Balancing health and harm reduction: The ongoing debate over tobacco and nicotine use

KUCHING (Sept 30): In public health, few issues are as controversial as the debate over the harm caused by tobacco and how to reduce smoking.

Though both sides of the debate agree that the ultimate goal is to reduce the health impacts of tobacco use, they however differ on the methods to achieve this outcome.

A balanced approach that considers both the benefits and risks of harm reduction products, alongside robust regulatory frameworks, could therefore be essential in protecting public health and reducing smoking prevalence.

That being the case, it is vital to keep the focus on science-based evidence.

Health Risks of Cigarette Smoking

Cigarette smoking continues to be a leading cause of numerous health issues, including cancer, cardiovascular diseases and respiratory conditions.

According to the WHO, despite global smoking prevalence declining from 22.7% (2007) to 17% (2021), there are still more than one billion smokers worldwide. Every year, smoking accounts for more than 8 million deaths, an estimated 1.3 million of which are non-smokers who are exposed to secondhand smoke.

This reduction in smoking rates can be attributed to various public health initiatives, including smoking cessation programs, increased taxation on tobacco products, comprehensive advertising bans and the implementation of smoke-free environments.

Despite efforts to reduce smoking, conventional cigarettes are still the most popular form of tobacco products worldwide. This continued use of cigarettes is seen in all age groups because they are easy to get, people are used to smoking them and nicotine is addictive.

However, the landscape of tobacco consumption is undergoing a significant transformation as smokers explore alternative products.

One of the most notable shifts in recent years has been the surge in the use of e-cigarettes and vaping devices, particularly among younger populations.

In some parts of the world, people use smokeless tobacco products like chewing tobacco, snuff and snus.

Dr. Peter Harper, a British-based consultant oncologist emphasized the reduced harm of electronic cigarettes compared to conventional ones, saying, “There’s no hype around smoking conventional cigarettes, it’s gone. The world has kind of stood on its head.

“It is concerned about something that all of us who independently assess the evidence know is 95 per cent less harmful than a burning cigarette, and an electronic cigarette is even 98 per cent less harmful than a conventional cigarette. They want to talk about a two per cent risk, but they ignore the risk that is 100 per cent.”

Malaysian scenario

In Malaysia, tobacco smoking prevalence has significantly declined, dropping from 23.1 per cent in 2011 to 19 per cent in 2023, according to National Health and Morbidity Survey 2023.

This decrease is particularly notable among men, with smoking rates falling from 43.9 per cent to 35.7 per cent.

Despite the declining numbers, tobacco-related complications have caused approximately 27,000 deaths annually in Malaysia.

In its fight against the tobacco epidemic, Malaysia took a crucial step by signing the World Health Organisation (WHO) Framework Convention on Tobacco Control in 2005 which was further strengthened with the country’s inaugural Global Adult Tobacco Survey (GATS) in 2011.

On a global scale, the WHO FCTC boasts participation from 183 countries, representing over 90 per cent of the world’s population to underscore the widespread dedication to tobacco control.

Since the launch of GATS in 2011, Malaysia has achieved remarkable progress in curbing tobacco and e-cigarette use by introducing key tobacco control measures, such as banning smoking in 23 indoor public places, prohibiting tobacco advertising, mandating graphic health warning labels as well as increasing tobacco taxes.

As a result, the prevalence of tobacco use has decreased from 24 per cent in 2011 to 19.5 per cent in 2023, with a notable decline among men from 44.9 per cent to 36.2 per cent, said the GATS Malaysia survey findings in 2023.

Conversely, the use of e-cigarettes has surged, increasing from 0.8 per cent in 2011 to 5.8 per cent in 2023. Notably, e-cigarette use among individuals aged 15 to 24 rose from 1.1 per cent in 2011 to 8.6 per cent in 2023.

Tobacco Taxation

Like many other nations, Malaysia has been diligently working to reduce cigarette smoking.

As it stands, besides the regulatory controls, taxation appears to be the most effective measure to curb smoking.

In 2004, tobacco taxation in Malaysia began at RM0.081 per cigarette stick which increased to RM0.40 per cigarette stick in 2015 and has remained unchanged to this day.

In 2020, amendment to Regulation 8C of the Control of Tobacco Product Regulations 2004 increased the minimum price of a pack of 20 cigarettes to RM12.

Last year, the government also set a RM0.40 per milliliter excise tax on liquid or gel of electronic cigarettes containing nicotine through the Excise Duties (Amendment) Order 2023.

The Health Ministry, however, felt that the tax increase implemented in November 2015 is still inadequate to achieve 15 per cent prevalence rate by next year (2025).

Based on the ministry’s studies, to reach a five per cent prevalence by 2045, this calls for a higher excise tax rates of more than 85 per cent.

Meanwhile, tobacco harm reduction proponents have argued for risk-proportionate taxation in order to minimise negative externalities when hiking taxes on cigarettes.

Tobacco products range in risk, with combustible ones being the most dangerous and electronic nicotine delivery systems the least.

Risk-proportionate legislation considers these differences, regulating more harmful products more strictly than less harmful ones.

PMI International Communications and Engagement vice-president Tommaso Di Giovanni opines that taxation can work to a certain extent.

He cited the example of France where country has invested heavily in various forms of restriction and prevention, including by sharply increased tobacco taxes but 30% of the France population are smokers.

“France has chosen not to distinguish between smoking and non-smoking products in its legislation. Nor does it encourage smokers to choose other alternatives. Instead, they have chosen to raise taxes. Smoking has not decreased; instead, a third of cigarette sales have moved to the black market. Every tenth cigarette in France is illegal,” said Di Giovanni.

According to Di Giovanni, countries like France, and by extension the WHO, should learn from the countries where smoking is declining the fastest.

“Cigarette sales have fallen fastest in countries where alternatives are allowed and encouraged. Sweden is a good example of this working, although the importance of snus is very much a local tradition. But the UK is also leading the way by actively encouraging smokers to switch to e-cigarettes. There, smoking is down to 14 per cent. This compares to 30% in France, which has chosen not to even allow retailers to properly inform customers about the products.

Ills of illicit fag

It can also be seen that the availability of cheaper illicit cigarettes makes the problem worse for the lower-income group.

Several past studies have found that illicit cigarettes contain significantly higher levels of harmful substances compared to legal ones.

Specifically, counterfeit cigarettes have been found to contain five times more cadmium, six times more lead, 160 per cent more tar and 133 per cent more carbon monoxide.

Analysis of illicit cigarettes have also uncovered traces of hazardous materials such as weedkiller, sawdust, and animal faeces.

As of May 2023, the illegal cigarette trade accounted for 55.3 per cent of the Malaysian market, according to the latest Illicit Cigarette Study conducted by Nielsen – a firm specialising in information, data, and market measurement.

In Sarawak, Nielsen found that the illicit cigarette trade controlled a staggering 79.9 per cent of the local market.

According to the Malaysia Integrity and Governance Society (MIG), the number of illegal cigarettes seized and confiscated has increased by over 20 per cent in the first quarter of 2024 compared to the same period in 2023.

Beyond the argument about the impact of taxes on the illicit cigarette trade, several other significant factors influence this issue.

These include industry involvement, inadequate law enforcement due to limited resources, the lack of tracking and monitoring systems for the illicit cigarette distribution chain, and the extent of corruption.

Advocating harm reduction

Proponents of tobacco harm reduction (THR) argue for a pragmatic approach that includes safer alternatives to traditional cigarettes such as e-cigarettes, heated tobacco products and nicotine replacement therapies (NRTs) which delivers nicotine without many of the harmful chemicals found in combustible tobacco.

While not entirely risk-free, research supports that these alternatives are significantly less harmful than smoking traditional cigarettes.

THR advocates also highlight that these products can assist smokers in reducing or quitting their cigarette consumption, leading to better health outcomes.

“There is a real need for an alternative for a less harmful, less risky alternative. We have to look at what is the reduction of risk for an individual and what is the reduction of harm on the population level,” PMI New Business and Chief of Staff Dr. Patrick Pivacet.

He added that they both interplay with each other and ideally quitting smoking is the best option for any smoker.

However, the reality is that many people continue to smoke and therefore, providing a less harmful alternative is crucial to reduce both individual risk and population-level harm.