OPINION | Harm reduction: the most effective tool for countries to go smoke-free

The public health benefits of an active harm reduction approach to the problem of tobacco smoking are becoming clearer all the time. This is because we can now compare the outcomes in countries that have put harm reduction at the centre of their efforts to combat smoking with their peers who have relied solely on conventional tobacco control methods.

Two case studies stand out because they are among the first nations in the world to arrive within touching distance of official smoke-free status, which is defined as a smoking rate of 5% or lower. In Sweden, this was done through a combination of public education, tobacco control measures and the adoption of and access to alternatives to smoking that do not involve burning tobacco.

Fortuitously for Sweden, its early progress on the path of tobacco harm reduction was aided by the use of snus, a smokeless oral tobacco product that was already widely used by men and women. The arrival of vaping in 2015 and modern oral nicotine pouches in 2018 accelerated the transition to smoke-free alternatives and by 2023, Sweden’s public health agency reported only 5.6% of Swedish adults were smokers, compared with 49% 60 years ago.

Today Sweden has a cancer incidence 41% lower than the European average and experiences less than half the tobacco-related deaths compared with almost all its EU counterparts. This is even though Swedes consume nicotine at similar rates to other high-consuming nations. The difference is they aren’t smoking tobacco, the combustion of which is the source of the vast majority of toxicants.

At the opposite end of the Earth, New Zealand has made a similar breakthrough against smoking in an even shorter period. In 1990, it became the first country to pass a comprehensive Smoke-Free Environments and Regulated Products Act. With excise tax increases, this continued a trend of gradually declining smoking rates that had begun after the release of the US Surgeon General’s Smoking Kills Report in 1964.

New Zealand was among the first countries to institute a complete ban on smoking in all indoor public workplaces in 2004.

Despite leading the charge on the legislative front, however, New Zealand’s goal of reducing smoking below 5% remained elusive.

This began to change as the government started to pay more attention to the phenomenon of vaping, after its introduction to the market in 2009. It began assessing the merits of vaping products through the establishment of an Electronic Cigarette Technical Expert Advisory Group in 2017, which was tasked with investigating global trends and product standards.

After a thorough analysis of the approach adopted in the UK and listening to the advice of local and international health experts and local smoking cessation practitioners, the country adopted evidence-based regulation of vaping and heat-not-burn products. This was augmented by a government-led mass media campaign called “Vape to Quit Strong” and the launch of a factual communications platform — www.vapingfacts.health.nz.

The latter aimed to “support smokers to switch to regulated products significantly less harmful than smoking”.

With this government-led campaign retailers were enabled to advise smokers on the benefits of switching to vaping, reaching them at the point of purchase with advice, product displays and posters on tobacco harm reduction.

Between 2011 and last year, smoking prevalence in New Zealand fell by more than half, from 16.4% to 6.8%. Meanwhile, adult daily vaping increased from 2.6% to 9.7%, with most regular vapers being either ex- or current smokers.

The Smokefree Environments and Regulated Products (Vaping) Amendment Act came into force on November 11 2020. This means vaping products, in addition to tobacco products and herbal smoking products, are now regulated under the Smokefree Environments and Regulated Products Act .

The Māori population, who had been neglected previously in anti-smoking campaigns, experienced a significant decline in smoking rates, from 37.7% in 2011 to 17.1% by 2023. There was a corresponding uptake of vaping, with Māori recording the highest daily vaping rate at 23.5%.

According to the leading tobacco control NGO Action for Smokefree 2025, the country is now on track to reach its goal of becoming smoke-free by 2025.

The New Zealand Public Health Communication Centre has concluded that, “the most plausible explanations for the observed changes in smoking prevalence [include] growing use of [vapour products] resulting in increased quitting smoking among people who smoke and/or reduced uptake if young people substitute vaping for smoking”.

By contrast, New Zealand’s neighbour Australia has taken a far more punitive approach, with limited effect. Though Australia had a lower smoking prevalence than New Zealand a decade ago, its island neighbour has since overtaken it and today 10.7% of Australian adults continue to smoke.

Unlike New Zealand, Australia has not embraced the concept of tobacco harm reduction and vaping products are available on prescription only. An unintended consequence is that about 90% of adult vapers access these products on the black market, while underage Australians continue to experiment with vaping. The country’s youth vaping rates are higher than those of New Zealand.

These examples are a clear indication that tobacco harm reduction can be far more successful in reducing smoking prevalence and the public health burden associated with it.

Now, however, New Zealand is putting its progress at risk by proposing the introduction of punitive measures to reduce youth vaping. Among others, the government intends to ban disposable vapes it says are preferred by youth. Still, harm reduction advocates and tobacco experts are concerned that this may result in a rise in the black market underground trade of unregulated products, exposing youth to greater risk.

Africa stands at a similar crossroads in its approach to reducing the health burden of smoking. Punitive regulation is on the table in multiple African countries, while the examples of Sweden and New Zealand show the way for a different, much more effective approach. The decisions taken will have profound consequences for years to come.

Harm Reduction Advocacy in Sub-Saharan Africa Society (HRiSSA) is an NPO dedicated to delivering appropriate, quality patient care supported with the latest scientific evidence-based data. 

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