Invisible Numbers – the WHO Hides the Evidence for Tobacco Harm Reduction
The WHO has just published Invisible numbers: The true extent of noncommunicable diseases and
what to do about them.
I’m not sure where the WHO gets the idea that the statistics on death and disease from
cardiovascular and respiratory diseases and cancer are ‘invisible’. There is a wealth of data out there
from national and international public health, medical and academic sources, including the Global
Burden of Disease annual reports and the WHO’s own International Agency for Research on Cancer.
IJERPH is now accepting submissions for a special issue on Tobacco Harm Reduction, on research that advances our understanding of the potential place of tobacco harm reduction strategies within a comprehensive approach to reducing the burden of smoking related disease, and that will assist policy makers to determine what level of regulation is most appropriate for potential reduced risk products.
A mammoth new report on the public health consequences of e-cigarettes finds there is conclusive evidence that e-cigarettes are less dangerous than regular cigarettes, and smokers who switch to vaping will reduce their exposure to lethal toxicants and carcinogens. Amounting to more than 600 pages, the National Academy of Sciences, Engineering and Medicine's report attempts to examine the health consequences of e-cigarettes for the population as a whole. All in all, NASEM presents 47 conclusions categorized by different levels of evidence, with "conclusive evidence" being the strongest.
Juul Labs has engaged in discussions with at least three major tobacco companies in an attempt to work out an arrangement that would revitalize the cash-strapped vape manufacturer. The talks are still in early stages. It’s unclear if potential partners are interested in buying Juul outright, but some kind of partnership makes sense for all of them. Even purchasing Juul—which means taking on all of the company’s liabilities and reputational problems—could make sense now. Juul has never been weaker and more in need of a savior.
A frontrunner in the global effort against smoking, the European Commission recently made clear in its Beating Cancer Plan that its objective was to create a ‘tobacco-free generation’, aiming at reducing the European Smokers to less than 5% of the overall Union’s population by 2040. The Commission embraces the ‘endgame’ strategy, a term in vogue in the public health community to describe a world where tobacco products have been phased out completely, or their sales severely restricted. It is no surprise that the Commission recently decided to register a European Citizen’s Initiative calling for ending the sale of tobacco and nicotine products to citizens born in 2010 and onwards.
The team consisted of researchers from the United States, Nepal and India. They conducted a cross sectional study looking at data held in a database covering 154,856 individuals. Bizarrely, they managed to discover that vaping poses more of a cancer risk than smoking – quite some effort given the accepted levels of reduced harm e-cigs offer. They say they found, “ that e-cigarette users have 2.2 times higher risk of having cancer compared to non-smokers. Similarly, traditional smokers have 1.96 higher odds of having cancer compared to nonsmokers .”
Tobacco Harm Reduction (THR) offers a promising approach to addressing the significant burden of smoking in Afghanistan. Over three million Afghans smoke daily, making it a leading cause of preventable deaths in the country. While the previous Afghan government implemented various tobacco cessation policies and strategies, these measures were only partially effective in reducing the number of smokers or smoking-related deaths. In 2021, community-based initiatives in Kabul and Herat started advocating for Tobacco Harm Reduction (THR) as a novel, realistic, and practical approach proven to promote smoking abstinence and minimize tobacco harm.
I’m not sure where the WHO gets the idea that the statistics on death and disease from cardiovascular and respiratory diseases and cancer are ‘invisible’. There is a wealth of data out there from national and international public health, medical and academic sources, including the Global Burden of Disease annual reports and the WHO’s own International Agency for Research on Cancer.
So, not invisible, but certainly worth highlighting again. And the figures make sober reading. The four major noncommunicable diseases (NCDs) are cardiovascular diseases (heart disease and stroke), cancer, diabetes, and chronic respiratory diseases. Over three-quarters of all deaths worldwide are caused by NCDs. Seventeen million people die from an NCD before the age of 70. The key risk factors are listed as tobacco use, harmful use of alcohol, diet, and lack of physical activity linked to obesity. And as with most global metrics of poor health, 86% of NCD deaths occur in lower- and middle-income countries (LMICs).
The whole thrust of the report is to restate the importance of achieving a 33% reduction in NCDs by 2030 in line with the Sustainable Development Goals. Without naming them, the WHO states that in 2022, “only a handful of countries” are on track to meet this target. Hard to imagine that the situation will improve much in the next eight years given the current state of the world economy and the health fall-out from the growing devastation caused by climate change.
In reality, the WHO can do little except to exhort individual governments to do more – invest in health care provision, restrict advertising on junk food, tobacco and alcohol, encourage people to do more exercise, and push for a collective investment of $140bn US to make a difference. But will it?
Take the idea of more physical exercise. Only the richest countries can afford to host an Olympic Games. Host cities spent millions and put themselves in debt on the legacy promise of shiny new sport facilities for local communities. Measurable impact on increased take-up of daily exercise as a result – zero. New stadiums fall into disrepair, while, for example, local authorities in England have been selling off school playing fields for housing development. At the other extreme, I can’t imagine that young people in the poorest countries walking miles to school or parents taking daily long hikes for fresh water need more exercise.
The impact of poor diet is not just junk food (which is causing a rise in cancers among younger age groups) – but no food. The war in Ukraine has shown how fragile the world’s food supply chain is.
The report majors on aspirations like ‘Leading from the top’; ‘Set the right priorities’; and ‘Choose the right policies and interventions’. Maybe those in charge of WHO tobacco control policies need to ponder on these, because currently they are failing in all respects to offer real leadership in tackling death and disease from smoking.
Let’s go back to the list of WHO key risk factors – tobacco and harmful use of alcohol. What’s the message here? Agreed that moderate use of alcohol is not harmful (but only in respect of NCDs with no reference to the damage caused by drunk driving, domestic violence and public disorder).
What about tobacco? There may be no safe moderate use of combustible tobacco, but the WHO knows full well, the welter of independent evidence shows that whether as tobacco or nicotine, the use of vaping, heated tobacco products, safer oral products such as snus or nicotine pouches carries none of the attendant NCD risks of smoking.
The WHO clouds the issue when it states that tobacco is the leading cause of preventable NCD deaths. It is smoking, which causes virtually all the 8 million tobacco-related deaths each year. The WHO response is to trumpet the fact that some five billion people are ‘protected’ from smoking as recorded by its MPOWER evaluation tool. It is delusional to imagine that smoking bans, plain packaging and warning labels ‘protects’ anybody. High tax may have some impact in reducing prevalence, but this just hits the poorest people who are likely to turn to readily available illicit supplies. These are just laws on the statute book which in many countries are simply unenforceable.
If the WHO was serious about tackling this most damaging source of NCD, it would be taking proactive steps to encourage countries to introduce risk proportionate legislation to promote uptake of safer products. If countries made products accessible through legislation, then the industry – big or small – could be left to determine which products were appropriate and acceptable for different countries and price them accordingly. And all at no cost to governments, many of whom in LMICs have enough health problems to worry about as the WHO report points out.
However, the WHO ignores all the evidence that could help spark a revolution in public health, instead focusing on an ideological war against nicotine funded by Bloomberg Philanthropies whose CEO makes this pronouncement in the report:
“Bloomberg Philanthropies will continue expanding our efforts to help more cities and countries take actions that will stop preventable deaths, and ensure longer, healthier and happier lives for all.”
For those millions looking to switch from smoking but unable to access or afford safer products, this must read like a sick joke with an emphasis on sick.
The WHO awarded a prize to Mexico’s president, Andrés Manuel López Obrador (known as AMLO) on May 31, the International No Smoking Day. Although the official reason was the approval of a new Tobacco Law, it is evident that AMLO was prized for his five presidential decrees that ban the commercialization and importation of Electronic Nicotine Delivery Systems (ENDS e-cigarettes and heat not burn products).
Commercialization of ENDS has always been illegal in Mexico, but in 2015
Def. Sea change or sea-change is an English idiomatic expression which denotes a
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