions would give them a chance to show their seriousness to transformation—something investors should reward.
United Nations agencies have a role to play at this time. Evidence emerging from inside Ukraine suggests that smoking rates have increased among those in the military and possibly among displaced peoples. This is understandable given the unprecedented stress to which people are exposed. The current U.N. response has been to ignore this reality and simply continue to support policies that ban cigarette sales during conflicts—something that is probably ignored. A far better way forward is to support people who smoke or seek nicotine to have ready access to nicotine-replacement products and approved reduced-risk nicotine products. This would mean that a generation of people may well emerge from the war with lower overall risks to their health.
War and tobacco use are intimately linked and currently interacting in dangerous ways to the health of populations. We should not wait for the transition to peace and health to begin before taking steps to accelerate the transition of smokers away from combustibles.
A global health expert and anti-smoking advocate for more than 30 years, Derek Yach is the owner of Global Health Strategies. Previously, Yach was the director of the Foundation for a Smoke-Free World and a World Health Organization cabinet director and executive director for noncommunicable diseases and mental health. He was deeply involved with the development of the Framework Convention on Tobacco Control.
A think tank in Malaysia has urged the Parliamentary Special Select Committee (PSSC) reviewing the tobacco generational endgame (GEG) bill to remove Clause 17 of the legislation.
The clause criminalises smoking, vaping as well as the possession of any tobacco products or smoking devices by those born in 2007 and onwards.
Galen Centre for Health and Social Policy chief executive officer Azrul Mohd Khalib said the law should instead put the burden on retailers, companies and corporations to not sell or supply tobacco and vape products to the GEG generation.
“Clause 17 makes the proposed legislation vulnerable to accusations of selective [prosecution], creates stigma and discrimination and marginalizes a group of people who will need support and assistance,” said Azrul in a statement. “Despite our best efforts, in the future there will be people in the GEG group who smoke and vape, and become addicted to nicotine. Should they be punished?
“The legislation should ensure that it is an offence to legally sell or supply tobacco or vape products to those born from Jan 1, 2007.”
Azrul stressed that anyone addicted to nicotine has the right to be treated equally under the law, with compassion and dignity.
He said the GEG bill should not be allowed to disproportionately affect young people, people from low income groups and vulnerable populations.
The U.S. Food and Drug Administration’s proposal to a menthol flavored cigarettes will improve public health only if there are viable menthol and flavored vapor products on the market, according to the Vapor Technology Association (VTA).
In April, the FDA announced a plan to ban the sale mentholated cigarettes, which account for about one-third of the U.S. market. The public was invited to share its thoughts on the measures and the official comment period ended Aug. 2.
In its official comment submission to the agency’s proposed product standards, the VTA urges the FDA to continue to build an “offramp” to menthol and flavored vaping products for smokers to access effective smoking alternatives.
“The menthol cigarette rule “has the potential to dramatically reducing cigarette smoking—the leading cause of death and disease of Americans—but only if the agency heeds the warning of scientists that menthol smokers must have access to less harmful vaping and other alternative nicotine products,” the VTA wrote in a statement.
“These limitations threaten to take what should be a public health victory and turn it into a half measure that, in the absence of other decisive action from the FDA, will fall far short of the benefits the agency claims.”
“FDA’s own proffered scientific experts acknowledge that at least 50 percent, and in some cases a larger percentage, of smokers will continue to smoke cigarettes or other combustible products after the menthol cigarette rule is put into effect unless provided access to effective alternatives.
“To fulfill its own harm reduction mission, the agency must use its PMTA process to ensure a rational, regulated legal marketplace with suitable less harmful non-combustible alternatives,” the VTA wrote.
The head of the Vapour Products Association of South Africa (VPASA) says the booming sector is plagued by continual misinformation and disinformation despite scientific evidence demonstrating that vaping is less harmful than smoking.
Chief executive of VPASA, Asanda Gcoyi said vaping is the single, most effective tool which can move smokers away from the deadly addiction to cigarettes, according to a story on IOL.
“We accept that vaping is not without risk, but it is a potentially less harmful alternative to smoking. What we cannot afford to do is to unduly stymie this technological innovation that can be the single most effective tool to move smokers away from their deadly addiction to cigarettes,” she said. “We have a collective responsibility to share correct information about vaping and other less harmful alternatives to smoking so that smokers can make an informed decision for their health.”
In the ongoing efforts to shed light and demystify vaping in South Africa, VPASA is on a drive to ultimately debunk some of the most prominent vaping myths circulating, according to Gcoyi.
The first myth is that vaping is as harmful as smoking.
“Although not risk-free, vaping is a potentially less harmful alternative to combustible tobacco. There are significantly lower levels of exposure to harmful chemicals in people who switch from smoking to vaping compared with those who continue to smoke,” she says. “The science that dates back as far as 2015 says vaping is a less harmful alternative to smoking, and recent updates continue to support this.”
The second myth is that vaping causes popcorn lung.
“According to Cancer Research UK, popcorn lung (bronchiolitis obliterans) is an uncommon type of lung disease, but it is not cancer,” says Gcoyi. “It is caused by a build-up of scar tissue in the lungs, which blocks the flow of air. E-cigarettes don’t cause the lung condition known as popcorn lung.”
Gcoyi said there was also a myth that vaping causes lung cancer.
“The fact is that burning tobacco in all its forms means exposure to carcinogenic chemicals. If you are a smoker, switching to vaping will reduce your risk of cancer. Most toxins from smoking are absent in electronic nicotine and non-nicotine delivery systems aerosol, she said. “Electronic non-nicotine delivery systems (ENDS) are a tool for consuming nicotine that is less harmful than if consumed via the combustion of tobacco. Coffee is brewed for caffeine. Vaping atomizes e-liquid for nicotine. Both caffeine and nicotine would [be harmful] if burned.”
A new report published by Belgian’s Superior Health Council supports vaping as a safer alternative to smoking or as a quitting aid that can significantly reduce health risks.
Based on the current state of knowledge, the report concludes that the exclusive use of e-cigarettes by (ex-)smokers—provided that they actually stop smoking—could lead to a significant reduction in health risks
The report also states that vaping is not risk-free and is therefore not recommended for nonsmokers, especially the young. Further long-term safety data are needed.
The council prepares scientific advisory reports to guide Belgian political decisionmakers and health professionals. The report took two years to prepare and was a consensus document prepared by a wide range of experts with different views.
While restrictions on vaping are prudent the report warns that “limiting vaping and other nicotine use does not jeopardize the goal of reducing the prevalence of smoking.”
Advocates of tobacco harm reduction welcomed the report. “Wisely, the guidelines advise risk-proportionate regulation of vaping,” wrote Colin Mendelsohn, a medical professional and founding chairman of the Australian Tobacco Harm Reduction Association, on his website. “Vaping is much less harmful than smoking and should be regulated much more lightly in line with the lower risk.
Tobacco harm reduction activists are outraged over a new Australian government document on vaping.
The National Health and Medical Research Council (NHMRC) recently published its 2022 CEO Statement on Electronic Cigarettes, which provides guidance to public health policymakers.
According to the Coalition of Asia Pacific Tobacco Harm Reduction Advocates (CAPHRA), the document falsely claims that vaping is not an effective quit-smoking tool, but a gateway to smoking with most vapers becoming dual users. Vaping, the document states, also increases the risk of smoking relapse. The NHMRC exaggerates the health impacts, poisoning and explosion risks of e-cigarettes, according to CAPHRA, while references to toxins and potential harms are made without a fair comparison to smoking.
“This latest government document on vaping makes outrageously false claims and will only cost more Australian smokers their lives,” says Nancy Loucas, executive coordinator of CAPHRA.
“Ridiculously, Australia’s chief medical officer considers vaping the next biggest health issue after COVID-19. Has he ever heard of smoking which kills over 20,000 Australians every year? This 18-page document is a complete joke. It is full of statements that can be easily debunked by international science and human evidence the world over,” says Loucas.
This egregious document is not worth the paper it’s written on, yet it’s now the bible for public health guidance in and around Australia.
CAPHRA says Australia’s hardline anti-vaping approach is increasingly out of step with other Asia Pacific countries, with the Philippines, Malaysia and Thailand set to lift their vaping bans. What’s more, New Zealand, across the Tasman, is already operating under a regulatory framework that has seen smoking rates decline.
“This egregious document is not worth the paper it’s written on, yet it’s now the bible for public health guidance in and around Australia,” says Loucas.
It is illegal to sell, supply or possess nicotine vaping products, with Australia the only Western democracy that requires a nicotine prescription to vape. Alarmingly, 2.3 million Australians continue to smoke cigarettes.
Last year Australia’s Therapeutic Goods Administration expanded its prescription-only model with customs clamping down at the border on the likes of personal imports of nicotine vaping liquids from overseas websites.
The Food and Drug Administration’s order to remove Juul products from the U.S. market threatens progress in tobacco harm reduction, according to Guy Bentley, director of consumer freedom at the Reason Foundation.
Guy Bentley
Writing on the foundation’s website, Bentley reminds his audience that e-cigarettes are not only less harmful than their combustible counterparts, but they are also more effective in helping smokers quit than FDA-approved therapies such as nicotine gum and patches
The FDA, he writes, acknowledged as much when it authorized Vuse e-cigarettes in 2021 and claims it recognizes the role these safer nicotine alternatives can play in reducing smoking.
If the Juul order is implemented, says Bentley, many Juul users will likely return to smoking, while a portion of smokers who would have transitioned to Juul will continue to light up.
Bentley says the FDA Juul denial makes a mockery of the claim that it’s evaluating science in the best interests of public health. A study published in the New England Journal of Medicine found e-cigarettes to be twice as effective as traditional nicotine replacement therapies.
According to Bentley, the decision also punctures a hole in the logic of the FDA’s recently announced policy to reduce nicotine levels in cigarettes to minimally or non-addictive levels. Without an acceptable legal alternative, smokers may simply smoke more cigarettes to get their nicotine fix.
“By banning the most popular e-cigarette among adults, the agency’s commitment to transitioning smokers to safer alternatives rings hollow,” writes Bentley.
A new study has found that long-term smokers who switched to vaping were halfway towards achieving the vascular health of a non-smoker within a month.
The research shows that while the use of non-tobacco nicotine products may still involve potential risks, the harm reduction they present have immense potential to prevent death and disability from tobacco use, and may indeed even boost government efforts towards a tobacco-free society, according to Journal Online.
The study saw a “clear early benefit” in switching from smoking to vaping, in the largest clinical trial to date.
Those who ditched cigarettes and vaped instead saw their blood vessel function increase by around 1.5 percentage points within four weeks compared with those who continued smoking.
The study didn’t claim that this benefit would be sustained, noting that more research is needed to delve into the long-term implications of vaping. It also warned that vaping isn’t safe, merely “less harmful” than smoking.
But it declared that if this improvement were sustained into the long-term, those who switched would have at least a 13 per cent reduced risk of cardiovascular events, such as heart attacks.
Medical and addiction experts called on the EU to embrace tobacco harm reduction during an event organized by the Centre for Economic and Market Analysis (CETA) in Prague.
Debating how a tobacco-free generation—where less than 5 percent of EU-citizens use tobacco—can be achieved by 2040, they concluded that the objectives laid out in Europe’s Beating Cancer Plan cannot be attained under current circumstances and that a revised tobacco control policy based on scientific evidence is needed.
“If the European Commission is serious about its plans to reduce the number of smokers and the impact of smoking, it must start considering the concept of risk reduction in the area of smoking,” said Czech National Drug Coordinator Manager Jindřich Vobořil, in a statement.
“The Czech Government has committed itself to this approach in its program statement for the upcoming [EU] Presidency. I will also promote it in relation to the ongoing evaluation of the Tobacco Products Directive, which is an effective policy to achieve a real reduction in the number of smokers of conventional cigarettes,” he added.
“The data show that the abstinence approach is inadequate. The solution for smokers is to switch to less harmful alternatives,” noted Ernest Groman, of the Vienna Nicotine Institute. The only European country close to the 5 percent target is Sweden. According to the experts, the low number of smokers is mainly due to the availability of less harmful alternatives.
During the event, the CETA published a study ranking EU member states according to their ability to implement the concept of risk reduction. The Czech Republic finished second.
The Czech government should use the upcoming EU Presidency to undertake a comprehensive review of tobacco dependence policies based on science rather than emotion, according to CETA Research Director Aleš Rod, who also sits on a Czech government advisory board.
