Enabling tobacco harm reduction and regulating smokeless nicotine products

In the Middle East, on average, 20% of the adult population are smokers[1], which makes smoking one of the most persistent cultural staples and a notable challenge to public health. This means that tobacco harm reduction (THR) – a public health strategy that advocates for providing adult smokers, who choose not to quit, with reduced-risk* sources of nicotine – is particularly relevant for the region. 

Governments and policymakers are essentially the gatekeepers that aim to reduce the health risks associated with smoking, and they can often make all the difference in the adoption and effective regulation of scientifically substantiated, reduced-risk* smokeless alternatives. Regulations based on the risk associated with smokeless product categories like vaping, heated products, and nicotine pouches, as compared to conventional cigarettes, can play a fundamental role in mitigating the health risks associated with smoking and lightening the burden on healthcare systems worldwide.

The figures also speak volumes in the Middle East. A study that encompasses the 390 million people living in the region, as well as Egypt and Pakistan, found that about 61 million adults use tobacco products[2], of which some 15% could be affected by a range of morbidities and other serious health issues by 2060. 

In this context, embracing THR is of the utmost importance. Increasingly abundant, credible research indicates that the use of smokeless alternatives is an effective method of helping vast numbers of adult smokers not only give up cigarettes[3], but also significantly improve their quality of life[4] while decreasing the risk of tobacco-related disease and other health issues[5].

According to the UK’s Royal College of Physicians, “the hazard to health arising from long-term vapor inhalation is unlikely to exceed five percent of the harm from smoking”[6]. 

At the same time, for Heat Not Burn (HNB) products, due to the heating of tobacco, as opposed to burning, these products are reduced-risk* compared to smoking for those who switch completely. To date, an increasing number of independent reports are supporting the role of HNB products as a less risky* alternative to smoking. For example, in 2018, Public Health England, while highlighting the need for more research, found that “compared with cigarettes, heated tobacco products are likely to expose users and bystanders to lower levels of particulate matter, and potentially harmful compounds.” [7]

That said, the potential benefits that THR and smokeless alternatives offer are unfortunately not being explored by the vast majority of nations. WHO estimates that “only 23 countries provide comprehensive cessation services with full or partial cost-coverage to assist tobacco users to quit. This represents just 32% of the world's population[8]”. The ineffectiveness of the conventional approach to smoking cessation is highlighted by the same organization, which has predicted that, without THR, the Middle East will experience only a nominal decrease in smoking, from 33.3% in 2020 to 31% in 2025[9].   

One of the authors of the 2024 ‘Effective Anti-Smoking Policies Global Index’, a wide-ranging analysis and ranking of public anti-smoking policies covering 69 countries and four regions, highlighted that in a regulatory context, “prohibitionist policies used to be the only way to deal with smoking.” He, however, resoundingly declares that this approach “is not the efficient way to punish people for what they enjoy and what they cannot give up on that easily[10]”.

In fact, studies have confirmed that THR strategy implementation and use of smokeless alternatives “increases with financial incentives[11]” Canada, for instance, has gone as far as “reimbursing [non-combustible] products use through provincial drug insurance plans[12]”.

But a more common regulatory approach to accelerating the switch for adult smokers, who would otherwise continue to smoke, and reducing smoking rates entails an evidence-based, risk proportionate taxation of reduced-risk* alternatives. The taxation of reduced risk* alternatives according to the level of risk associated with the category, in comparison to cigarettes, presents a pragmatic approach to tobacco control that prioritizes harm reduction and positive public health outcomes. 

By recognizing the adoption of smokeless alternatives through sensible, risk-appropriate regulations, policymakers can enable adult smokers to make informed choices while reducing the overall incidence of smoking and the likelihood of lapsing back to conventional tobacco use.

Indeed, countries across the globe that have opted for regulations that secures the mass availability of reduced-risk* alternatives have produced noteworthy success stories. Japan was estimated to represent 85%[13] of global heat-not-burn (HNB) sales by 2018, resulting in the decline of cigarette sales from 197.5 billion units in 2011 to 93.7 billion in 2021[14]. Modern Oral products such as nicotine pouches also play a key role in the effectiveness of THR strategies, the success of which is illustrated by Sweden’s experience in transitioning to smokeless tobacco consumption. Since 2012, the country has seen an increase in snus and nicotine pouches consumption, resulting in a steady decline in smoking rates[15], and currently has “the lowest male smoking prevalence in Europe… of just 5% among Swedish men compared with the EU average of over 25%”[16]. Sweden is on track to declare themselves smokefree this year – defined as having fewer than 5% of daily smokers in the population – 16 years ahead of the 2040 EU target. This success, significantly ahead of the EU’s smoke-free goal, lies not only in the availability of smokeless nicotine alternatives but also in a regulatory environment that supports their use. 

The Middle East stands at a crossroads in its longstanding relationship with conventional tobacco. Traditional control measures are inadequate on their own, so legislation enabling acceptability, accessibility and affordability of smokeless nicotine alternatives and risk proportionate regulations is a critical component of a comprehensive tobacco harm reduction strategy. By adopting such measures, countries in the Middle East can reduce the health burden of conventional tobacco and pave the way for a better, smokeless tomorrow.

*Based on the weight of evidence and assuming a complete switch from cigarette smoking. These products are not risk free and are addictive.

Attributed to: Marwan Hamade, Head of Legal for BAT Middle East Cluster covering the following countries: KSA, Kuwait, Qatar, Bahrain, UAE, Iraq, Lebanon and Jordan. 

[1]Kargar S, Ansari-Moghaddam A, (2023), “Prevalence of cigarette and waterpipe smoking and associated cancer incidence among adults in the Middle East”. Available at: https://www.emro.who.int/emhj-volume-29-2023/volume-29-issue-9/prevalence-of-cigarette-and-waterpipe-smoking-and-associated-cancer-incidence-among-adults-in-the-middle-east.html

[2]Webster N (2024), “Action needed to halt two million smoking-related deaths by 2065”. Available at https://www.thenationalnews.com/health/2024/06/13/action-needed-to-halt-2-million-smoking-related-deaths-by-2060/

[3] TobaccoHarmReduction.net, “Benefits”. Available at: https://www.tobaccoharmreduction.net/benefits

[4] TobaccoHarmReduction.net, “THR: Lives saved”. Available at: https://www.tobaccoharmreduction.net/lives-saved

[5]Levy DT, at al. (2017), “Potential deaths averted in USA by replacing cigarettes with e-cigarettes”. Available at: https://tobaccocontrol.bmj.com/content/tobaccocontrol/27/1/18.full.pdf 

[6] Royal College of Physicians (2016), “Nicotine without smoke: Tobacco harm reduction”. Available at:

https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction

[7] McNeill A, Brose LS, Calder R, Bauld L, Robson D. (2018). Evidence review of e-cigarettes and heated tobacco products. A report commissioned by PHE. London: PHE. Vaping in England: evidence update February 2021

[8] World Health Organization, “Quitting tobacco”. Available at: https://www.who.int/activities/quitting-tobacco

[9] World Health Organization (2023), “WHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke”. Available at: https://www.who.int/publications/i/item/9789240077164

[10] We Are Innovation (2024), “Effective Anti-Smoking Policies Global Index”. Available at: https://antismoking.global/world-map

[11] Hoffer A, et al. Property Rights Alliance, International Best Practices for Tobacco and Nicotine Public Policy. Available at: https://www.propertyrightsalliance.org/wp-content/uploads/Final-International-Best-Practices-for-Tobacco-and-Nicotine-Public-Policy-White-Paper.pdf

[12]Ibid.

[13]Watase Y, (2023), “Safer Nicotine Works: The Cases of Japan and Sweden”. Available at: https://tholosfoundation.org/wp-content/uploads/2023/10/Tholos-Safer-Nicotine-Works.pdf

[14]Ibid.

[15] Yach D, et al. (2023), “Lives Saved: Available at: https://smokefreesweden.org/lives-saved.pdf

[16] BAT, “Modern oral”. Available at: https://www.bat.com/science-and-research/modern-oral