The RCP got this right: Promotion of tobacco harm reduction is playing right into the tobacco industry’s hands

I previously published three detailed critiques of the 2024 UK Royal College of Physicians report E-cigarettes and Harm Reduction: An Evidence Review for being an incomplete and selective review of the literature in three areas — underestimating the magnitude of disease risk caused by e-cigarettes, ignoring the large body of real world evidence that e-cigarettes as consumer products are not associated with stopping cigarettes, and ignoring or downplaying the risks of nicotine beyond addiction. In contrast to the rest of the report, the Chapter 9: Tobacco industry interests, recent conduct and claims around harm reduction provides a cogent summary of why the industry uses harm reduction claims to protect and promote its interests and how e-cigarettes help maintain and expand industry profits at the expense of health.

Here a a few highlights:

Internal industry documents reveal that, at each stage, TTCs’ [transnational tobacco companies’] interest in ‘new’ products was never genuinely driven by harm reduction priorities, but rather by a desire to generate new users and sources of profit, to increase sales and to rehabilitate the tobacco industry’s reputation (Table 9.1). [page 191]

…

The timing of TTC investments [in e-cigarettes] coincides with a period when the tobacco industry and its primary product – the cigarette – were arguably under greater threat than in previous decades. Implementation of tobacco control policies had been advancing around the world and since at least 2000, smoking prevalence rates had been steadily declining. More worryingly for the industry, the retail value of cigarettes (a proxy for profitability) had also begun to fall (Fig 9.5). [page 196]

…

TTCs are now reporting to investors that e-cigarettes and HTPs represent significant growth opportunities, serving to expand, rather than substitute, revenue from declining
cigarette sales. … It also highlighted the importance of poly-use to the TTCs’ bottom line because it maximises their ‘revenue per consumer’. TTCs also sell e-cigarettes and HTPs in bundles, thereby encouraging poly-use.

Such patterns are consistent with evidence from tobacco industry documents that reveal the TTCs’ real interests in potentially reduced risk products. Dating back to the 1970s, industry documents explicitly state that such products could work as a viable long-term business strategy only if they were to enable TTCs to recruit new users rather than merely replace existing smokers.

For example, in the 1970s and 1980s, BAT documents demonstrate that interest in new smokeless tobacco products was driven by a desire to attract new young users who otherwise would not have initiated smoking due to health-related concerns. Similarly, PMI’s
documents from the 1990s reveal that its motivation behind developing a device that closely resembles the modern-day e-cigarette was to maintain and possibly extend nicotine addiction in the context of ‘a declining US market, the growth of smoking restrictions … and a marked decline in social acceptability of the smoking experience’. Ultimately, however, PMI abandoned this research due to concerns that this development could lead to further regulation of smoked tobacco products. Furthermore, leaked documents from PMI detailing its 10-year strategy to 2024 highlight the company’s underlying motivations behind investing in ‘reduced risk products’ including to ‘drive future growth’, ‘normalise’ the company’s image and allow it to shape regulation in its own interests.

9.4.2 Tobacco industry capture of harm reduction

Such plans are, of course, inconsistent with genuine harm reduction – a public health concept that involves reducing harm from addictive behaviours by reducing harm for the individual user and for the community and society in which they live. In tobacco control, harm reduction, as conceived by public health, would therefore involve shifting current smokers who were unable to quit to lower-risk products, but would not encompass using reduced-risk products to drive product use among nicotine naïve consumers who would otherwise not have taken up smoking. Genuine harm reduction is not, therefore, a longterm, sustainable business model for TTCs: once the current generation of smokers and former smokers dies, there are fewer and fewer potential new consumers. [page 199-200] [emphasis added, citations dropped]

While Chapter 9 is cross-referenced through the rest of the report, the obvious implication that RCP’s promoting e-cigarettes is helping the tobacco industry go unheeded. The simple reality is that health forces cannot skate along next to the industry and not have the tobacco industry’s much larger and more sophisticated presence dominate the situation.

Indeed, the RCP recognizes that UK’s embrace of e-cigarettes has contributed to an overall decline in industry resistance:

The need to de-normalise the tobacco industry and protect public policy from tobacco industry interference in line with Article 5.3 of the Framework Convention on Tobacco Control (FCTC) is more important than ever; the decline in the UK’s position in the Global Tobacco Industry Interference Index indicates that this is a key issue in the UK. [page 190] [emphasis added]

The RCP recognizes that the tobacco companies are effectively using England’s pro-e-cigarette policies to promote its position around the world: “TTCs, often via their allies and front groups, have been actively promoting the UK approach to harm reduction as an exemplar model that other governments should follow. [page 203; emphasis added, citations dropped]

Finally, the RCP highlights the importance of following FCTC Article 5.3 with regard to e-cigarettes and the tobacco companies’ other purportedly “harm reduction” products:

Our findings also highlight that the need to continue to protect the policymaking process from the commercial and other vested interests of the tobacco industry, as enshrined in Article 5.3 of the WHO FCTC, remains a priority. This situation may therefore require implementation of measures beyond those recommended in the original set of guidelines on Article 5.3 of the WHO FCTC, as reflected in the COP 6(9) 2014, COP 7(9) 2016 and COP 8(22) 2018 decisions. The COP 6 and COP 7 decisions invited parties to consider:

> taking certain measures to protect tobacco control activities from all commercial and other vested interests related to ENDS/ENNDS (electronic nicotine delivery systems / electronic non-nicotine delivery systems), including interests of the tobacco industry ensuring that Article 5.3 (and its eight guideline recommendations) are respected when developing and implementing e-cigarette legislation and regulations.
> The COP 8 decision further reminded parties that ‘their commitments under the WHO FCTC’ extended beyond ENDS to ‘emerging tobacco products such as heated tobacco products […]’. [page 203] [citations dropped]

In sum, experience since the introduction of e-cigarettes, heated tobacco products, pouches and other similar products has shown that, as the tobacco companies hoped when they started developing these products decades ago, the nicotine market has expanded by attracting include millions of kids at low risk of initiating nicotine use with old-fashioned cigarettes, displaced effective cessation interventions for adults and promoted adult dual use.

The bottom line: an increase — not a reduction — in overall harm.

It’s time for authorities, including the RCP and NHS in England and the FDA in the US, to accept this reality and change their policies to base them on reality, not wishful thinking.