The situation about tobacco harm reduction and how this approach is perceived in non-European countries, such as Indonesia, Costa Rica, Malaysia, Philippines, South Africa, Tunisia and India, was presented by seven prominent panelists at the panel discussion “Tobacco Harm Reduction in low- and middle-income countries”, chaired by Nimesh G. Desai, Director of the Institute of Human Behavior and Allied Sciences (IHBAS), Delhi, India.
When e-cigarette was first introduced in Indonesia, nobody knew about harm reduction strategy and everybody believed that it was as harmful as conventional tobacco products, Dr. Amaliya Amaliya, Dental Surgeon from Indonesia pointed out. Although during the last three years the Government has decided to issue regulations and rules about e-cigarette, unfortunately there is still a lot of misleading information and strong resistance from health authorities supporting that it is as harmful as combustible cigarettes. There is still a lot of work to be done in Indonesia for harm reduction strategy to be recognized and accepted, Dr. Amaliya concluded, but hopefully there are also a lot of people working hard for it.
Unfortunately, Latin America, particularly Costa Rica, seems also to be lagging on the concept of tobacco harm reduction, Dr. Efrain Cambronero, Chief of Surgical Oncology in Costa Rica, stated. Tobacco harm reduction (THR) is an important measure that all countries have to implement, not only for its value for public health but also for the impact it can have in the economy, since smoking-related morbidity and mortality is associated with high healthcare expenditure and lost productivity. Complete smoking cessation is always the best option, Dr. Cambronero added, but THR products can be realistic alternatives for ‘hardcore’ smokers who fail to quit. However, WHO stands against THR, mainly e-cigarettes and heated tobacco products, a position that is not expected to change any time soon, and Costa Rica has strong ties with WHO. Reducing tobacco consumption through the implementation of comprehensive tobacco control programs, focused on preventing minors from getting access to tobacco products, and helping smokers to quit or reduce the risk of smoking for their health, can save lives and benefit the population in general. We need to remember that 80% of smokers are from our countries, Dr Cambronero mentioned, therefore implementing harm reduction approaches at population level in our countries is really important.
In Malaysia, combustible tobacco use is still an important problem, although smoking has been reduced during the last years, Professor of Hospital Management and Health Economics, Sharifa Ezat Wan Puteh said. According to 2019 data, prevalence of current tobacco smokers is about 21.3%, while prevalence of e-cigarette use is 5%, and that of heated tobacco products is still unknown. Unfortunately, a raise in taxes and the price of tobacco applied as a measure to reduce the consumption resulted in the growth of the market of illegal cigarettes in the country. Malaysian authorities aim to 15% fewer smokers by 2025, Professor Ezat Wan Puteh added. Yet, THR approach is not well received, since there are concerns about the efficacy of non-tobacco nicotine containing products, such as NRTs, and the possibility that e-cigarettes could, on the one hand increase onset of smoking in youth, and on the other hand, be used by smokers as complementary to combustible cigarettes. Additionally, there is no proper monitoring of use, switching and total abstinence in Malaysia. All these are problems that must be solved, she said, since harm reduction products can be very helpful especially for heavy smokers in Malaysia.
Smoking is still considered as a ‘sin’ by most countries and is addressed as such, and unfortunately there is a great deal of ignorance about the harm reduction approach, Dr. Kgosi Letlape, President of the Health Professions Council of South Africa (HPCSA) and Chairperson of the Medical and Dental Board at Johannesburg, said. There are physicians in South Africa who advice patients about smoking risks and smoking cessation, he explained, but they don’t know what an e-cigarette is like, they have never heard about heated tobacco products, and they don’t know the differences between combustible cigarettes and non-combustible nicotine-delivering products. Therefore, it is absolutely necessary and our greatest duty to inform correctly the public and educate healthcare professionals about harm reduction approaches to ensure that we will have evidence-based regulations. Of course, we always have to remember that harm reduction is for those that can’t quit, and take care not to induce uptake from youth, whether it concerns combustible cigarettes or alternative tobacco products. People need to understand that combustion is the problem, that there are less harmful products; we need a different legislative framework that recognizes that not all smoking products are the same, Dr Letlape concluded.
India remains far from achieving the declared targets of tobacco control, which are 15% reduction of tobacco burden in 2020 and 30% reduction in 2025, although WHO FCTC tobacco control measures have been fully implemented in the country, Dr. Rajesh Sharan, Professor at the Department of Biochemistry of North-Eastern Hill University in India, said. Reality shows that quitting efforts have poor outcomes, since government services are inadequate, inefficient, and poorly funded and trained. On the other hand, he added, the availability of nicotine replacement treatments and reduced harm products in the country is limited, while e-cigarettes were banned in 2019. Yet, since India along with China are the major contributors to low- and middle-income countries’ and global tobacco burden, it is necessary to take action, he stressed. Strengthening the concept of tobacco harm reduction among people, healthcare providers, and policy makers, as well as enhancing availability and portfolio of nicotine replacement treatments and reduced harm products can be a solution, he proposed; however, it is also urgent to upgrade healthcare professionals’ knowledge, attitude, and practice regarding tobacco cessation approaches.
In Tunisia also, smoking is a big problem with an overall prevalence of 25%, Pulmonologist and President of the NGO “Societé Tunisienne de Tabacologie et des comportements d’ addiction”, Dr. Fares Mili stated. One in 2 men and 1 in 4 young people are smokers, while female smoking prevalence is reaching up to 20%, he added. Since the national tobacco control program has not achieved any of its objectives, he pointed out, the Tunisian Society of Tobaccology and Addictive Behaviors is putting efforts to reframe tobacco control programs so that smoking is considered as addictive behavior and not just as a harmful habit. Since it is becoming evident that harm reduction is an essential tool as an additional choice for smokers, Dr. Mili concluded, scientific societies are putting more and more pressure to regulatory authorities in order to include harm reduction strategies to the overall tobacco control effort.
Tobacco harm reduction is even more important now among the low- and middle-income countries, considering the huge health and economic burden of smoking in these countries, Dr. Ron Christian G. Sison, Lead Convenor at the Harm Reduction Alliance of the Philippines, said. In Philippines, although almost 80% of smokers say that they plan or are thinking to quit smoking, only 4% of those who smoked over the previous year succeeded to quit. Philippines, as well as other countries, need to reevaluate their strategy in controlling cigarette smoking, Dr Sison said. The first step is always, to promote smoking cessation, but if this doesn’t work there must be other choices at least to reduce the harm. Of course, there must be a good balance between providing access to less harmful alternatives to adult smokers, and ensuring that minors cannot access these products, he added. The Regulation Act of 2020 for non-Combustible Nicotine Delivery Systems highlights a policy aiming to consider harm reduction measures as public health strategies, while ensuring that non-combustible cigarettes are properly regulated. Based on this policy, Philippines Department of Health has proposed harm reduction measures, like the use of e-cigarettes, to be included as part of its national tobacco control strategy.