Innovative individuals in the Asia-Pacific region, home to the largest population of smokers, have an opportunity to end the smoking epidemic by improving the technologies to deliver nicotine in a much less hazardous and more affordable way, according to experts who convened during the 3rd Asia Harm Reduction Forum held in Seoul, South Korea on August 29.
“We have the ability to use business and create regulatory incentives to change the [tobacco] market. We have tremendous opportunity to do really amazing things,” David Sweanor, an adjunct professor of law at the University of Ottawa, says during the 3rd Asia Harm Reduction Forum in Seoul, South Korea.
The forum was jointly organized by the Korea Harm Reduction Association and Yayasan Pemerhati Kesehatan Publik (YPKP) Indonesia. Sweanor, who has worked on tobacco and health policy issues since the early 1980s and played a key role in setting a wide range of Canadian and global precedents, is among the 100 experts from 18 countries who gathered at GLAD Hotel Yeouido to discuss the topic of harm reduction.
Sweanor says Asian innovators have the chance to improve the electronic nicotine delivery systems and make them less expensive and more accessible to the public in the same way that Japanese electronics manufacturers and Korean automotive makers became dominant in the global arena.
Sweanor says innovators can further improve the technologies behind non-combustible tobacco products. “Over time, the technology gets better and gets cheaper. That’s what we can do through innovation and technology. If we want to make them available to more smokers, if we want to make them less expensive than smoking, if we want to make them safer, if we want to make it easier for people to quit smoking, we have the ability to do that,” he says.
“It starts at whatever technology we have now and we use regulation to try to speed up the change. Mobile phones are really a good example. You look around Asia and everybody has mobile phones today and they are better than 20 years ago,” he says.
Sweanor says such innovations will have a tremendous impact on public health as they will dramatically reduce the rate of smoking which is responsible for 20,000 deaths globally each day. He describes smoking as a public health catastrophe which causes a human death for every 4.5 seconds.
Sweanor says it is smoking, and not the nicotine in tobacco, that was found to be hazardous to human health. “The problem is not the nicotine, but the delivery system,” he says, adding that electronic cigarettes, heat-not-burn tobacco and Swedish snus that also contain nicotine were found to be much less harmful to human health.
“Cigarettes are really hazardous way for people to get nicotine. There are over a billion people in the world who are seeking nicotine by smoking cigarettes. It kills people because they have to breathe in smoke. We have the ability to get rid of the smoke. If we get rid of the smoke, we get rid of the disease,” says Sweanor.
“As you replace old products, you get better at it, you create a new business that could be very, very powerful and very wealthy because the cigarette market globally is so huge. Any company that takes 10 percent of that [$850-billion tobacco] market is gonna be probably worth as much as Amazon or Apple,” says Sweanor.
An expert independent evidence review by Public Health England concluded that e-cigarettes are around 95 percent less harmful than smoking and that e-cigarettes may be contributing to falling smoking rates among adults and young people in the UK.
Sweanor says non-combustible products were also found effective in making people quit smoking in several countries. He says the introduction of heat-not-burn devices in Japan has dramatically reduced smoking incidence in the country. “Look at what Japan has now achieved. Roughly a third of Japanese cigarette market has disappeared, replaced by non-combustible tobacco products,” he says.
He says in Iceland, smoking prevalence went down by 40 percent in just three years by substitution of electronic cigarettes and Swedish snus.
Sweanor says the challenge is how to speed up the adoption of technology to save more lives as soon as possible. “We could cause a revolution in these products,” says Sweanor. “The history of innovation usually comes from new players. There will be some bright young people, somewhere who will say I have an idea. Juul is a company nobody heard of three years ago. Then it became worth $40 billion,” he says, referring to American e-cigarette manufacturer Juul Labs Inc.
“People who are willing to take risks, who see the world differently, people who don’t have vested interests in the old technologies or old ideas, they can cause a big change. Asia is fascinating because many innovative companies, new technologies, new ideas are coming out of Asia. Many governments understand and support that,” says Sweanor.
“And if they did that on issues of alternative nicotine, we could have a revolution very quickly as new technology came forward. It would make the technology that we have now, heat-not-burn and the vaping and snus and products like that look like the early mobile phones that we used to have. People could look at the technology and say I can do that better,” he says.
Sweanor says Indonesia, for one, has enormous potential like many other Asian countries because it has a very large domestic market. “You have the ability to create domestic industrial champions the way many Asian countries have in ship manufacturing, car building or semi-conductor or consumer electronics. Indonesia is in a good position to do that because they have such a big domestic market,” he says.
Professor Tikki Pangestu, a professor at Lee Kuan Yew School of Public Policy (Public Health) in the National University of Singapore, says smoking rate among Asian males is very high. “In Indonesia where I come from, 76 percent of males are smokers but you can also see that in many other Asian countries, the rates are also very high. Six out of nine countries with the highest number of deaths from smoking are in Asia,” he says.
He says among the countries with the highest number of deaths from smoking are China (1.8 million); India (743,000); Indonesia (180,000); Japan (166,000); Bangladesh (153,000); and Pakistan (124,000).
Within the region, smoking incidence among males is highest in Indonesia at 76 percent; Laos, 57 percent; South Korea, 50 percent; China, 48 percent; Vietnam, 47 percent; Cambodia, 44 percent; Malaysia, 43 percent; the Philippines, 43 percent; Pakistan, 42 percent; Thailand, 41 percent; Bangladesh, 40 percent; Nepal, 37 percent; Japan, 34 percent; Myanmar, 32 percent; Sri Lanka, 28 percent; Singapore, 28 percent; and India, 20 percent.
Data also show that half of the largest tobacco-producing countries in the world are in Asia, including China, India, Indonesia, Pakistan, Bangladesh, Korea, Thailand, Vietnam, the Philippines and Laos.
Pangestu says while there are safer alternatives to smoking, Asian countries such as Singapore, Thailand, Brunei and Cambodia ban the use of electronic cigarettes and there are ongoing debates about e-cigarettes in Indonesia, Malaysia, Vietnam and the Philippines
He says promoting harm reduction in Asia is quite a challenge because of misinformed and misguided policymakers, the position of the World Health Organization on harm reduction, political and economic drivers, “fear factor” among smokers, affordability of e-cigarettes and HNB devices and the lack of quality local research.
Professor Okryun Moon of the Korea Harm Reduction Association says smokers in Asia deserve access to better alternative tobacco products.
Dr. Konstantinos Farsalinos, a cardiologist and researcher at Onassis Cardiac Surgery Center in Greece, says countries and governments should realize that harm reduction is a human right.
“In my opinion, tobacco harm reduction is an absolute necessity. There are mainly two reasons. One is that millions die of smoking every year. There are more than 1 billion smokers in the world today. Eight million of them die prematurely every year because of smoking-related diseases. It is a huge burden for the whole world,” says Farsalinos.
“The second reason is that quitting smoking is extremely difficult and approved methods to quit failed in the majority of smokers,” he says.
Farsalinos says harm reduction products such as e-cigarettes, heated tobacco and snus are found to be less harmful than combustible cigarettes. “They have far lower risks for smokers. We have seen a large reduction in cigarette sales when heated tobacco products are becoming more available. We have seen that in Japan and Korea,” he says.
Data show that in 2005, 49 percent of men and 14 percent of women in Japan were smokers. In 2018, the country’s smoking rate decreased to around 18 percent of the total population.
A new study by University College London says that smokers are three times more likely to succeed in quitting smoking with the use of electronic nicotine delivery systems or e-cigarettes, compared to those prescribed with nicotine replacement therapy based on research covering nearly 19,000 smokers in England over a 12-year period from 2006 to 2018.
“Due to the difficulty in quitting smoking, tobacco harm reduction represents a historical opportunity to eliminate smoking globally,” says Farsalinos.
“Harm reduction is a strategy that everyone knows, everyone understands because we all practice this every day in our lives. We need to emphasize that harm reduction is a human right,” says Farsalinos.