Global Harm Reduction Overview
Dr. Konstantinos Farsalinos (Cardiologist & Researcher at Onassis, Greece) described harm reduction as a pragmatic concept to use when ceasing any risky behavior was not feasible. Harm reduction talks about interventions to reduce risk, like a seatbelt in car or medicines in our daily life. Tobacco harm reduction was necessary because first, over 1.1 billion people smoked tobacco in 2015 and 8 million premature deaths was caused by smoking annually. Second, quitting smoking was very difficult and efficacies of approved methods like NRT (Nicotine Replacement Therapies) were very low (under 7% for NRT). Tobacco harm reduction (THR) products like e-cigarettes, Heat-not-burn (HnB) and oral smokeless tobacco fit perfectly to the harm reduction definition due to their effectiveness as smoking cessation aids and lower toxin emissions.
Asia Harm Reduction Overview
Prof. Tikki Pangestu (Lee Kuan Yew Scholl of Public Policy, Singapore) stated that male smoking rates were high in Asian countries, especially for Indonesia where 76% of men are smokers. Some Asian countries have banned e-cigarettes, and there were 6 challenges for tobacco harm reduction in Asia – a key challenge was the position of the WHO on harm reduction, which was important because health regulators in some countries looked at WHO guidelines as reference. Next, political & economic drivers were important because state owned tobacco monopolies accounted for 40% of global cigarette production in Asian countries – 6% of total government revenue for Indonesia came from tobacco. Also the lack of quality local research was a challenge that needed to be overcome. So the three things to move forward were as follows: Most importantly, push for a more effective and integrated advocacy and communication strategy with more local contextual factors. Secondly, stronger links and research collaborations with international harm reduction community was needed. Finally, work with sympathetic government to influence and change the WHO’s stance on harm reduction.
Rethinking Nicotine: The Role of Public Health Law in Ending an Epidemic
Prof. David T. Sweanor J.D. explained that there was a global public health catastrophe occurring daily as 20,000 deaths result from people inhaling cigarette smoke and the problem here was not the nicotine, but the delivery system. He said this could be solved by our public health policy, which people have always done with public health advances in history: reduce the risk where we find it, with technology, policy changes, and gathering information. Changes such as dramatic increase in Korean life expectancy happened with policy changes. We need to make pragmatic policies to reflect science. By coming up with sensible health regulations and laws, Canada has reduced teenage smoking by 60% in 10 years. Countries need to replicate other countries’ precedents. The potential exists to rapidly reduce cigarette smoking, and now we have ability to lead and change the world. Canada did cigarette taxation, package health warnings, cigarette advertising bans, and these are currently done all over the world. Now we can do a more fundamental thing – by changing the products itself. There are tremendous opportunities via the combination of technological knowledge, understanding of public policy to help markets develop alternatives to do amazing things.
How to be Part of the Change? -Policy Interventions for Differentiated Products
Dr. Carrie Wade (R Street, USA) stated that in the USA, there were tobacco control policies like taxation, mandatory labels on tobacco products to reduce the smoking prevalence of to about 15%. However, it was found that amongst the lower income and less educated segments of society, these groups still had a higher smoking rate. The US FDA was partly committed to allowing e-cigarettes to be made available to smokers, but they have set up a system such as a need to make a Pre-Market Tobacco Application (required to sell ENDS products) and a Modified Risk Tobacco Product Application (required to make ‘reduced risk’ claims) to ensure a robust process is in place.
Dr. Marewa Glover (Center of Research Excellence: Indigenous Sovereignty & Smoking, New Zealand) described how New Zealand had advanced tobacco control programs and a commitment to a smoke free environment. She mentioned that a policy sweet-spot was important to politicians, and the important thing now was to gather and better organize the vaping proponents Now, the New Zealand government was running a campaign encouraging people to switch to vaping. There was even a government-funded website providing accurate information about vaping.
Dr. Hiroya Kumamaru (AOI Universal Hospital, Japan) provided updates from Japan in tobacco harm reduction. The number of deaths due to smoking in Japan was increasing, and the medical expenses caused by smoking were high. After HnB products were introduced to Japan in 2014, they successfully reduced cigarette smoking in Japan to 21% in 2018. According to research conducted by the Japanese government, it turned out that HnBs are not causing the “gateway phenomenon” for youths as had been widely-feared. In addition, HnBs were being favored by nicotine-dependent people.
Dr. Tan Kok Kuan (Republic Healthcare, Singapore) mentioned how the Singapore government had banned the importation, distribution, and possession of any alternative tobacco products. As there was Coke Zero for substitute Coke and HIV medicine to reduce the risk of HIV, harm reduction product for tobacco was sorely needed. He said he wanted to be part of the change, and persuade policy-makers to implement regulations on alternative tobacco products for people who cannot quit smoking.
Dr. Hyuck-Myun Kwon (University Industry Foundation, Yonsei University, Korea) explained risk management in Korean chemical industries. He spoke about how risk was a combination of consequences and frequencies, and the aim in risk management in ESH field was to reduce frequencies. Since 1995, Korea had introduced PSM (Process Safety Management) for the Korean chemical industry containing 12 elements, and for the installation of the system in all companies, many stakeholders and public organizations groups put in great efforts. This led to a decrease in the occurrence of accidents by 75% in 20 years.
How to be Part of the Change? - Harm Reduction and its Application
Dr. Ng Yee Guan (Occupational Safety and Health, University Putra Malaysia, Malaysia) highlighted the application of hierarchy of control in occupational safety and health. First and most effective step was elimination, but if that was not possible, we should try substitution then engineering control, administrative control, and finally with personal protective equipment. This could be part of harm reduction and applied in tobacco or other addiction problems in the same way like using substitute tobacco devices. In Malaysia, there was a medical report for the use of clinical practice guidelines, and ‘MQUIT’, a substitute management plan.
Dr. Willy Wong (Hong Kong Psychiatry and Integrated Medical Centre, Hong Kong) shared about the harm reduction situation in Hong Kong. Hong Kong has adopted harm reduction in drug use and alcohol area since 2002 with HIV harm reduction hotlines. There have been controversies and discussions about tobacco harm reduction issues, with the Hong Kong government proposing to regulate e-cigarettes and tobacco heat products as a traditional cigarette. In fact, when announcing the Bill to ban on e-cigarettes and THPs in Hong Kong, the reason given was that e-cigarettes smokers were more interested in fashionable aspect of it and not smoking cessation.
Dr. Grzegorz Krol (Director, Knowledge. Action. Change, UK) described the western harm reduction experience, especially in Norway and Sweden where the daily smoking prevalence dramatically reduced by 5% and 11% through the use of less harmful products.
Dr. Tri Budhi Baskara, S. Ked (General Practitioner in Primary Care and Hospital Bali) recommended that regulatory frameworks should be formulated based on scientific evidence that is specific for heated tobacco product, and encourages smokers who do not want to quit to switch to alternative products.
Dr. Jong-Tae Park (Professor, Occupational & Environmental Medicine, Korea University Ansan Hospital, Korea) said that there are no practical solutions to the problem of reducing smoking in the Korean work health care system. The concept of quit or die was too strong and people were not familiar with the concept of ham production. To improve the workplace health care in Korea, the concept of harm reduction seems to be necessary.
How to be Part of the Change? - Views from Korea
Prof. Aeree Sohn (Professor, Health Management, Sahmwook University, Korea) explained how compared to other countries, Korea had weak regulations on alcohol and that alcohol-related availability and pricing policies should be considered
Keun Ho Joe (Director, Mental Health Service, National Center for Mental Health, Korea) said that from the psychiatric aspect, harm reduction should be carefully applied to people who have usage disorder issues. It can be difficult for a complete cure. It was recommended for gambling or gaming disorder, but still there were some limits and questions left of whether other kinds of alcohol or cigarettes could be an alternative.
Prof. Jae Wook Choi (Professor, Preventive medicine, Korea University, Korea) stated that it was important to know the exact pros and cons of harm reduction. There was still alot of limitations in Korea to implement harm reduction, as the voices of experts was definitely necessary. Providing the public with accurate information on smoking alternatives and the substances in these products could meet the expectation of citizens’ right to know.