## Effective Altruism ForumEA Forum

Global health and development

# 16

This post is a submission for Open Philanthropy's Cause Exploration Prizes contest. Big thanks to Andrew Cutler, Steve Hunter, Adam Jacobi, Jonathan Lansey, and Violeta Vicario for their many helpful suggestions!

# Summary

Cigarette smoking kills millions of people every year. We spend a lot of money trying to reduce this number, but much of it is ineffective because we’re focused on getting people to stop doing something they enjoy. It’s demonstrably better to help them use products they would like just as much as cigarettes, but don’t cause health problems. Most of the alternatives involve ingesting nicotine without burning tobacco, and donors have an opportunity to (1) advocate for removing restrictions on them, (2) inform consumers that they’re available and safer; and (3) fund innovation to improve them.

# What is tobacco harm reduction?

While the definition of harm reduction is contested, this document will use the phrase in the sense articulated by Shaun Shelly: "meeting people where they are at, without judgment, and helping them achieve their drug use aims (including abstinence) in the way that causes the least harm to them, irrespective of the current legal and policy framework." I will use the phrase "tobacco harm reduction" (THR for short) to refer to the application of this approach to the use of both tobacco and nicotine products.

As tobacco researcher Michael Russell famously stated in a 1976 article in the British Medical Journal, “people smoke for nicotine but they die from the tar.” Accordingly, the majority of effective THR methods and the efforts to promote them involve the ingestion of nicotine without the combustion of tobacco. They include the use of heat-not-burn (HNB) devices which warm tobacco leaves without burning them, liquid-based vaping devices that aerosolize a solution of nicotine in propylene glycol and/or vegetable glycerin (also called e-cigarettes), smokeless oral tobacco products like snus, and pharmaceutical nicotine sources like gum and lozenges.

# Importance

Tobacco smoking has been identified by 80,000 Hours as taking an "enormous toll on human health," causing more deaths per year than HIV, malaria, and tuberculosis combined. The health effects of smoking are also an increasing problem in some parts of the world, as smoking prevalence is on the rise in a number of countries and the total number of daily smokers in the world was estimated to exceed 1.1 billion for the first time in 2019. Several million of them die due to its effects every year.

While most policies around tobacco focus on efforts to reduce supply and demand for all tobacco products, harm reduction is also enshrined in the WHO Framework Convention on Tobacco Control, the largest supranational agreement related to tobacco. It defines tobacco control as a “range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke.” Prominent EAs have also supported THR. For example, Robert Wiblin has publicly expressed his view that the “idea that vaping isn't vastly vastly safer than smoking is among the most personally harmful falsehoods a person can believe.”

In practice, however, the WHO, while promoting certain THR tools (for example, by including nicotine gum and patches in its Model List of Essential Medicines) expends significant resources on opposing others, including public misinformation on the risks of e-cigarettes, awards to officials implementing vaping bans in developing countries, and recommendations against the use of smokeless oral tobacco.

In parallel, some of the best-funded philanthropic organizations attempting to address health problems related to smoking also neglect or are openly hostile to THR. The largest of these is Bloomberg Philanthropies, which in 2019 committed $160 million to a campaign against flavored e-cigarettes used by millions of vapers worldwide, and has not made any comparable investments in promoting THR to current smokers. Inaccurate perceptions of the risks of nicotine in both the general population and among doctors specifically both result from and drive hostility to THR. More than 80% of doctors surveyed in one recent study falsely claimed that nicotine causes cardiovascular disease, COPD, and cancer. Among the general population, the US National Cancer Institute’s HINTS survey indicates fewer than 20% of Americans think e-cigarettes are less harmful than combustible cigarettes. # Tractability There are several examples of countries where high prevalence of THR has had a direct and significant effect on the prevalence of smoking and smoking-related illness. Two of the clearest examples come from Sweden and Japan. Sweden, at 7%, currently has the lowest rate of smoking in the European Union, less than ⅓ of the EU average of 23% and about half of the country with the next-lowest prevalence, The Netherlands at 12%. Sweden is also the only country in the world where women smoke more than men. The overall rate of tobacco use in Sweden is similar to other countries in Europe, as is the percentage of women who smoke. The main difference is that the majority of male consumers use snus, a smokeless, steam-pasteurized, non-carcinogenic oral product banned in the rest of the EU. Sweden thus has Europe’s lowest male death rate from tobacco-related diseases including lung cancer. Japan has had one of the largest declines in cigarette smoking rates in the past decade of any country in the world, going from about 21% to 13% between 2012 and now. The total number of cigarettes sold has also seen a massive recent drop, going from 43 billion to 25 billion between 2016 and 2021. Tobacco control policies in Japan are similar to those of other wealthy countries that haven’t seen declines of this magnitude, and there has been no significant change in tobacco control policies during this period. What is different about Japan as compared to other wealthy countries is that it was the first place tobacco companies introduced the latest iteration of heat-not-burn (HNB) products such as Philip Morris’ IQOS, and continues to be the largest market for them, claiming about 85% of global sales in 2018. As a result, HNB now makes up nearly 30% of tobacco sales in the country. While the shift is too recent for a significant amount of evidence on health outcomes to have accumulated, although the extensive data the company submitted to FDA in the US led it to conclude that heating instead of burning “significantly reduces the production of harmful and potentially harmful chemicals” and authorized the company to accordingly make marketing claims about reduced exposure. In the USA, there has also been a strong correlation between the popularity of THR and the drop in smoking. While there has been neither a decades-long cultural shift toward smokeless use, as in Sweden, nor a large industry deliberately promoting new products, as in Japan, the introduction of the first e-cigarette in 2007, the increasing availability of open-system vaping devices, and the proliferation of vape shops selling e-liquid and accessories has led to an increase in vaping prevalence to about 6% of the total population in 2021. Vapes and cigarettes are economic substitutes; particularly among young people, a dramatic rise in vaping has closely accompanied a drop in smoking. # Neglectedness Smoking-related illness is not a neglected issue in global health in general, nor among EAs specifically. In the USA, state governments spent over$700 million on smoking-related efforts in the most recent fiscal year and the Centers for Disease Control provides over $1 million in annual funding for tobacco control to every state. Globally, Michael Bloomberg and Bill Gates pledged a combined investment of$500 million to fighting “the tobacco epidemic” in 2008. The World Health Organization lists tobacco as a top-level health topic and the first international treaty it negotiated (the aforementioned Framework Convention on Tobacco Control) was on this subject and ratified by 181 countries. 80,000 Hours has a problem profile specifically about smoking in the developing world.

However, very few of the efforts funded by governments and philanthropists support any form of THR. In fact, all of the non-EA organizations mentioned above have taken steps actively opposing it. Federal agencies, state legislatures, and local governments in the USA have promulgated regulations to restrict smoke-free products. The CDC has confused consumers about an outbreak of lung illnesses caused by Vitamin E Acetate in black market cannabis products, leading to wildly incorrect risk perceptions about nicotine vaping. Bloomberg recently earmarked another \$160 million exclusively for efforts related to restricting the use and advertisement of e-cigarettes. The WHO has been criticized by the former tobacco control VP of the American Cancer Society, among many others, for their “efforts to destroy the one version of harm reduction whose potential far surpasses that of all others.”

The parties promoting THR consist mainly of two groups: businesses selling lower risk nicotine and tobacco products and consumer organizations advocating for the rights of their users.

Businesses include large tobacco companies like Swedish Match, the largest manufacturer of snus, and Philip Morris International, which has spent significant funds setting up and funding a foundation specifically to promote non-combustible products. Consumer and pharmaceutical businesses like GlaxoSmithKline and Johnson & Johnson, makers of nicotine replacement therapy products, have generally stayed away from public lobbying (although they did sponsor a yacht racing team). Vape device manufacturers, e-liquid makers, and retailers, many of whom belong to a trade group, the American Vapor Manufacturers Association and are active in efforts to fight restrictions on the products they sell. Most consumer organizations operate at the national level and belong to an international group, the International Network of Nicotine Consumer Organizations (INNCO).

While each of these organizations have contributed to harm reduction efforts, they are often constrained by either reputational concerns, as many policymakers and philanthropists are either unwilling to engage or have specific policies against engaging in discussions with representatives of the tobacco industry, or funding issues, as THR is not a prominent cause even within harm reduction circles. For example, Harm Reduction International’s Global State of Harm Reduction 2020 report, one of the most comprehensive annual publications of its kind, does not mention tobacco at all in its nearly 200-page text.

# Areas of Funding

There are several ways donors could support the promotion of THR. Three of the most promising avenues are advocacy, education, and research. I will not be recommending specific existing partners and projects as this exploration didn’t focus on evaluating their effectiveness, but will mention a few potential fundees in each area as a starting point for future exploration.

In the world of advocacy, the primary battleground in the past decade has been on laws regulating the use of e-cigarettes. National legislatures have enacted restrictions of various levels: full bans in Brazil, India, and Mexico; flavor bans in The Netherlands and a number of US states; prescription-only status in Australia. On the more permissive side of the ledger, The Philippines passed a law supported by consumers this year after furious lobbying and allegations of illegal donations to its Food and Drug Administration from the Bloomberg Foundation; the UK is considering abandoning the ban on snus now that Brexit allows it to diverge from the EU’s Tobacco Policy Directive. There are ongoing debates about regulation in many other countries, giving funders an opportunity to support efforts to enact pro-THR policies. Some of the existing organizations working on projects in this area include INNCO, CASAA, and AVM.

The importance of the dissemination of more accurate information about product risks, to key decision makers and to the general public, is crucial to building legitimacy for pro-THR regulations. Legislators can be convinced to change their minds and advocate for liberalizing regulations they themselves passed before they learned more about the subject.

Even more importantly, there’s a huge opportunity to inform smokers that THR exists and that it works. Some modeling on the effects of the initial information shock from the Surgeon General’s 1964 report on smoking suggests that this shock and subsequent social contagion caused most or even all of the subsequent reduction in smoking. By the same token, better-informed smokers can more easily make decisions that benefit their health. Simple websites with clearly presented information in New Zealand and the NHS in the UK can serve as a model for effective outreach. Filter Magazine serves as an independent media organization funding investigative journalism on harm reduction, and devotes regular space to THR. Attention Era Studios produced the feature films A Billion Lives and You Don’t Know Nicotine, both of which managed to attract significant media attention including appearances by the director on South Africa’s largest public broadcaster and CNBC. Knowledge Action Change funds the Global State of Tobacco Harm Reduction, a comprehensive overview of the regulatory landscape and public health impacts of THR.

Finally, while non-combustible products have been around much longer than cigarettes, there is still room for innovation in the products themselves, as was made obvious by the explosive growth of vaping technology in the 21st century and the rapid changes in batteries, form factors, and e-liquid formulations. Donors could support further research into compelling alternatives to combustible products both through innovation in existing products and exploration of entirely new product categories.

# A Note on Health Effects

A major crux of any discussion of THR is the health effects of various non-combustible nicotine and tobacco products, both in absolute terms and in comparison to those of cigarette smoking. It’s challenging to establish confident conclusions as a layperson due to the highly politicized history of the research around this question. Awareness of the strategy of extensive deception by cigarette manufacturers that began in the 1950’s is widespread - one of the best resources on the details of this topic is Allan Brandt’s The Cigarette Century. The extensive exaggeration of the risks of various forms of tobacco use - beginning with one of the earliest and most entertaining, King James VI’s A Counterblaste to Tobacco written in 1604 - is less well known, but no less relevant, as societal taboos surrounding the use of psychoactive substances have led to many shaky claims that aren’t based on credible evidence. The conclusions of epidemiological research on cigarette smoking like the British Doctors Study by Doll and Hill in 1951 demonstrating a causal link between smoking tobacco and lung cancer have been repeatedly confirmed. However, recent work has debunked commonly believed and widely disseminated claims about oral cancer and chewing tobacco, vaping and popcorn lung, and heart attacks and second hand smoke.

Due to the time necessary to properly explore this topic, this cause area overview doesn’t focus on detailed arguments about health effects of noncombustible products. However, two fairly uncontroversial claims can be made:

1. Inhaling concentrated smoke from burning plant matter is the cause of almost all health problems associated with smoking. This involves the well-understood carcinogenic effects of polycyclic aromatic hydrocarbons created by combustion and the effects of various components of smoke on mucociliary clearance and other defense mechanisms in the lung.
2. Research so far has failed to discover any causal link strong enough to shift our priors from “no effect” between the use of a currently available noncombustible product and a specific disease involving both a proposed biological mechanism and population-level correlation, as is the case for combustible products.

A number of utility calculations in the spirit of the EA “shut up and multiply” ethos have been attempted by economists and public health researchers. Even under fairly pessimistic assumptions, they indicate that promotion of THR is a net benefit under a wide range of assumptions, even for those skeptical of the two claims above. Estimates range from millions to tens of millions of QUALYs gained in the next few decades in the USA.

The assumptions made even in the optimistic scenarios of the analyses linked assume non-zero harms from the use of non-combustible products. It’s very plausible that some or all of them not only have no measurable harms, but confer a net health benefit, as downsides may be more than offset by the effects of nicotine on cognition and mood that could stave off the symptoms of mild cognitive impairment and Alzheimer’s disease. In this regard, tobacco may be more analogous to tea or coffee than to alcohol, despite being closer in the regulatory framework and cultural context to the latter.

# Potential Objections

While I find the reasons to fund pro-THR work convincing, below are some possible reasons one could think it’s not a good use of a donor’s money and attention.

## Objections to neglectedness

1. The large companies and governments currently selling cigarettes have an incentive to promote THR so that they are no longer selling deadly products. In some cases (e.g. PMI developing and marketing IQOS) they have already committed significant resources to this effort. They are well-connected enough to overcome regulatory barriers and have arguably captured, at least in part, some of the institutions posing the biggest roadblocks, like FDA in the US. Additional funding from EA-affiliated sources may not significantly affect the timeline of this transition.

## Objections to tractability

1. Governments benefit extensively from cigarette sales - the largest tobacco company in the world is the China National Tobacco Company, fully owned by the Chinese state - and it may be too difficult and costly to influence their decisions.
2. Taboos around psychoactive substances are as old as their use by humans. Similarly to the prohibition of other stimulants like cocaine or opiates like heroin, the impulse to prohibit may be too deeply rooted in feelings of sacredness, disgust, and in-group/out-group distinctions to be intentionally dislodged by arguments about health. The dynamic is similar to that of the larger “drug war.”
3. Many in the public health and medical fields  regard THR as illegitimate because it’s a non-medical solution to a problem they frame as a medical issue; in Carl Phillips’ words, “Those who spent their careers trying to get people to stop smoking [...] resent the possibility of smoking being substantially reduced in spite of their efforts rather than because of them.” It may be too difficult to overcome this bias enough to shift opinions noticeably.
4. Where most successful, THR has often been more an organic social phenomenon spread through social networks than a formal medical intervention. It may be too difficult to discover and implement a specific, repeatable set of actions that accelerates its growth.

## Objections to importance

1. If new research discovers currently unknown health risks, the utility calculation could shift and estimates may need to be revised, perhaps even to the point where THR promotion becomes a net negative. If this ends up being the case, organizations funding such promotion could suffer reputational harms from being perceived as recklessly pushing dangerous behaviors.
2. Utility calculations assume that THR promotion results in a net reduction in the use of combustible products. This assumption could be wrong, and the gateway effect to smoking could outweigh the reduction in combustible use from people that switch to smokeless products. (I don’t find this and the previous point very convincing, but they are both pretty commonly argued - see a more detailed response.)

# 16

New Comment

I think you would need to engage much more fully with gateway effect arguments. Those arguments are strongly proposed by some domain experts, and bear directly on the intervention (Becky Freeman's work was my introduction - but here's a systematic review and meta-analysis). The rates of those who go from no-smoking-->e-cigarettes-->smoking are significant. Even if they are smaller than the rates of those who go from smoking-->e-cigarettes-->no-smoking, they would reduce the overall benefits of THR. And they are especially concerning when considering effects on adolescent cohorts (here's another systematic review and meta-analysis).

The response you cite is from an org with ties to tobacco companies,  by an author who is substantially funded by tobacco companies. I think a higher degree of scepticism is warranted. Also,  consider the strategic implications: would Phillip Morris be pushing so hard in the area if they thought e-cigarettes led to dramatic rates of smoking cessation?

Thanks for taking the time to read and comment, and sorry I didn't see this earlier! You bring up a couple of really interesting points that I'll try to respond to separately.

Gateway effects

There are a couple of reasons I'm unconvinced by the gateway hypothesis, i.e. that the observed correlation between non-combustible use and subsequent smoking implies that the growth of the former is causing an increase in the latter.

An alternative explanation is that lack of adjustment for confounders ('common liabilities' between vapers and smokers, like living with family that smokes, smoking peers, or a higher propensity for risk-taking) is what drives the majority of the observed correlation. The meta-analysis on vaping that you linked makes exactly this point: they reviewed 11 original studies on the association between vaping and subsequent smoking, and found that only two of them made comprehensive adjustments for key confounders, with one of these having other serious methodological errors, and the last one showing a small effect size. Thus their conclusion is that "while there is evidence of a relationship between vaping and subsequent smoking, there is much less conclusive evidence for a gateway effect."

If the gateway effect were significant, I’d also expect this to eventually show up in population-level data. Of course, this may be masked by other factors that are causing drops in the smoking rate at the same time, but attempts to detect the first while controlling for the other in England and the US haven't turned up much so far. I haven't seen a lot of data on other countries.

Finally, and this is a more informal point, no clear and plausible causal mechanism comes to (my) mind for why someone who wouldn't otherwise have become a regular smoker would become one after and due to use of a non-combustible product. If I enjoy snus, lozenges, or vaping, why would I switch to a more expensive product with a much worse health impact?

Bias

I agree that this is a field where an unusually high degree of skepticism of claims is warranted. Because of the amount of money and lives at stake, many of the people doing research have strong feelings and/or financial incentives related to the policy implications of their findings; or they enter the field specifically because of an opportunity for funding or a preexisting belief about the danger or opportunity presented by non-combustible products. As Andrew Gelman puts it, "Tobacco research is a mess, and it’s been a mess forever."

That said, If we were to disregard the work of everyone with some sort of conflict of interest, I don't think there'd be a lot left to read, so I generally try to take a trust-but-verify approach. For example, Carl Phillips has received tobacco industry funding, but the article I linked doesn't present original data but a logical argument I can follow and identify holes in, and the factual claims can be checked against other sources. Becky Freeman is a strident advocate for increased regulation of both combustible and noncombustible tobacco and a protégé of Simon Chapman, who has repeatedly stretched the truth both with regard to the risks and benefits of snus and vaping. Tobacco Tactics, the organization whose articles you linked, receives funding from Michael Bloomberg, who has led global efforts to ban flavored vaping and made numerous exaggerated statements about vaping. I don't think these biases should disqualify the evidence either of them present from being taken into account, as long as their factual claims are thoroughly checked.

Tobacco company strategy

I think PMI's actions are pretty consistent with an established business responding to the emergence of a disruptive new product cannibalizing sales of its existing one. They initially worked to shut upstart competitors out of the new market through regulation in their support of the PMTA process. They've since acquired innovative competitors in the vaping space like Juul and are trying to purchase the largest snus producer. Non-combustible products accounted for 30% of their revenue in the first half of 2022, and this percentage has been growing for years. As this shift continues, it makes more and more sense for them to continue to lobby for broader accessibility.

In addition, I'd speculate that while companies like PMI don't want to say so out loud, they recognize that the total addressable market for tobacco could grow substantially if health concerns are alleviated. Not that long ago, almost half of the adult US population used tobacco, and many of the people that stopped since then did so mainly because of those concerns, so the non-combustible market could be even bigger than the cigarette market ever was.

edit: typo

Thanks for such a detailed and considered reply!

I agree that a gateway effect in adolescents is unclear due to confounders. I think this uncertainty should motivate caution though, rather than a conclusion that the gateway effect is non-existent. What are your thoughts on the Adermark et al. (2021) systematic review?

I wouldn't expect a clear pattern to arise in population data due to the opposing factors driving rates down, which you mention. However, those time-series on the U.S. and U.K. have led me to decrease my credence, so thank you for pointing me to them!

I confess that on the mechanism point, we appear to have completely opposing intuitions. I think there are very plausible social patterns that could be at work. A 13 year old vaping because some of her friends vape would be easy; smoking because some of her friends smoke less so. At 15, if she had been vaping for 2 years she would have experience buying, owning, sharing, and using tobacco and/or nicotine products - I would think it there would be much less of a barrier to her starting to smoke occasionally and then consistently, compared to the case where she never vaped. But these are just contrasting intuitions we have - maybe we could look into qualitative studies to calibrate ourselves better.

On bias, thanks for illustrating that the picture was more complex than I originally thought. However, I think I want to push back strongly on the idea that those pushing regulation have bias similar to those pushing against. Tobacco companies have an extremely strong financial motive, bordering on existential. Bloomberg, Freedman, Chapman, and others don't have that motive, so far as I can tell. Your points about them mainly point to the fact that they have been pro-regulation for some time and at some volume, which shouldn't be surprising, and perhaps with some methodological flimsiness. That flimsiness would be concerning, but I think it's a quite different concern to the tobacco industry's bias.

That's a fair point that you were convinced by Philips' arguments rather than his credentials or history.  But I think in a report arguing for substantive action,  and concerning a major counter-argument, it would have been better to explain and defend those arguments rather than just linking to them and saying that you found them persuasive. However, that's a point of form and  other readers may think differently.

Your final points on tobacco company strategy are interesting and thought-provoking. I certainly feel less resilient on my original point, especially since I don't know corporate strategy well. On reflection, I think I am perhaps quite cynical, though I'd argue that cynicism is justified. Phillip Morris' ideal world would be one with much more vaping and smoking, and their history in causing and then hiding millions of deaths has made me view them with great distrust.

Thanks again for your substantive and thoughtful reply, I think it's likely my beliefs on this will shift with time!

I am glad you addressed my concern by going over the health effects of nicotine distinct from plant combustion/smoke. I particularly liked your line about "tobacco may be more analogous to tea or coffee than to alcohol." But I am unconvinced that this addictive substance has a net positive effect on well being.

My impression is that, much like caffeine, the body acclimates and suffers withdrawal without regular doses. Additionally, to get the same effect, an increasing treadmill of doses is required. This withdrawal and dependence seems to leave the user worse off than they were before substance use, (jittery, anxious, irritable) unless the use is regulated and occasionally paused. This is exceptionally hard with addictive substances.

In the case of caffeine, I have heard it argued that even if you arrive at the same net outcome of awareness, productivity and happiness total, there is a lot of utility in being able to control when one is awake, productive, and happy.  This makes sense to me. But I don't think nicotine allows that same control except for a few abnormal individuals. Rather, I expect abuse and over-dependence to be the normal state of affairs. This seems net negative. Even if it had a neutral effect, people would still be spending money to maintain neutral utility.

Non-addictive nicotine would change my mind, and I would be potentially interested to apply it in my own life.

Thanks for reading and commenting! I've deliberately avoided the term "addictive" in this discussion, as usage of the term in both formal and informal discussions is so broad and loose that I've found it to be more confusing than illuminating. Phillips has a couple of wordy but informative discussions arguing that the word is more like the opposite of an applause light than a term that cleaves reality at its joints.

I'm not aware of much evidence that nicotine use is harder to control than caffeine use in the sense you describe. If anything, the fact that 80% of people in the US use caffeine daily and only about 15-20% use nicotine seems to point in the opposite direction, although there are obviously many other factors affecting those numbers.

Also, I think the utility calculation on whether the promotion of THR is net positive and cost-effective is pretty robust to changes in the net effect on a potentially larger group of new non-combustible users, even if that net effect is negative. This is mostly because the health costs of combustible use are so high. In other words, as long as there's a reasonable substitution effect (lots of smokers dropping smoking as they start using other products), it likely outweighs the net harm to non-smokers that start using non-combustibles.

Just want to circle back around and say that I appreciate your points and have updated to be more in line with your position. I am still unconvinced by your strongest claims, but agree with most of the base assertions. For example I think nicotine is a lot less addictive and abuse is much less harmful than I previously thought. Some minor points that contributed to causing me to re-evaluate:

1. All the users who had self control to stop due to cancer warnings/social stigma did stop; leaving those with worse self control to continue making cigarettes look much more addictive on average than they necessarily are.
2. Comparing the community of users with other communities: Highly addicted smoker's lives are not falling apart, unlike other addictive substance users.

Now my support hinges on a complicated calculus over how many and how bad the most abusive users are, how good and general the positive use is, how cheap combustibles are versus cartridges, and other specifics. But in principle we now agree.