Dr. Derek Yach, a lead architect of the WHO’s global tobacco control treaty, reflects on how harm reduction was sidelined by institutional inertia, donor pressure, and deep-rooted distrust. He calls for renewed scientific dialogue, greater nicotine literacy, and an end to the moral panic that falsely equates nicotine with smoking. Despite resistance from the top, consumers are leading the charge by switching in the millions, to safer nicotine products worldwide.
Featuring:
DR. DEREK YACH
Global Health Leader, Tobacco Control Policy
Fmr. Cabinet Director, World Health Organization
@swimdaily
Transcription:
00:10 - 01:32
[Brent Stafford]
Hi, I'm Brent Stafford and welcome to another edition of RegWatch on GFN.TV. The global public health response to the ongoing epidemic of tobacco-related disease and death is frankly a mess. Tobacco harm reduction, a proven measure to help smokers quit, is mired in misinformation, moral panic and institutional betrayal. While millions of adult smokers could benefit from safer nicotine products, powerful forces from the World Health Organization to U.S. public health agencies and billionaire-funded NGOs are working overtime to suppress safer nicotine alternatives. So how did science get sidelined? Who's pulling the strings? And is there a path back to reason? Joining us today to unpack the global mess surrounding tobacco harm reduction is Dr. Derek Yock. Dr. Yock is best known for his leadership in tobacco control and harm reduction. He served as executive director for non-communicable diseases and mental health at the World Health Organization, where he was instrumental in the development of the WHO Framework Convention on Tobacco Control, which is the first global treaty aimed at reducing tobacco-related disease and death. Derek, welcome back to the show.
01:33 - 01:35
[Derek Yach]
Nice to be with you, Brent.
01:35 - 01:42
[Brent Stafford]
So you were a key architect of the WHO Framework Convention on Tobacco Control. What motivated your work back then?
01:45 - 04:02
[Derek Yach]
I had been involved in tobacco control before going to the World Health Organization in South Africa and was deeply concerned about the trends which were suggesting that low middle-income countries and African countries would feel the brunt of what then was not a major epidemic. and would come at a time when we were on the verge of the worsening of the HIV AIDS epidemic, tuberculosis and many other major challenges, adding the burden of tobacco would be a disaster for the health systems. So I did a series of meetings in South Africa and one actually in Zimbabwe in 1993, where for the first time we had a discussion around the potential of having a framework convention We had some of the very early thinkers around the subject give us some of the inputs. I then got recruited to WHO as the first South African to join after the end of apartheid. And when Gro Harlem Brundtland became the director general, she wanted to have two major global projects that would demonstrate a new way in which WHO was going to work going forward and be less bureaucratic. The one was what was called rollback malaria, which just to address the very poorest African countries. And the second one was the tobacco free initiative, which he asked me to head. And the rationale for it was based entirely on the numbers. The numbers were huge. Projections were pretty negative. And we believe that the best strategy forward was going to be to go beyond what individual countries were doing. to try and have a treaty to galvanize the forces of what international collaboration could do. And just remember that at the time, this is 1998, she had been the prime minister of Norway. She had been instrumental as minister of the environment, of the environmental treaties that formed the backbone of all of our climate change and environmental work today. And she understood that to get political support and political power, you needed to have an international treaty. And that's how we got going.
04:02 - 04:11
[Brent Stafford]
So looking back then at the Framework Convention of Tobacco Control, how has it evolved or devolved from the original mission?
04:12 - 06:20
[Derek Yach]
Well, it's what's called a framework convention. And a framework convention means that it gets strengthened, supposed to get strengthened year on year. And you can also add additional elements called protocols I think over the first few years, there was the development of a range of paper-based guidelines. What was the best approach to smoking cessation? Which marketing strategies would work? How would education programs make a difference? How do you address the undue influence of the tobacco industry? And a lot of effort was put into these guidelines. The guidelines tended to remain in Geneva and not get translated or adapted the least developed countries or to the countries where the smoking rates were going up. And increasingly over the 20 years, we saw that the countries who went into the treaty doing well on tobacco control simply did better. They didn't go markedly better, but they did better. Countries which came in with very high smoking rates, they stalled. many of them have very high smoking rates. So it's a mixed bag of success. There were many elements. I think the fact that tobacco became an issue that was spoken about in global health circles, it's a big achievement. Before then, global health was regarded as many, including infectious diseases and maternal and child health. And that opened the door to us talking about the diseases we were concerned about, the chronic diseases, cardiovascular disease, lung disease, cancer, that respect as i say it was success says and we'll talk later about tobacco harm reduction where i don't think um we saw the success early on we knew that we were going to have to have significant funding uh to get behind the low middle income countries being able to put in place effective programs and that actually didn't really come neither did the funding for research in low middle income countries to ensure that each country was able to carry out its own surveillance and its own work. That also, unfortunately, never came to a large extent.
06:20 - 06:37
[Brent Stafford]
So you mentioned harm reduction. I think that's one question that a lot of laypeople and also tobacco harm reduction advocates have, is whether or not the FCTC actually has harm reduction as a part of its mandate.
06:37 - 07:50
[Derek Yach]
Yes, it does. The very definition of tobacco control that we all worked on and the governments worked on explicitly includes the fact that tobacco control includes harm reduction. And the time we're talking about 2002, 2003 in the final years of negotiation, we included under harm reduction even things like smoking less or using nicotine replacement therapy. We didn't have the armamentarium of vapes and heat not burn and nicotine patches that we do today. But it was certainly at the back of our minds that many of these innovations could come. And in fact, to see how far we were along, we hosted a meeting of the tobacco industry, their scientists, at the World Health Organization, believe it or not. It was the first and last such meeting, where we had them come in and give us an update on just the science telling us in 2001, 2002, about farm reduction strategies and where they're likely to take off. Unfortunately, they were not particularly impressive in what they presented. And as you know, it took a few more years before we started seeing products getting out into the field.
07:51 - 08:00
[Brent Stafford]
Would you characterize the folks at FCTC as being supportive of vaping and other safer nicotine products?
08:03 - 12:22
[Derek Yach]
I characterize them as being hostile and opposed to the whole area of harm reduction. Being generous to them. We have to remember that many today still involved in tobacco control are now in their 50s, 60s, and they grew up in an era when distrust of the tobacco industry was both justified and needed. It was a time when the industry was trying to subvert public policy. The whole idea of putting out light cigarettes turned out to be not a very good idea for public health. And many delegations, even during the Framework Convention, were being heavily lobbied to make sure that the strongest approach, marketing bans, advertising taxes, never went through. And I experienced it directly. Some of the companies came directly to us at WHO and said they prefer voluntary agreements. I mention that because all of that is deep in the psyche, in the background, the leaders who are still there today. They haven't been able to move on, as so many others, to see that what happened since then was the explosion of innovation in science and technology and opportunities. And this innovation was happening not just to try and find ways to develop products that were truly going to be harm reduction. It was happening across the whole of biotechnology and pharmaceuticals and so on. But this deep set historical prejudice and concern about the industry remained then and to now. What then oiled the process even more was when Michael Bloomberg, the philanthropist, got involved with WHO. And the first thing that happened was he became one of the ambassadors to the director general on non-communicable diseases. Michael Bloomberg's advice on tobacco control and on harm reduction came primarily from his previous commissioner of health for the city of New York, Tom Frieden, who, well over a decade ago, had done a review suggesting that harm reduction and vapes were not going to be good for public health. That carried all the way through into the way he planned his philanthropy. And an incredible network globally was established who opposed all forms of tobacco harm reduction. A nonprofit was set up in the UK called Stop at the University of Bath whose sole goal was to check people who were in some way advocating for harm reduction and may have a link to the tobacco industry. Large groups like the Campaign for Tobacco-Free Kids in the US got on board with others to say that the primary concern should be one of children, and that if children started to vape, that represented a disaster. And on that basis, we should be banning and prohibiting these products. And that eventually took off. People got funded to do enormous amount of research and advocacy. And once you had a community established, the norm in harm reduction was to oppose it and to address the children. The needs of adults and adult smokers to prevent their cancers and heart disease and everything else bundled into the background. The WHO became very clear, very explicit about this when we formed the Foundation for a Smoke-Free World, which I'd put together in 2017 with a grant from Morris International at the time. Despite the fact that we went to extreme measures to make sure that the workings and the decisions of the foundation were in no ways linked to any tobacco company or influenced by it, WHO issued a fatwa against the foundation and anybody associated with it, that they may not interact, link, or be involved. And I find myself in this really bizarre position that even though I'd spent a decade at WHO, I was banned from walking through the doors of the WHO building because of that.
12:23 - 13:47
[Brent Stafford]
Well, Derek, I'm glad you brought that up. I want to point out that around the time that the foundation was set up, that The Lancet did an editorial called Tobacco Control, A Foundation Too Far. This is from October 14th, 2017. And they state in this, the launch of the foundation, initially announced on September 13th, has been condemned by medical societies, public health campaigners, and tobacco control advocates. Critics are skeptical of the Tobacco Multinational's motives and contempt for the initiative has been palpable. They end the editorial with this, Every piece of evidence available so far about the role of the tobacco industry in the tobacco control movement suggests that this initiative will fail, and will fail badly. The default of the tobacco industry is to sow doubt, lie, obfuscate, attack individuals, and obstruct all efforts to control tobacco use. Now, Derek, how does that square with, you know, almost 10 years later now, we see that companies like PMI have transitioned 40% of their revenue is now based on safer nicotine products.
13:48 - 15:59
[Derek Yach]
Yeah, I couldn't agree more. Yeah. Well, I think, you know, luckily, we've all lived long enough to feel vindicated by the decision to create the foundation and So many tens of colleagues around the world who taught me what they know about harm reduction, people, pardon people in public health, who looks at the evidence and the science and looks at the epidemiology, the behavioral reality, the modeling, the economics. And I've been able to draw upon, I think some of the best brains, people you've come across over the last few years, to actually feel that we were on the right track. The hard proof of progress must be to look at the numbers. So where are we a decade after all this critique started? Who would have thought that here in 2025, 20 years after the Framework Convention, we would be able to make the point that for this year, there will be more people using tobacco harm reduction products than combustible cigarettes in the United States. That's unbelievable. Less people are using Marlboro than are using a combination of vapes, heat not burn, and nicotine pouches. It's not just the U.S. where we're seeing this dramatic change. We've seen the consumption of cigarettes cut by 50% in seven or eight years in Japan. We've seen the markets dramatically increase the percentage of heat not burn, vapes, nicotine pouches, snus across Eastern Central Europe, across many of the major cities of Europe. Plus places like Pakistan, where nicotine patches are now starting to displace very toxic forms of oral tobacco products. And of course, we know the figures in the UK, Sweden, Iceland, Norway. Basically, if you look at a worldwide basis, the trend driven by consumer demand, consumers who smoked and used tobacco products or healthier products is dramatically shifting. And it almost makes the point that One needs to ask, has WHO put itself now in an irrelevant position given the speed of change that's happening underway?
16:01 - 16:40
[Brent Stafford]
Derek, I'd like to show you some materials highlighting the WHO's communications around vaping and safer nicotine products. The social media posts claim that vaping increases your risk of seizures, is linked to an increased risk of heart disease and lung disorders. This one is posted by the WHO on Ramadan. It states that vape and heated tobacco are harmful products. They are not safer alternatives to cigarettes. And in this post, WHO asks what looks cute, smells good, but is designed to kill. The answer is a vape.
16:41 - 18:31
[Derek Yach]
So the irony of that of course is, um, I'm actually heading back to the Middle East next week, but, um, The government of Saudi Arabia is investing in a nicotine pouch company. Pakistan is supportive of nicotine pouches displacing toxic products. Places like Egypt have reversed the ban that they previously had on e-cigarettes. Why are they doing this? They're doing this because they're looking at the smoking rates, particularly among men in many of these countries where they exceed 30 or 40 percent, and they are committed to improving the health of their population. And I've looked very carefully at the evidence and recognized this really is going to make a difference. Remember, it's coming at a time when many of the Middle East countries are getting involved in work on longevity and healthy aging. And they realize you cannot achieve a society's healthy aging goals if you don't tackle the number one preventable risk, smoking and tobacco. I'd say as well that where WHO normally relies on the fact that It's the member states, governments, who really control the direction of WHO. I think we're getting close to the point when many of the major member states are supportive of harm reduction. And the proof of that is through their own regulatory processes. Take China, for example. Yes, they're still selling a huge amount of cigarettes, but they have e-cigarettes on their market. They're regulated. They're not banned. They're not prohibited. The Philippines has reversed and now supports the use of harm reduction products. I could go around the world and show that we're starting to see the trend, I think, moving towards where the consumer wants the government to go. Products that can save our lives and give us what we want in terms of products for longevity.
18:32 - 18:35
[Brent Stafford]
So what do you think has gone wrong at the WHO?
18:36 - 21:46
[Derek Yach]
Well, I think that what went wrong, as I said, is that first, you've got a group of staff who've grown up in a system where innovation and critical thinking has simply not happened. They haven't looked at the science. They haven't looked at the evidence. Second, there's been so much money for them to do other things in the tobacco field, focus on the kids, find the marginal impact of some damaging effect of nicotine that they haven't been able to do the right thing. And I don't think there have been enough serious scientists and adults in the WHO and itself been willing to say, we go with what the UK government should do. We go with what the Cochrane Collaborating Center or NICE or even what the FDA is doing. People have not been willing to simply stand up, mainly because they tend to focus on what is the easy way out. And I fear that that is going to be a reality until we get a change in the director general position, which will happen quite soon. The next planned election is in two years from now. And even though it sounds a long way off, I think this is exactly the time when one starts thinking about what kind of future leadership do we want at WHO? Do we want to have science-based leadership that's going to be able to reduce the number one cause of death and disease in the world? Or do you want somebody who's going to be so pleased to have Michael Bloomberg's money and presence, they'll do whatever a non-profit and philanthropist sitting in the U.S. is going to dictate? I suspect that it's very unlikely that we'll have the same scenario as the new director general. The discussion starts warming up. And remember, it also comes at a time when WHO is in a terrible position financially. I grew up in an era when global health was starting to flower and flourish. we spoke of the golden age of global health today that has come to an end for many reasons obviously the trump decisions to pull the funding has had a huge devastating effect the governments of germany and the uk and france have also reduced their overall aid funding or putting pressure on who which means that you think that a future director general is going to ask the question about What should we be doing with our limited and increasingly limited resources to maximize global health? And if I was sitting there, I would see this as such a big win for two reasons. First of all, tobacco harm reduction we know works. We know it's going to save thousands of lives, millions of lives. We've quantified that across many countries. But there's a second aspect to it. The beauty of tobacco harm reduction is that it's driven by the finances of the private sector, which means that you save the money of the public purse. You don't have to run the campaigns. You don't have to educate people. That's all done in the normal course of getting a consumer product out. That is a huge saving compared to what we need to do, say, for malaria or tuberculosis or HIV AIDS.
21:48 - 21:55
[Brent Stafford]
So it seems to me that the industry does have a role in tobacco harm reduction.
21:55 - 26:04
[Derek Yach]
I worked at PepsiCo for five years. I've worked with a number of pharmaceutical companies, everything from to Pfizer. I've worked with private insurance companies. I've seen the agricultural science world. I've worked with meetings of many of the tobacco industry and vaping industry scientists. And I'm always left with a couple of overwhelming views that many of my colleagues in public health don't understand. Scientists and researchers in all of these private companies are deeply dedicated, highly qualified, committed to doing what's in the interest of the public overall, whether it's for tobacco, whether it's for food, or whether it's for overall longevity. Second, they are deeply frustrated by not being able to engage in an open, mature dialogue with their colleagues in the public sector, because that robs public scientists, publicly funded scientists, of the insights and the capabilities of the private sector and vice versa. Whenever you land up to think about having a vaccine in unbelievable time during the pandemic, It wasn't just Pfizer and the pharmaceutical companies doing it alone. It was because they could build on the incredible basic science and research funded by the NIH and funded by public researchers and had an intimate, ongoing discussion between public and private scientists. That's how we should be tackling any major global health problem. We should be encouraging the dialogue. We should encourage more dialogue. That doesn't mean that there aren't going to be conflicts of interest. Yes, there are going to be conflicts of interest. It's the nature of of the reality when you have private and public working together. But I think we have pretty sophisticated ways of dealing with it to make sure that you don't have undue influence on the policy environment in a private company. The net benefit of getting the innovation to people to save their lives seems to me such an obvious win that it should be a greater focus. I hosted a private meeting last year of a number of the scientists from the tobacco industry. and some from the public health community. It was done under Chatham House rule. So I can't say who was there, but I can tell you that the outcome was very clear. The one question we had on the table was, what will it take and what are the issues that the public and private sector tobacco control researchers need to work on together and why? The top priority was We all accept that we need better information on the long-term effects of many of these products. We accept that we're not going to wait 40 years for it, and we could be using biomarkers of exposure and outcome for much more sophisticated ways of getting answers, as already many companies are starting to do. The companies were willing to invest probably hundreds of thousands, if not millions, in the studies needed to answer these questions, but they would only do it if the public sector scientists will actually say, these are the methodological criteria that you see to use before they go into the field, since you don't have millions spent on a study and afterwards people turn around and say, oh no, they didn't do it methodologically correctly or perfectly. Engagement has to happen as you're designing the studies. Then the public sector can walk away, let the studies run. And when the results are out, evaluate them as you evaluate any other peer review publication. I have no doubt that if we do this, we would see large-scale investment in the very science and research that people still believe we need to know if we're going to make progress. And there are areas. We've done very well, for example, in being able to answer the question, how effective are vapes compared to a nicotine replacement therapy as cessation tools? Not to get people to switch, but as cessation tools. We know from the Cochrane studies now that they are twice as effective as nicotine replacement therapy. We don't know. It's not effective on nicotine patches or heated tobacco products. We need equivalent studies on those. And to do them, there need to be accepted methods between the public and private sector.
26:05 - 26:39
[Brent Stafford]
So explain then a bit more about biomarkers for some of our audience who are unfamiliar, because the biomarker studies are designed and intended to answer what's probably the most thorny question if you're a tobacco harm reduction advocate, is that the opposition says, we don't know the long-term effects of these products. you know, essentially saying we need, we can't know for 30 or 40 years, which is such a box to be put in, but biomarkers help that and how so?
26:40 - 30:00
[Derek Yach]
So there are two types of biomarkers. Biomarkers are more objective ways of being able to assess on the side of exposure, what you smoke and how much you smoke. So for example, if you look at most studies today, They're still based upon asking a bunch of questions to people. How much do you smoke and are you smoking X, Y, and Z? And there's a huge problem with that. People forget. They're unable to describe exactly. They forget the poly use that they have and they forget what happens over time and months. It's very difficult to record it. So biomarkers of exposure have now been developed, which can give you a better sense of are you predominantly a smoker, data, use of nicotine pouch, or heated tobacco products, by doing blood tests. I'm not saying you cut out the questionnaires, it's still going to be useful, but you don't have to rely on the vagaries of people's own recall or how they're using it. You can look at more objective measures. Biomarkers of outcome really are indicating whether you're likely to go on to get cardiovascular disease, respiratory disease, cancers, by looking at the products produced in the body or the changes in function that precede you actually having disease is diagnosed by a doctor. So for example, for lung disease, changes in your ability for your lung to function can give you a hint as to whether you're on the road to chronic obstructive airways disease or emphysema. They're circulating bits of your genetic background in RNA and DNA. a hint whether you are likely to get a cancer. And there are many early biomarkers of cardiovascular disease that will predict what you like and if you like to get heart disease. Now, these biomarkers are not just being used now in these tobacco harm reduction studies. They are mainly being used to look at things like cancer therapy, vaccine outcomes. Many of the major pharmaceutical companies have for years developed very sophisticated approaches to use biomarkers because they also don't want to wait 30, 40 years to see whether people get finally the ultimate outcome of interest, which may be a cancer 30 years from now. The world of aging and longevity has become even more sophisticated in building up batteries of these outcomes. And I can see these cutting the time that we have to be able to give a greater assurance to the public. These products are extremely unlikely to put you at greater risk of cancer. Of course, we'll look at the real data and see how it correlates. And I think the other aspect that we're seeing, not on the biomarker side, but also starting to ask the question of, yes, I'm interested to know whether I have an increased risk of heart disease or cancer or lung disease from these products. But I'm also interested in how am I going to generally function in society? Do these products help me generally improve my cognition? Is it going to continue the way I want? What about my mobility? Am I going to have mobility issues? So there are a range of functional issues that we can start measuring that'll give you an overall assessment without having disease specific issues.
30:01 - 30:31
[Brent Stafford]
Dr. Jock, I know that you're familiar with the 12th edition of the Global Forum on Nicotine, the annual conference on safer nicotine products, which takes place again this year in Warsaw, Poland, from June 19 to 21, 2025. The conference theme is challenging perceptions. In your mind, what are some of the solutions to address the misunderstandings, misconceptions and mischaracterizations that are holding back progress for safer nicotine products?
30:31 - 31:13
[Derek Yach]
I think we have to just double down on countering the obvious myths, starting with nicotine. I think we need to have a real focus on what I call nicotine literacy, spelling out the facts based upon hard data, using every possible media, social media influencer capability And I'm hopeful that we're starting to see a number of people in the longevity, health and aging, chronic disease space starting to talk about the benefits of nicotine and the difference between nicotine in a cigarette and nicotine in a pot or a vape or whatever. There is no other shortcut. We're going to just have to get this going to a far greater extent.
31:14 - 31:19
[Brent Stafford]
Let me ask you, do you have hope for the future for harm reduction?
31:21 - 32:03
[Derek Yach]
I wish I had. I think if you look at the numbers, and remember it's a decade since many of these products launched, and to see that half the users of tobacco and nicotine products in the US will be using harm reduction products by the end of this year, and the massive drops in countries where it was so entrenched among particularly the male population that the only way to go was through combustible cigarettes, the fact that the push consumers to lead healthier lives is so strong, it's not going to weaken, it's going to get stronger. Eventually, through their support of government, it will break through and WHO will change. And I anticipate that will happen definitely with the next director general.