Sundheds- og Forebyggelsesudvalget 2013-14
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Statement from specialists in nicotine science and public health policy 
Dr Margaret Chan 
Director General 
World Health Organisation 
Geneva 
CC: FCTC Secretariat, Parties to the FCTC, WHO Regional Offices 
 
Dear Dr Chan 
Reducing the toll of death and disease from tobacco – tobacco harm reduction and the 
Framework Convention on Tobacco Control (FCTC) 
We are writing in advance of important negotiations on tobacco policy later in the year at 
the FCTC Sixth Conference of the Parties. The work of WHO and the FCTC remains vital in 
reducing the intolerable toll of cancer, cardiovascular disease and respiratory illnesses caused 
by tobacco use.  As WHO has stated, up to one billion preventable tobacco‐related premature 
deaths are possible in the 21st Century.  Such a toll of death, disease and misery demands 
that we are relentless in our search for all possible practical, ethical and lawful ways to reduce 
this burden.  
It is with concern therefore that a critical strategy appears to have been overlooked or even 
purposefully marginalised in preparations for FCTC COP‐6.   We refer to 'tobacco harm 
reduction' ‐ the idea that the 1.3 billion people who currently smoke could do much less harm 
to their health if they consumed nicotine in low‐risk, non‐combustible form.  
We have known for years that people 'smoke for the nicotine, but die from the smoke': the 
vast majority of the death and disease attributable to tobacco arises from inhalation of tar 
particles and toxic gases drawn into the lungs.   There are now rapid developments in 
nicotine‐based products that can effectively substitute for cigarettes but with very low risks. 
These include for example, e‐cigarettes and other vapour products, low‐nitrosamine 
smokeless tobacco such as snus, and other low‐risk non‐combustible nicotine or tobacco 
products that may become viable alternatives to smoking in the future. Taken together, these 
tobacco harm reduction products could play a significant role in meeting the 2025 UN non‐
communicable disease (NCD) objectives by driving down smoking prevalence and cigarette 
consumption.  Indeed, it is hard to imagine major reductions in tobacco‐related NCDs without 
the contribution of tobacco harm reduction. Even though most of us would prefer people to 
quit smoking and using nicotine altogether, experience suggests that many smokers cannot or 
choose not to give up nicotine and will continue to smoke if there is no safer alternative 
available that is acceptable to them.
 
We respectfully suggest that the following principles should underpin the public health approach to 
tobacco harm reduction, with global leadership from WHO: 
 
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26 May 2014 
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Statement from specialists in nicotine science and public health policy 
1.
Tobacco harm reduction is part of the solution, not part of the problem.  It could make a 
significant contribution to reducing the global burden of non‐communicable diseases 
caused by smoking, and do so much faster than conventional strategies. If regulators treat 
low‐risk nicotine products as traditional tobacco products and seek to reduce their use 
without recognising their potential as low‐risk alternatives to smoking, they are 
improperly defining them as part of the problem.  
2.
Tobacco harm reduction policies should be evidence‐based and proportionate to risk, and 
give due weight to the significant reductions in risk that are achieved when a smoker 
switches to a low risk nicotine product. Regulation should be proportionate and balanced 
to exploit the considerable health opportunities, while managing residual risks. The 
architecture of the FCTC is not currently well suited to this purpose.  
3.
On a precautionary basis, regulators should avoid support for measures that could have 
the perverse effect of prolonging cigarette consumption. Policies that are excessively 
restrictive or burdensome on lower risk products can have the unintended consequence 
of protecting cigarettes from competition from less hazardous alternatives, and cause 
harm as a result. Every policy related to low risk, non‐combustible nicotine products 
should be assessed for this risk. 
4.
Targets and indicators for reduction of tobacco consumption should be aligned with the 
ultimate goal of reducing disease and premature death, not nicotine use per se, and 
therefore focus primarily on reducing smoking. In designing targets for the non‐
communicable disease (NCD) framework or emerging Sustainable Development Goals it 
would be counterproductive and potentially harmful to include reduction of low‐risk 
nicotine products, such as e‐cigarettes, within these targets: instead these products 
should have an important role in meeting the targets. 
5.
Tobacco harm reduction is strongly consistent with good public health policy and practice 
and it would be unethical and harmful to inhibit the option to switch to tobacco harm 
reduction products. As the WHO's Ottawa Charter states: “Health promotion is the process 
of enabling people to increase control over, and to improve, their health”.  Tobacco harm 
reduction allows people to control the risk associated with taking nicotine and to reduce it 
down to very low or negligible levels.  
6.
It is counterproductive to ban the advertising of e‐cigarettes and other low risk 
alternatives to smoking.  The case for banning tobacco advertising rests on the great harm 
that smoking causes, but no such argument applies to e‐cigarettes, for example, which are 
far more likely to reduce harm by reducing smoking.  Controls on advertising to non‐
smokers, and particularly to young people are certainly justified, but a total ban 
would have many negative effects, including protection of the cigarette market and 
implicit support for tobacco companies. It is possible to target advertising at existing 
smokers where the benefits are potentially huge and the risks minimal. It is inappropriate 
to apply Article 13 of the FCTC (Tobacco advertising, promotion and sponsorship) to these 
products. 
 
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Statement from specialists in nicotine science and public health policy 
7.
It is inappropriate to apply legislation designed to protect bystanders or workers from 
tobacco smoke to vapour products.  There is no evidence at present of material risk to 
health from vapour emitted from e‐cigarettes. Decisions on whether it is permitted or 
banned in a particular space should rest with the owners or operators of public spaces, 
who can take a wide range of factors into account. Article 8 of the FCTC (Protection from 
exposure to tobacco smoke) should not be applied to these products at this time. 
8.
The tax regime for nicotine products should reflect risk and be organised to create 
incentives for users to switch from smoking to low risk harm reduction products. Excessive 
taxation of low risk products relative to combustible tobacco deters smokers from 
switching and will cause more smoking and harm than there otherwise would be. 
9.
WHO and national governments should take a dispassionate view of scientific arguments, 
and not accept or promote flawed media or activist misinterpretations of data.  For 
example, much has been made of 'gateway effects', in which use of low‐risk products 
would, it is claimed, lead to use of high‐risk smoked products.  We are unaware of any 
credible evidence that supports this conjecture.  Indeed, similar arguments have been 
made about the use of smokeless tobacco in Scandinavia but the evidence is now clear 
that this product has made a significant contribution to reducing both smoking rates and 
tobacco‐related disease, particularly among males. 
10.
WHO and parties to the FCTC need credible objective scientific and policy assessments with 
an international perspective. The WHO Study Group on Tobacco Product Regulation 
(TobReg) produced a series of high quality expert reports between 2005 and 2010.  This 
committee should be constituted with world‐class experts and tasked to provide further 
high‐grade independent advice to the WHO and Parties on the issues raised above. 
The potential for tobacco harm reduction products to reduce the burden of smoking related 
disease is very large, and these products could be among the most significant health 
innovations of the 21
st
 Century – perhaps saving hundreds of millions of lives.  The urge to 
control and suppress them as tobacco products should be resisted and instead regulation that 
is fit for purpose and designed to realise the potential should be championed by WHO. We 
are deeply concerned that the classification of these products as tobacco and their inclusion 
in the FCTC will do more harm than good, and obstruct efforts to meet the targets to reduce 
non‐communicable disease we are all committed to.   We hope that under your leadership, 
the WHO and FCTC will be in the vanguard of science‐based, effective and ethical tobacco 
policy, embracing tobacco harm reduction.  
We would be grateful for your considered reaction to these proposals, and we would like to 
request a meeting with you and relevant staff and a small delegation of signatories to this 
letter. This statement and any related information will be available on the Nicotine Science 
and Policy web site (http://nicotinepolicy.net) from 29 May 2014. 
Yours sincerely, 
 
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Statement from specialists in nicotine science and public health policy 
Signatories this statement at 26 May 2014  
Professor David Abrams
Professor of Health Behavior and Society.
The Johns Hopkins Bloomberg School of
Public Health. Maryland. USA.
Professor of Oncology (adjunct).
Georgetown University Medical Center,
Lombardi Comprehensive Cancer Center.
Washington DC.
United States of America
Professor Tony Axéll
Emeritus Professor Geriatric Dentistry
Consultant in Oral Medicine
Sweden
Professor Pierre Bartsch
Respiratory physician,
Faculty of Medicine
University of Liège
Belgium
Professor Linda Bauld
Professor of Health Policy
Director of the Institute for Social Marketing
Deputy Director, UK Centre for Tobacco
and Alcohol Studies
University of Stirling
United Kingdom
Professor Ron Borland
Nigel Gray Distinguished Fellow in Cancer
Prevention at Cancer Council Victoria
Professorial Fellow School of Population
Health and Department of Information
Systems
University of Melbourne,
Australia
Professor John Britton
Professor of Epidemiology;
Director, UK Centre for Tobacco & Alcohol
Studies,
Faculty of Medicine & Health Sciences
University of Nottingham,
United Kingdom
Associate Professor Chris Bullen
Director, National Institute for Health
Innovation
School of Population Health,
University of Auckland,
New Zealand
 
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Professor Emeritus André Castonguay
Faculty of Pharmacy
Université Laval,
Quebec,
Canada.
Dr Lynne Dawkins
Senior Lecturer in Psychology,
Co-ordinator: Drugs and Addictive
Behaviours Research Group
School of Psychology,
University of East London,
United Kingdom
Professor Ernest Drucker
Professor Emeritus
Department of Family and Social Medicine,
Montefiore Medical Center/Albert Einstein
College of Medicine
Mailman School of Public Health
Columbia University
United States of America
Professor Jean François Etter
Associate Professor
Institut de santé globale,
Faculté de médecine,
Université de Genève,
Switzerland
Dr Karl Fagerström
President, Fagerström Consulting AB,
Vaxholm,
Sweden
Dr Konstantinos Farsalinos
Researcher, Onassis Cardiac Surgery
Center, Athens, Greece
Researcher, University Hospital
Gathuisberg, Leuven,
Belgium
Professor Antoine Flahault
Directeur de l'Institut de Santé Globale
Faculté de Médecine, Université de
Genève, Suisse/ Institute of Global Health,
University of Geneva, Switzerland
Professor of Public Health at the Faculté
de Médecine, Université Paris Descartes,
Sorbonne Paris Cité,
France
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Statement from specialists in nicotine science and public health policy 
Dr Coral Gartner
Senior Research Fellow
University of Queensland Centre for
Clinical Research
The University of Queensland,
Australia
Dr Guillermo González
Psychiatrist
Comisión de Rehabilitación en Enfermedad
Mental Grave
Clínica San Miguel
Madrid,
Spain
Dr Nigel Gray
Member of Special Advisory Committee on
Tobacco Regulation of the World Health
Organization
Honorary Senior Associate
Cancer Council Victoria
Australia
Professor Peter Hajek
Professor of Clinical Psychology and
Director, Health and Lifestyle Research
Unit
UK Centre for Tobacco and Alcohol
Studies
Wolfson Institute of Preventive Medicine,
Barts and The London School of Medicine
and Dentistry Queen Mary University of
London,
United Kingdom
Professor Wayne Hall
Director and Inaugural Chair, Centre for
Youth Substance Abuse Research
University of Queensland
Australia
Professor John Hughes
Professor of Psychology, Psychiatry and
Family Practice
University of Vermont
United States of America
Professor Martin Jarvis
Emeritus Professor of Health Psychology
Department of Epidemiology & Public
Health
University College London,
United Kingdom
Professor Didier Jayle
Professeur d’addictologie
Conservatoire National des Arts et Métiers
Paris,
France
Dr Martin Juneau
Directeur, Direction de la Prévention
Institut de Cardiologie de Montréal
Professeur Titulaire de Clinique
Faculté de Médecine,
Université de Montréal,
Canada
Dr Michel Kazatchkine
Member of the Global Commission on Drug
Policy
Senior fellow, Global Health Program,
Graduate institute, Geneva,
Switzerland
Professor Demetrios Kouretas
School of Health Sciences and Vice Rector
University of Thessaly,
Greece
Professor Lynn Kozlowski
Dean, School of Public Health and Health
Professions,
Professor of Community Health and Health
Behavior,
University at Buffalo,
State University of New York,
United States of America
Professor Eva Králíková
Institute of Hygiene and Epidemiology
Centre for Tobacco-Dependence
First Faculty of Medicine
Charles University in Prague and General
University Hospital in Prague,
Czech Republic
Professor Michael Kunze
Head of the Institute for Social Medicine
Medical University of Vienna,
Austria
Dr Murray Laugesen
Director
Health New Zealand, Lyttelton,
Christchurch,
New Zealand
 
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Statement from specialists in nicotine science and public health policy 
Dr Jacques Le Houezec
Consultant in Public Health, Tobacco
dependence, Rennes,
France
Honorary Lecturer, UK Centre for Tobacco
Control Studies,
University of Nottingham,
United Kingdom
Dr Kgosi Letlape
President of the Africa Medical Association
Former President of the World Medical
Association
Former Chairman of Council of the South
African Medical Association
South Africa
Dr Karl Erik Lund
Research director
Norwegian Institute for Alcohol and Drug
Research,
Oslo,
Norway
Dr Gérard Mathern
Président de l'Institut Rhône-Alpes de
Tabacologie
Saint-Chamond,
France
Professor Richard Mattick
NHMRC Principal Research Fellow
Immediate Past Director NDARC (2001-
2009)
National Drug and Alcohol Research
Centre (NDARC)
Faculty of Medicine
The University of New South Wales,
Australia
Professor Ann McNeill
Professor of Tobacco Addiction
Deputy Director, UK Centre for Tobacco
and Alcohol Studies
National Addiction Centre
Institute of Psychiatry
King's College London,
United Kingdom
Dr Hayden McRobbie
Reader in Public Health Interventions,
Wolfson Institute of Preventive Medicine,
Queen Mary University of London,
United Kingdom
Dr Anders Milton
Former President of the Swedish Red
Cross
Former President and Secretary of the
Swedish Medical Association
Former Chairman of the World Medical
Association
Owner & Principal Milton Consulting,
Sweden
Professor Marcus Munafò
Professor of Biological Psychology
MRC Integrative Epidemiology Unit at the
University of Bristol
UK Centre for Tobacco and Alcohol
Studies
School of Experimental Psychology
University of Bristol,
United Kingdom
Professor David Nutt
Chair of the Independent Scientific
Committee on Drugs (UK)
Edmund J Safra Professor of
Neuropsychopharmacology
Head of the Department of
Neuropsychopharmacology and Molecular
Imaging
Imperial College London,
United Kingdom
Dr Gaston Ostiguy
Professeur agrégé
Directeur de la Clinique de cessation
tabagique
Centre universitaire de santé McGill
(CUSM)
Institut thoracique de Montréal,
Canada
Professor Riccardo Polosa
Director of the Institute for Internal
Medicine and Clinical Immunology,
University of Catania, Italy.
Dr Lars Ramström
Director
Institute for Tobacco Studies
Täby,
Sweden
 
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Statement from specialists in nicotine science and public health policy 
Dr Martin Raw
Special Lecturer
UK Centre for Tobacco and Alcohol
Studies
Division of Epidemiology and Public Health
University of Nottingham,
United Kingdom
Professor Andrzej Sobczak
Department of General and Inorganic
Chemistry,
Faculty of Pharmacy and Laboratory
Medicine,
Medical University of Silesia, Katowice,
Poland
Institute of Occupational Medicine and
Environmental Health
Sosnowiec,
Poland
Professor Gerry Stimson
Emeritus Professor, Imperial College
London;
Visiting Professor, London School of
Hygiene and Tropical Medicine
United Kingdom
Professor Tim Stockwell
Director, Centre for Addictions Research of
BC
Professor, Department of Psychology
University of Victoria, British Columbia,
Canada
Professor David Sweanor
Adjunct Professor, Faculty of Law,
University of Ottawa
Special Lecturer, Division of Epidemiology
and Public Health,
University of Nottingham,
United Kingdom
Professor Umberto Tirelli
Director Department of Medical Oncology
National Cancer Institute of Aviano
Italy
Professor Umberto Veronesi
Scientific Director
IEO Istituto Europeo di Oncologia
Former Minister of Health,
Italy
Professor Kenneth Warner
Avedis Donabedian Distinguished
University Professor of Public Health
Professor, Health Management & Policy
School of Public Health
University of Michigan
United States of America
Professor Robert West
Professor of Health Psychology and
Director of Tobacco Studies
Health Behaviour Research Centre,
Department of Epidemiology & Public
Health,
University College London
United Kingdom
Professor Dan Xiao
Director of Department Epidemiology
WHO Collaborating Center for Tobacco or
Health
Beijing Institute of Respiratory Medicine,
Beijing Chao-Yang Hospital,
China
Dr Derek Yach
Former Executive Director, Non-
Communicable Diseases
Former Head of Tobacco Free Initiative,
World Health Organisation (1995-2004)
Senior Vice President Vitality Group plc
Director, Vitality Institute for Health
Promotion
United States of America
 
 
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