Reduce the harm if it cannot be stopped

ACCORDING to the World Health Organisation (WHO), the practice of tobacco smoking will persist into the near future with over one billion smokers globally.

Worldwide, tobacco use kills more than seven million people (both first-hand and second-hand smokers) every year, WHO says.

This practice persists despite extreme measures to stop it, such as banning advertising of tobacco products and smoking in public places, mandating pictorial health warnings on cigarette packs and imposing high taxes on cigarettes.

To date, “quit or die” messages have yet to show their effectiveness, and repeated failed attempts to quit have only led to frustration among smokers. The fact is they smoke cigarettes for the nicotine, on which they are dependent, but are killed by the harmful chemicals in the smoke.

In this regard, a number of forward-thinking public health authorities are exploring the role of alternative products, a strategy that aligns to the principle of tobacco harm reduction.

There is a growing body of scientific evidence proposing smoke-free alternatives such as electronic cigarettes, including heated tobacco products (HTPs), to potentially reduce the health risks associated with smoking.

Public health institutions in countries like the United Kingdom, Canada and New Zealand, for example, have officially endorsed the role of vaping products in helping to reduce the harms from smoking.

The US Food and Drug Administration, one of the world’s most influential regulatory institutions that often sets a high bar to ensure product safety and efficacy, in a surprising move on July 7,2020 authorised the marketing of a heated tobacco product as a modified risk tobacco product (MRTP).

The decision was made based on a review of scientific evidence which claimed that the product was distinctly different from conventional cigarettes because it does not burn tobacco, thus significantly reducing exposure of users to harmful chemicals.

The MRTP allows marketing communication on “reduced level or exposure” to consumers. Intriguingly, it also requires conduct of post-market surveillance and studies to ensure that while the product is available to promote public health, it does not encourage unintended use among youths.

In Malaysia, the Pakatan Harapan government had been deliberating on whether to ban or allow (with restrictions) electronic cigarettes, but the battle against the Covid-19 pandemic may have diverted most, if not all, of the resources and attention of the present administration for now.

Conflicting messages or policies from different government agencies (on e-cigarettes) also appear to have caused further confusion among the public. But what we know for a fact is that smokers constitute an occupationally active segment of the Malaysian population, and the well-being of the workforce should be the top priority of any government.

The seriousness of the tobacco smoking problem is an urgent call for the government to take pragmatic steps to reduce the harms of smoking if elimination is not possible.

From an occupational safety and health perspective, the adaptation of reduced risk products for smokers who cannot or will not quit smoking reflects the essence of substitution in the hierarchy of control principle. Specifically, scientific evidence on reduced risk products should guide evidence-based policy setting.

Malaysian regulators can take best practice points from Dutch regulators at the National Institute for Public Health and the Environment (RIVM), who conduct their own research to develop testing methods to quantify the risk of electronic cigarettes in their product assessment. Alternatively, systematic review and meta-analysis of available research data can also be performed to further guide the policy.

Policymakers should adopt impartiality in measuring the rigour of scientific evidence, be it from industry sponsored or independent research.

Tobacco harm reduction, if recognised and implemented rationally, could be of great value in guiding the journey of smoking cessation, thus reducing smoking-related morbidities and mortality.

ASSOC PROF DR NG YEE GUAN

Occupational safety and health expert

Universiti Putra Malaysia