To cause or prevent 100 million deaths?

Clive Bates, the former director of Action on Smoking and Health, the UK's oldest and largest tobacco control charity, argues that tobacco harm reduction (THR) represents an exceptionally promising intervention to address smoking-related illness, and that it is principally stymied by a well-funded opposition unwilling to think pragmatically about the problem.

I’m often asked, “What’s the point of working on tobacco harm reduction?” or “Why are you so bothered about vaping?” Would I be wrong to say that there is nothing else with quite so many lives - and deaths - at stake? For public health, it is an unusually tractable problem: the right decisions could perhaps prevent 100 million deaths in the present century, but the wrong decisions would do the opposite. It is a cause worth fighting for, but the forces ranged against rational pragmatism are formidable, well-funded, and unaccountable.

Since several million people die annually from smoking-related diseases and not from nicotine itself, he argues we should focus on facilitating market transition from combustible cigarettes to far safer smoke-free nicotine products like vaping, pouches, and heated tobacco as quickly as possible, for two main reasons.

First, it provides a relatively simple way for existing smokers to switch to products that eliminate nearly all the additional risks of continued smoking. When someone who smokes switches, they do not have to give up the nicotine, the sensory (taste, throat hit) experience, or much of the behavioural ritual. The barrier to stopping smoking is far lower if you do not also have to quit nicotine.

Second, these products provide low-risk alternatives available to people who will use nicotine in future (whether we like it or not) without ever starting to smoke. This second function is essential because we do not believe it will be possible to stop future nicotine use (or desirable to try) any more than we could wind down the use of caffeine, alcohol or cannabis. There will be new users; they require the option of far safer products.

He claims that the tobacco control establishment doesn't just fail to help this transition along but actively undermines it through "anti-proportionate regulation": advertising bans, flavor restrictions, taxation equivalent to cigarettes despite orders-of-magnitude lower risk, and misinformation campaigns exaggerating the risks of alternatives. This protects the cigarette market while claiming to promote public health. He argues that a key driver of the disconnect between where policy is and where it should be is an accountability gap among policymakers.

One of the strangest things about public health, and especially tobacco control, is the disconnect between incentives (employment, pay, grants, personal prestige) and the nominal outcomes (avoiding needless death and suffering).

The bureaucrats at WHO, attending COP meetings, and advising governments worldwide ought to behave as if their own lives depended on getting this right, because the lives of many others depend on it. I estimate about 1,000 people attended the recent FCTC meeting in some sort of official capacity, so that’s roughly one million people worldwide who smoke for every tobacco control bureaucrat. Even if you assume approximately 20,000 people are professionally engaged in tobacco control worldwide (government, academia, activism, healthcare), this still yields a ratio of approximately 50,000:1.

With such awesome responsibility, there ought to be more accountability.