Experts lead the discussion during the 5th Global Forum on Nicotine in Warsaw.

A GFN participant explains the difference between cigarette and heat-not-burn tobacco product.

A small electronic device invented by a Chinese pharmacist in 2001 is now being viewed as the human race’s best hope to end smoking, while dividing healthcare professionals and disrupting the cigarette industry. Around 500 healthcare experts, researchers, academicians, consumers, vaping advocates, parliamentarians and even tobacco executives from 60 countries gathered together under one roof in Warsaw, Poland to push for the regulation of electronic cigarettes, heat-not-burn devices, Swedish snus and other low-risk non-combustible smokeless tobacco products that they say could save millions of smokers from premature death globally. “Vaping is 95-percent less harmful than smoking,” Dr. Joe Kosterich, an Australian doctor, says during the 5th Global Forum on Nicotine held at Marriott Hotel in Warsaw on June 14 to 16. The Public Health England reported in 2015 that e-cigarettes are 95-percent less harmful than smoking, as the harmful chemicals present in cigarette smoke are either not in EC vapor or only found at much lower levels. Vaping is an act of inhaling and exhaling the vapor produced by an e-cigarette—a battery-operated device which vaporizes a flavored liquid made of water, nicotine, propylene glycol, glycerol and flavorings. Sarah Jakes, a UK-based consumer group representative, says vaping is equally pleasurable but less risky than the traditional burning of cigarettes. Unlike traditional cigarettes, vapes or e-cigarettes are heated and thus do not produce tar which is harmful. Dr. Colin Mendelsohn of the University of New South Wales in Australia says the addiction to vaping is not as strong as it is to smoking. “More importantly, what it achieves is it removes the harm from smoking. You remove the harm by taking away the smoke. What kills people is the smoke. The nicotine is relatively harmless. It is what people get addicted to, but it has relatively minor health effects,” he says. “The tobacco harm reduction is about eliminating the harm. It is not about necessarily eliminating nicotine. We are not too worried about the nicotine. We just want to stop the smoke which could kill them. And the e-cigarettes give them the hand-to-mouth behavior and the nicotine they want and the whole smoking experience, without the smoke and the risk,” says Mendelsohn. While some scientists and experts support vaping as a harm reduction tool, the World Health Organization, along with health ministries and medical associations in many countries refuse to endorse e-cigarettes.Armando Peruga, who has two decades of experience in tobacco control, is quoted on the WHO website that “these devices have become popular over the last four or five years, so there are only a few studies on the health risks and we don’t know the long-term effects.” In response, Kosterich says there is sufficient evidence to say that vaping is much safer than smoking. “If we wait 20 years to find out and do the epidemiological studies, a lot of people would have died unnecessarily. Do we need to have an absolute proof for something that is really quite obvious now…People will lose years of their lives, and people will die while we are waiting,” he says. Gerry Stimson, a public health social scientist and an honorary professor at the London School of Hygiene and Tropical Medicine, says conventional medical treatments have a huge failure rating. “Nicotine replacement therapy for example has about 5 percent success rate or 95 percent failure rate,” he says. David Sweanor, a law professor at University of Ottawa, says that without a better option, millions will have premature deaths because of smoking. “The WHO tells us that based on current trends and consumption, we can expect about a billion deaths this century as a direct result of inhalation of tobacco. Currently, there are over 7 million deaths annually or 21,000 people die each day. So the idea that some of us in wealthy countries have solved this problem is very far from the truth,” he says. Sweanor says there are a billion smokers worldwide, while tobacco companies generate $800 billion in annual sales.Mendelsohn says many of his patients who tried medication to quit smoking eventually failed. “E-cigarettes are illegal in Australia. That’s the problem. Nicotine is illegal to possess in Australia without a prescription. You can’t have nicotine for vaping to help you stop smoking, but you can buy cigarettes with nicotine everywhere which is much more harmful,” he says. Mendelsohn says it is the tar from smoking, and not the nicotine that is harmful to the body. “In Australia, 19,000 people die from smoking every year...We need every possible tool to help smokers to quit. The health effects are devastating,” he says. Stimson says around 35 countries currently ban e-cigarettes, and “55 countries have some sorts of regulation.” A survey by the International Network of Nicotine Consumer Organizations among its members listed Thailand as the worst country in the world to be a vaper, followed by Australia and India. The Philippines ranked 11th, together with Brazil, among countries with difficult environment for vapers. Dr. Konstantinos Farsalinos, a researcher at Onassis Cardiac Surgery Centre in Athens, earlier identified the Philippines and Malaysia as two Southeast Asian countries with large populations of vapers, yet without regulation on e-cigarettes. Data from the Philippine Statistics Authority show that in 2015, 16.6 million adults or 23.8 percent of the Philippine population were smokers. Of the total, 76.7 percent planned or were thinking about quitting, but only 4 percent were able to successfully quit. Data from the consumer group The Vapers Philippines show that about 4 million or 4 percent of the Philippine population are vapers. There are more than 2,000 e-cigarette juice manufacturers in the country, mostly individuals, which make the market basically informal.Meanwhile, the UK was listed as the most vaper-friendly, followed by Germany and France. “The United Kingdom government has had the most remarkable change of heart on vaping. Four years ago it was trying to ban all e-cigarettes on the market. Today, the UK has three million vapers—and this is accelerating the decline in smoking among the British,” says Stimson, who represents the UK charity New Nicotine Alliance.

“In Japan, over the last two years, sales declined about 27 percent in tobacco volume. That is an extraordinary change and was never seen anywhere else. Sweden, Norway, UK, Iceland—we’ve got lots of examples now where safer nicotine products are leading people away from smoking,” says Stimson. Sweanor says Sweden has the lowest incidence of smoking at 5 percent. Iceland reduced smoking from 14 percent to 9 percent in three years. “In Korea, there was a double-digit decline in cigarette sales. In France, a million people stopped smoking. In the UK, there is a huge increase in vaping. We’ve got lots of evidence that this is happening,” he says. Kosterich says the problem with Australian health authorities is that they do not mix with people who are not like themselves. “They generally live in nice suburbs, they don’t mix with smokers, they don’t mix with people with different background. They have no concept of these people, so they don’t know. They assume that their policies work because everybody that they talk to is like them,” he says. Mendelsohn says smokers who keep smoking from the age of 35 will most likely die earlier. “Every year they smoke, they shorten their lives by three months. There is some urgency because they are shortening their lives. The sooner the people quit, the better. If the standard treatments are not working, then they should be able to try other methods. But in Australia, they are banned effectively,” he says.

Amid the voluminous evidence against smoking, cigarette manufacturers have invested billions of dollars in research as a part of the transition to smoke-free products. Dr. Cristina Apetrei, manager of device projects at Philip Morris International, says the company is investing in new technologies that offer improvements in the e-cigarette category. “That will be our mission to transition the PMI portfolio towards that technology,” she says. Manuel Peitsch, chief science officer at PMI, says the company invested $4.5 billion in development and manufacturing of iQos heat-not-burn product and other platforms. “What attracted people in Japan to iQos is that it does not stink, it does not bother people around them, it does not produce ash and it is clean,” he says. “Why did PMI do it? Where we are is because of the vision of some of our leaders. It has come to the point that you have to be extremely determined, you have to be patient and you have to follow through,” he says. Christelle Haziza, clinical research and development manager at PMI, says a clinical study shows improvement in eight measures of the health of people who had used IQos for six months. She says the results imply that “switching to IQos is a better option than continue to smoke.” Chris Proctor, chief scientific officer of British American Tobacco, says the tobacco industry invested around $10 billion over the past two to three years on next-generation products such as vapor products and tobacco heating products.

Ian Jones, reduced risk products science vice president at Japan Tobacco International, says the industry is changing. “We now have electrical engineers, mechanical engineers—things we have not seen in the past,” he says. Cecilia Kindstrand-Isaksson of Swedish Match says the tobacco industry is quite committed to consumer safety. “We spend a number of years and spend a lot of money into investing in quality control,” she says. While many countries have already allowed e-cigarettes, others remain cautious. Marewa Glover, a professor of Public Health at University of New Zealand who works to reduce smoking among Maori, says she and her colleagues had to convince the court in New Zealand about the benefits of e-cigarettes as a harm reduction tool. “Luckily, the public understood, and the young people understood,” she says. She says while the court eventually ruled in favor of e-cigarettes, there are still some groups who lobby against it. “The people who are against e-cigarettes, many in tobacco control, are lobbying for the law to be changed. We still have a battle ahead of us,” says Glover. Sweanor says e-cigarettes will likely continue to proliferate. “E-cigarette came out of nowhere—something like what happened with disruptive technology,” he says. “Even regulation cannot stop it from happening.” Hon Lik, a Chinese pharmacist, is credited as the inventor of the modern e-cigarette in 2001. The lineup of smoke-free tobacco products has expanded since then, after studies found that it is the tar from the burned cigarette, and not the nicotine, that is harmful to the body. Tar, a product of burning, reportedly contains thousands of harmful chemicals. “Clearly tobacco use is extremely dangerous to health, and there should be support and intervention available to help people switch to lower-risk ways of using nicotine. For the good of public health, we need to promote positive discourses on recreational nicotine use in order to promote engagement of reduced harm alternatives to tobacco smoking,” says Dr. Catilin Notley, a senior lecturer in Mental Health at the Norwich Medical School, University of East Anglia (UK). Swearnor says e-cigarette and other smoke-free nicotine products have the best chance to end the smoking epidemic. “Tobacco harm reduction is on a par with the elimination of smallpox in terms of public health impact. It is all down to whether politicians will seize the opportunity,” says Sweanor. Two out of three smokers are expected to develop illnesses related to smoking, according to experts. Farsalinos says while vaping offers them a great opportunity to quit smoking and avoid those illnesses, many countries, that follow the line of thought of the World Health Organization continue to deprive them of a less harmful alternative. "It is unethical to deprive smokers of additional option to quit their smoking habit," says Farsalinos.