Brent: Hi, I'm Brent Stafford and welcome to another edition of RegWatch on GFN.TV. It's become commonplace to take history for granted. Events and decisions from the past are first ignored and then forgotten, leaving a present and future vulnerable to mistakes. And in the case of tobacco harm reduction, failure to learn lessons from the past could cost the lives of millions. Joining us today to discuss the history of tobacco harm reduction and the seismic disruption it has brought is Harry Shapiro, author of the 2022 Global State of Tobacco Harm Reduction report titled The Right Side of History. Since 2018, GSTHR reports have tackled the full breadth of issues in the battle over safer nicotine products. They've exposed compromised science, revealed global funding streams biased against THR, described the no platforming culture excluding researchers, clinicians and consumers from the international tobacco control debate and chronicled the significant and growing evidence in support of safer nicotine products now used by over 100 million people across the world. Harry, thanks for joining us again on RegWatch.
Harry: Well, thank you very much for inviting me back, Brent. Pleasure to be here.
Brent: I'm looking forward to this conversation. But first off, the report is now just out and I highly recommend to our viewers to go to Gsthr.org to check it out. So Harry, please tell us about tobacco harm reduction. What is it and why is it important?
Harry: When people talk about tobacco harm reduction or harm reduction generally, they make an analogy with people wearing seatbelts, people wearing crash helmets or construction workers wearing safety gear on the basis that nobody is planning to ban cars or ban motorbikes or ban construction sites. So what you do is you try and reduce the dangers. You try and reduce the risks with some safety interventions whether it's seatbelts or whatever, which is bare enough as far as it goes. But from my point of view, I think harm reduction goes beyond what I would call health and safety and it goes back really to the founding of the WHO in 1948. And one of its founding statements was that healthcare is a universal right. In which case the implication of that is that if it's a universal right then nobody should be left behind. And it doesn't matter whether you approve of these people or what they're doing or what they might be taking, what behaviors they're exhibiting, it doesn't matter. They are entitled. And harm reduction as a kind of public health phrase intervention really came out of the HIV epidemic of the 1980s.
Brent: Why do you think the tobacco harm reduction movement has been so turbulent?
Harry: I think the one key word here that I would use is disruption. There's obviously been disruption within the industry. I mean, a whole new vaping industry has grown up. The larger companies, the big tobacco companies themselves have spent quite a lot of money investing in new technology. New factories have been buying up companies to promote their tobacco harm reduction credentials. But I think that was kind of obvious would happen because as they say, no commercial company wants what people call their Kodak moment. The time when the company Kodak never believed that digital cameras would ever catch on and were left behind of course, when the new technology happened. But I think more profoundly well, the second thing is that governments, legislators, regulators have also been caught napping really and they've been running to try and catch up with all the new safer nicotine products. But I think more profoundly and more disturbing, I think it's the fact that the global tobacco controlled establishment, medical agencies, public health officials, actually see what I would call an existential threat from tobacco harm reduction simply because many of these people working in these agencies come from a period of tobacco wars when life was actually a lot simpler. It was very black and white. You had evil tobacco companies with their dangerous products that kill half of the people who use them on one side and the doctors and clinicians and public health workers on the other side. The angels on one side and the devils on the other. Trouble is of course, that the safer nicotine products have allowed much, much safer use of nicotine once taken out of the cigarette. And that's caused a huge mist, a huge gray area in the middle somewhere where people's careers, their reputations, their funding have all been based on this insurmountable war with the tobacco industry.
Brent: Do you think then that there's this tobacco control industrial complex? Are you speaking of an entire coordinated and integrated industry that includes researchers and universities and public health people at state, national and global levels?
Harry: I think it is. I mean, obviously one begin to sound some like conspiracy theories, but it's quite clear that you have the WHO. You have American medical and public health agencies, you have doctors and health ministries all over the world that buy into the idea that tobacco harm reduction, that these products are no safer than cigarettes. It may even be more dangerous. And of course weaving it all together is some significant philanthropic funding which is keeping this whole juggle really of opposition to tobacco harm reduction just turning over and over and over. And it gives me no pleasure really to be criticizing an agency like the WHO, who are obviously a very credible and well respected source of information across the whole landscape of communicable and noncommunicable diseases. But they've really failed in their leadership in relationship to trying to reduce death and disease from smoking, which takes 8 million people every year and still 30 years on the projected figure of a billion deaths by the end of the century has not been challenged. So yes, I would say there's a fairly well funded, well organized attempt. Peer reviewed journals, clinical researchers, legislators, politicians, NGOs who are all banded together to try and spread as much misinformation about these new products as possible. And spread what I would call fear, uncertainty and doubt amongst health professionals who are uncertain as to whether to recommend to people who want to quit smoking that maybe they could switch away from the most dangerous ways of consuming nicotine. And also fear, uncertainty in doubt amongst existing smokers who read the media stories and are unclear as to whether these products are actually safer than what they've been doing. And their conclusions will be, but if these products are not any safer than what I'm doing, I might as well carry on smoking. That's a terrible situation for the public health community to find itself in.
Brent: Harry, let's talk about the 2022 report a bit. And if we go back to 2018, in the first report, which was No Fire, No Smoke, and then 2020 Right to Health 2020, there was also Burning Issues, and in 2021, a Burning Issue for Asia, which were all great reports. This one's different. You've taken a step back to take a look at the history. Why the historical focus?
Harry: Well, all the reports that you've mentioned to date really looked by and large, they kind of set the scene. Certainly that first one, No Fire, No Smoke, because nobody ever taken a global look at tobacco arm reduction. Most people didn't even really understand what it meant. And I suspect there was still an awful lot of people who don't understand what it means. But there we kind of set out the landscape, we set out the clinical evidence, we set out the products, what they look like, how they work, what the current state of regulation was. And then when it came to the next set of reports, it was quite clear, and we've already referred to this, that there was a concerted opposition to tobacco harm reduction, and we needed to unpick that and try and get to the root of what was actually going on. This report, we decided that we needed to kind of step back because it makes it sound as if the search for safer nicotine use only happened when, you know, Hon Lik came up with his very first e-cigarette in China in 2006. But looking all the way back, we realized there were all sorts of attempts doomed in the end, I might say, first of all, to find the safer cigarette, which was really a chimera. It was really a doomed enterprise. But all the different attempts to have certain sort of filters and all the things that tobacco companies were trying to do actually already in the knowledge that they were probably wasting their time. But it was good PR and then really a kind of hidden history about the attempts to provide noncombustible products. BAT, Philip Morris and others were in the game to try and find a way, because they knew, they knew that people smoked for the nicotine, but they died from the task. So how do you make cigarettes safer? A lot of this was kept secret, of course, because the lawyers were saying, well, hang on a minute. If we produce products and start promoting them as safer, what does that mean for the products that are already out there? Because there was still a lot of public concern in the 50s, 60s and 70s about tobacco, about the dangers of smoking. But the crucial thing really, was even these efforts that noncombustible products failed for the very simple reasons that the consumers didn't like them. They didn't taste good, they didn't deliver the smoking experience that they wanted, or the nicotine hit or anything like it. And that was really the nub of it. So despite the millions of pounds that were spent, they couldn't find the right products. But then the other kind of untold story really takes us more into the sort of the early naughties and onwards. But really a lot of what happened in the Vaping world was consumer driven. Thanks to the internet, there were people exchanging information and ideas, people were actually making their own products. And that really resonates with me, because it's similar, really, to what was happening in the drugs and HIV world back in the 80s, that people were feeling empowered, they felt they had agency and needed agency to try and protect people around them, themselves and their friends and so on. And that's kind of what happened in the very early days when people were hearing about these products, what's this? How does it work? And there were new websites and chat rooms and people saying, Well, I could do better than this. And they often went to their own shed at the bottom of the garden and actually did produce products that were better. And then eventually, of course, the industry itself began to take off. And we reflect that story. What happened in China, what happened when the big companies woke up, to the fact that from about 2012 onwards so I think also what the history shows, and this goes back centuries, that there are certain things that you do that don't work. So initially across Europe and other countries, there was an attempt just to ban tobacco because it was felt to be morally repugnant and it was quite serious punishment for people who smoked or sold in tobacco. And then kings and monarchs realized that they actually needed a tax from tobacco because there were fightings in ruinously, expensive wars and their treasuries were being emptied. So then they introduced tax, but they introduced tax at such a level the ordinary people can't afford it. And so what happens then? You get the illicit market. And this was going on in England centuries ago, coming more up to date during this period of trying to find the safer cigarette. There were attempts to produce cigarettes with kind of little or no nicotine in them, because people understood, misunderstood, I should say, the fact that it was the nicotine that was the most dangerous element in the cigarette, when, of course, it was actually probably the most benign element in the cigarette. And so there was a kind of enthusiasm for denicotinasing cigarettes, which of course, has come back into fashion. The idea that, again, it will be a disappointment, the idea that people will give up smoking because all they can buy is cigarettes with no nicotine in them, they will find workarounds. And the illicit market, which is already booming, is testament to the fact that people will find a workaround if you produce products they don't like or they're too expensive.
Brent: The title of the 2022 Report is The Right Side of History. What does that mean? Does it actually mean there are people on the right side and people on the wrong side of this battle?
Harry: Yes. And it reflects back on what we've touched upon earlier, that there is a concerted effort amongst credible sources of public health and medical information. The WHO and various NGOs and health ministries and medical agencies, powerful medical agencies with lots of funding behind them, CDC, FBI in America, all essentially, as far as we're concerned, they are on the wrong side of history. Because if you look at the statistics, the WHO produced this report called Empower, it's their monitoring strategy for determining the progress in tobacco control. And they claim that 5 billion people are protected by the regulations and controls that are in place. And it's just nonsense. It's delusional. How can 5 billion people be protected when 8 million people are dying? And that was a forecast some years ago. That a target we would hit by 2030. But we're already there. And that is not a target to be, an achievement, to be proud of. Billions of people, millions of people are going to die. And there's been research that has shown that the Framework Convention on Tobacco Control and all the various perfectly reasonable attempts to control tobacco use that are in place the public smoking bands, the plain packaging, the warnings and all the rest of it are making just a dense or hardly a dent in these terrible mortality statistics of illness and death. Because smoking related diseases, it's the most preventable, noncommunicable disease, the emphysema, the cancer, the COPD, nobody would suggest that these products are going to wipe out all of these problems. But it's what we call a third way. So we're not trying to suggest to anybody that they stop with all their current backup control interventions and laws and policies, but they're clearly not working. And this whole thing about if you're digging a hole, you're not going anywhere. Stop digging. And I think it's actually twofold. You might say, well, why is there this opposition? There is this whole idea of the tobacco wars and stuff. So one thing about this is that people are still mired in the idea that you can't trust Big Tobacco, that there must be something going on here and you can't trust what they say. And of course, in the past you couldn't, you know, there was all kinds of lives, misinformation, misdirection and all the rest of it back in the day. But it's quite clear that the independent evidence shows that these products are substantially safer. 95%, say Public Health England. And to be perfectly honest, speaking personally, I couldn't give a damn who's making these products. If Toyota decided to make vaping devices, great, I'm not really bothered who's making them as long as the products are out there and people can afford them and they're accessible. The other thing that's going on here, under the radar, I suppose, is a moral objection to people using nicotine. Before, the fact that nicotine was wrapped up in a cigarette and causing all this damage meant it was easy to condemn smoking, because it killed people, still does kill people. But if you take the nicotine out of the cigarette, you've got a whole different ballgame. You've got a product which, according to a chemical, rather according to the UK Royal Society of Public Health, is no more dangerous than caffeine. So unless you've got a serious heart problem, in which case you shouldn't be drinking caffeine either, there really is very little physical and psychological problems associated with using nicotine. But from something like 2014, 2015, WHO put a paper out, a kind of background paper for the delegates to the Framework Convention on Tobacco Control, and they quite openly said in this document that medicinal use of nicotine is acceptable. In other words, nicotine replacement therapy, gums, lozenges and patches, recreational use of nicotine is not acceptable without any explanation or anything. It was just a bold statement. And that, to me, is bringing kind of an ideology and morality into public health where it shouldn't be. So it's suspicion of the industry, despite all the independent evidence and a moral objection to people using nicotine, even if it is actually not doing them any harm. And many, of course, will benefit from using nicotine in all sorts of different ways.
Brent: In my mind, it's hard not to see that, then as being that the WHO is not interested in allowing people, individuals to enjoy small pleasures. I mean, it's an individual pleasure that use of nicotine, and they're saying, unless it's a medical use in a nonpleasible manner, you're not allowed to do that.
Harry: Well, yes, I mean, it's absolutely right. There can be no other explanation for their position. When these products first became available, it was going to be like, oh, well, it will lead young people to smoke. Well, no, it didn't. I mean, you got to look in the USA, the FDA's own statistics on smoking to show that teen smoking is coming down. Vaping has made no difference to those figures. In fact, even vaping is beginning to tail off slightly, went up a little bit and then it dropped down again, and then it's like, well, vaping causes brain damage in young people, which is gobsmackingly inaccurate. If nicotine caused damage to young people, brain development, I think we'd have known about it by now, after decades of tobacco research.
Brent: Well, not to mention that there would have been a boatload of lawsuits decades ago on the issue.
Harry: Yeah, absolutely. So, I mean, there are plenty of lawsuits under the tobacco industry, but none that's specifically kind of related to that. It's a problem you get when you start trying to regulate or do something about noncommunicable diseases. Because when you've got things like communicable diseases, you've got malaria, Ebola, COVID, all the rest of it, then you need, obviously, medical intervention. Nobody thinks it's a good idea to have malaria. You want vaccines, you want a robust treatment system to deal with it. And it's a completely medical condition. When you talk about noncommunicable diseases, it begins to drift into lifestyle choices. When you start talking about smoking, drinking, eating, diabetes and obesity and things like that, it begins to shift into more about trying to control lifestyle. And there's a danger then that there's a kind of moral agenda begins to creep in about what behaviors are acceptable and what behaviors are not. And I think that's where nicotine has found itself in relationship to the WHO and its various kind of NGO medical and public health allies.
Brent: Harry, we just had Moira Gilchrist on the show and she's from Philip Morris International and PMI has made a commitment to transitioning at least 50% of their business to reduce risk products by 2025. Now, is this a decision as a result of the disruption you were talking about?
Harry: Yeah, I think it's a recognition. You said in your introduction we've got over 100 million people using various safer nicotine products, whether that's vaping, whether that's heated tobacco products or various oral products. So yes, there's a recognition that there is a growing market for these products and I think it's perfectly understandable that companies would want to move in that direction. I mean, PMI have just negotiated the takeover of Swedish Match and so therefore they will be adding Snus to their harm reduction portfolio, which will greatly, I suspect, accelerate their aim of increasing their range of products that are smoke free. Unfortunately, this progress is patchy, not least, of course, because tobacco cigarettes are still total global value, something like 800 billion. As far as all these new safer nicotine products, I mean, the analysis differs. Depends how you count it. It's at least a market worth 25 billion at the moment, if not more. So it's still relatively small, but people, they want skin in the game. But the other thing, of course, which is slowing progress, is concerning companies about regulation and control, because you've got governments around the world that have banned these products or banned some of them, or imposed very high taxation, or have been talking about banning flavors. Various ways of making it really difficult for these companies and their investors and shareholders, I think, to be convinced that they need to put a huge amount of effort into these products. I mean, everybody wants everybody's doing something, but one or two companies like PMI and also I think BAT are kind of ahead of the game and leaving some of the others in the dust.
Brent: What do you hope readers of this report will take away?
Harry: I think people should realize that the opposition to tobacco harm reduction is actually incredibly damaging to public health globally, particularly in low and middle income countries where most of the decent disease occurs and where most of the smoking happens. I mean, it's one of those kind of hidden in plain sight, really. People need to be aware of why we're not really making much of a dent in the smoking related deaths and diseases. They need to be made aware that there's a huge amount of misinformation deliberately put through academic journals and into the media to try and blacken the name of all of these products. And I have to say it's working. Not a good thing to be able to say, but it's actually working. The triumph of doubt, backed by the science of deception is doing a good doing the job it set out to do. So even in the UK, where these products are readily available, with the exception of Snus, which one hoped would be reversed since the UK left the European Union, but the government doesn't seem to be minded to do anything about that at the moment. But even in the UK perception of the dangers, the perceived dangers of vaping over cigarettes, the perceptions are getting worse, and certainly in other countries the same. There's still a huge chunk of the medical profession that believe nicotine causes cancer. I mean, this is basic ignorance, really. It's nicotine illiteracy. And so what we hope is that people will read this and take away the notion because we've underlined it in everything we've done. We've said it in reports, in conferences and speeches and interviews, and it's a message we have to keep hammering home. The battle that people in the tobacco harm reduction community face, whether they're consumers or researchers or public health people, is that the disinformation campaign that's underway? It's get out of jail free card. It's just to say, you're all big tobacco shields, you're all in the pockets of big tobacco. So of course you would say that these products are much safer. And I turn around and say, well, look at the bloody evidence. Public Health England, National Institute of Clinical Existence, British Medical Association, even the FDA started to give market approval to some of these products. New Zealand government has taken a reasonably pragmatic approach to this and there are countries in the forest that are considering liberalizing some of their rules and regulations about these products. So, you know, this is outside the realm of Big Tobacco science. The evidence is there. The latest report from the UK government, 8000 pages long, reiterates the same thing they've been saying since the first reports a few years ago that these products had been monstrably safer.
Brent: One of the things that struck me, Harry, about the report is such a strong focus on the consumer and how the consumer drove the development of this. And I get the sense that part of that focus is one is to try to take activists focus on Big Tobacco a little off and try to go, hey, look, this is a consumer driven movement.
Harry: Consumers are completely written out the script of negotiations and strategies and policies. So if you make a comparison with Cop 27, there are 40,000 people, stakeholders from every conceivable viewpoint. When the tobacco control establishment get together for their cop meetings, the whole thing is completely regimented. Media are kept out, consumer activists are kept out, the only NGOs allowed in are the ones who follow the party line. And so, you know, there's no meeting in the middle. There's no attempt to engage with the people who use these products because the tobacco controlled establishment doesn't want to use these products, they just don't want them. So what's the point of engaging with these people? Because we don't even want them to be doing this in the first place. What brings about a change in all of this? I don't know, but I think this bit isn't in the report, but it's something I intend to say when we actually launched the report, if there was one thing that could help speed this process up is if the WHO actually came clean, they don't have to go away for five years and produce a ten volume report. All they need to do is produce one press statement that says, OK, we've now had another look at all the evidence and we are prepared to state that these products are significantly safer than smoking. One, two, that they do actually help smokers switch away from smoking cigarettes to a safer and also the evidence is that they will help some people quit altogether. And the third point is that they should be encouraging member states to enact risk proportionate legislation. So in a sense, do what you like with a cigarette but make these other products accessible to whoever wants them, and then you can leave it to the market to decide price points, what particular product is most acceptable for a particular part of the world. But if the WHO brought out one side of a four press release that would begin to speed up this process, I believe.