Dr Margaret Chan
Director General World Health Organization
Avenue Appia 20 CH-1211
Geneva 27, Switzerland
7 November 2016
Dear Dr Chan
We write as physicians, scientists and health policy experts living and working in Africa and the Middle East. We all share your goal of mitigating against and ultimately eliminating the epidemic of disease and premature death caused by smoking. We are committed to doing as much as possible to reach the ambitious targets to reduce non-communicable diseases by 25 percent by 2025, and the measures necessary to achieve it – including a substantial reduction in smoking. However, the trends in Africa and the Middle East are not encouraging. WHO’s data suggests that smoking prevalence is rising, and driven by population increases and economic growth we can expect Africa and the Middle East to bear a greater share of the burden of smoking related disease in coming decades. We are fully committed to the implementation of the FCTC in our countries and believe that a comprehensive approach to tobacco control across the continents is both necessary and urgent. We believe that every opportunity should be taken to reduce smoking and smoking-related health risks across Africa and the Middle East. This should include the approach of ‘harm reduction’ as a strategy in tobacco control as defined in Article 1 of the FCTC. We know that combustion of tobacco leaf and the inhalation of toxic smoke is by far the overwhelming cause of tobacco related disease, while nicotine itself plays a minor role in disease, if any. An ever-increasing range of smoke-free nicotine products are now available, including e-cigarettes, personal vaporisers, heated tobacco products, smokeless tobacco and novel nicotine products such as inhalers, lozenges or films. We believe that we should not allow the opportunities that these products present to be lost, at a cost of more avoidable death and disease. We believe that by giving smokers a less harmful alternative, as well as the motivation to quit completely, we will be able to persuade far more smokers to stop smoking. Harm reduction is supportive of conventional tobacco control, and does not aim to replace or oppose it but rather work in tandem with it. To that end, we hope the Director General and staff of WHO and FCTC secretariat will put their weight behind the tobacco harm reduction strategy as a fourth major foundation of tobacco control, alongside prevention, cessation and protection of bystanders. We propose the following agenda, and ask you as Director General to support it:
1. Endorse the strategy of tobacco harm reduction. The WHO and Parties to FCTC should recognise in declarations, decisions and statements of policy that switching from high-risk
2. to low-risk nicotine products is a valuable public health strategy that complements current tobacco control and the FCTC. 2. Offer alternatives to prohibition. We believe that no ethical or scientific justification exists for the banning of low-risk smoke-free nicotine products, especially when high-risk combustible cigarettes are widely available. No government should deny smokers access to products that are sure to be much lower risk to health than smoking. Prohibitions of lowrisk smoke-free alternatives serve mainly to protect cigarette sales, prolong smoking and cause more ill health and premature death. Citizens should have the right to healthier choices in addition to abstinence.
3. Develop proportionate and appropriate regulation. Product regulation should be proportionate to risk and it should never be the case that the burden on low-risk smokefree products are greater than on high-risk products like cigarettes. The alternative nicotine products are not medicines and nor do they pose the same risks as cigarettes – they should not be regulated in the same manner as either medicines or cigarettes.
4. Implement pro-health taxation policies. Tobacco and nicotine taxation policy should encourage switching from high-risk smoked products to low-risk smoke-free products as well as discouraging initiation.
5. Allow marketing of low-risk alternatives. The FCTC calls for comprehensive bans on tobacco advertising based on the high death toll from smoking. However, the marketing of low-risk nicotine products serves to reduce smoking without requiring government spending. Bans on marketing low-risk smoke-free alternatives serve mainly to protect cigarette sales, which is surely an undesirable outcome.
6. Communicate risks to the public clearly. It is the responsibility of experts and public bodies to communicate risks of different nicotine products as honestly and transparently as possible. Warnings should communicate relative risks compared to smoking, as this is the most important information for making informed choices regarding health.
7. Reconsider the tobacco target. The World Health Assembly target to reduce prevalence of tobacco use by 30 percent by 2025 unfortunately obstructs one of the fastest acting, successful and valuable options to meet the overall target to reduce non-communicable disease. That is switching from high-risk to low-risk tobacco products such as lownitrosamine snus, heated tobacco products or electronic delivery systems and other forms of tobacco/nicotine. The target should focus on the main driver of disease – inhaling tobacco smoke – and not ignore valuable options to reduce disease.
8. Engage with stakeholders. Transforming the market for nicotine is a major undertaking, involving health experts, regulators, fiscal authorities, scientists, consumers, innovators and businesses. In particular, we need to see more engagement with consumers who understand these products and are trying to stop smoking.
9. Sound science and policy. There must be a well-funded but open-minded approach to science that is sensitive to regional differences in culture, tastes and history. In the policymaking for public health we must use the best analytical techniques and be careful to assess and avoid the unintended consequences of poorly designed policies, which lead to more smoking.
We are concerned that the WHO is not embracing the harm reduction agenda, but actually opposing it. If that is the case, then there is a real danger that more smoking, more cigarette sales and more death and disease will be the result and burden on our health systems across Africa and the Middle East will become increasingly unbearable.
We hope you will consider our proposals and engage in discussion. We intend to share our views with relevant officials and politicians, and we would welcome a reply, which we would also circulate. Please address the reply to the Middle East and Africa tobacco harm reduction group on email address Harmreductiongroup@integraafrica.com or call us on +27 (0)11 513 4254
Note: this letter represents the personal views of the signatories only, and does not necessarily reflect the opinions of their employers, funders or their institutions.
Dr Kgosi Letlape President of the Africa Medical Association - South Africa
Dr Tarek Safwat President of the Egyptian Scientific Society for Bronchology - Egypt
Professor Barthelemy Nyasse University of Bamenda Deputy Vice-Chancellor in Charge of Academic Affairs - Cameroun
Professor Sameh Farid Former Health Minister, 2011 President of the Egyptian Society of Otorhinolaryngology Egypt
Dr Nasser Loza MB BCh, MSc., DPM&N, FRCPsych Director – The Behman Hospital Egypt
Dr Khaled Al-Kattan Consultant Thoracic Surgery Riyadh Saudi Arabia
Dr Fares Mili Pulmonologist, Allergist & Tobaccologist Tunisia
Professor Ibra Wane Former Technical Advisor, Ministry of Health Senegal
Dr Imane Kendili Head of Addiction Department at the Cheikh Khalifa Hospital, Head of Psychiatry – Addictologie Morocco
Dr Obaid Aljassim Cardiothoracic Surgeon United Arab Emirates