Selection of Tobacco Harm Reduction Stakeholders' Views

• The World Health Organization (WHO) takes the view that: "ENDS [(electronic nicotine delivery systems)] contain varying amounts of nicotine and harmful emissions. E-cigarette emissions typically contain nicotine and other toxic substances that are harmful to both users and non-users who are exposed to the aerosols second-hand. Some products claiming to be nicotine-free (ENNDS) [(electronic non-nicotine delivery systems)] have been found to contain nicotine. Nicotine exposure in pregnant women can adversely affect the development of the foetus. Further, the consumption of nicotine in children and adolescents has negative impacts on brain development, leading to long-term consequences for brain development and potentially leading to learning and anxiety disorders"^[4].
• In the U.S. the Food and Drug Administration (FDA) has acknowledged a risk continuum of tobacco and nicotine products and has a regulatory pathway to introduce new products and to market qualifying products as reduced-risk^*†[5].

In the UK, Public Health England^{^} and the Government have adopted harm reduction as a key pillar of tobacco control^[6].

Te Whatu Ora (Health New Zealand, the primary publicly funded healthcare system of New Zealand) acknowledges Vapour Products to be less harmful than smoking; however, not totally harm free: "The difference between smoking and vaping is that smoking delivers nicotine by burning tobacco which can cause smoking related illnesses, and vaping can deliver nicotine by heating a liquid in a much less harmful way. There are some risks to vaping, and the biggest is that long term effects are not yet known. While vaping is less harmful than smoking it is unlikely to be totally harm free. Scientists will not be certain for many years of any health risks associated with vaping. Ideally, smokers who are vaping to quit should look to eventually stop vaping too. Vaping is not for children and young people, and people who don’t smoke should not vape"^[7].

Australia has taken an opposite view, continuing a prohibition on Vapour Products other than through the pharmacy model. It has maintained that: "Vaping can harm your health. The known health risks of vaping include: irritation of the mouth and airways; persistent coughing; nausea and vomiting; chest pain and palpitations; poisoning and seizures from inhaling too much nicotine or ingestion of e liquid; burns or injury caused by the vape overheating or exploding; nicotine dependence; respiratory problems and permanent lung damage; harm to a developing adolescent brain; some chemicals in vape aerosols can cause DNA damage.

There are other health concerns of vaping: unknown risks of developing lung disease, heart disease and cancer; an increased risk of taking up smoking cigarettes, which has serious health issues, such as cancer; exposure to higher levels of toxic chemicals if you vape and smoke cigarettes"^[8].

Finding more common ground between tobacco control advocates and supporters of Tobacco Harm Reduction is crucial for further reductions in smoking prevalence. Tobacco control advocates primarily focus on policies that aim to reduce tobacco use through regulations, taxes, public education campaigns, and even prohibition. Meanwhile, harm reduction supporters emphasise the role of Smokeless Products as reduced-risk^*† alternatives to smoking for those smokers who would otherwise continue to smoke. Both approaches share the common goal of reducing the health impacts associated with smoking, but their methods differ. Increased collaboration between these groups can lead to more comprehensive strategies that address both prevention and harm reduction, thereby reaching a broader population and accelerating progress towards lower smoking prevalence.

By integrating the strengths of both tobacco control and harm reduction, a more nuanced and effective public health strategy can emerge. Some tobacco control measures like taxation have been effective in reducing smoking rates. However, recognising that some individuals may continue to use tobacco and/or nicotine, harm reduction strategies can provide better alternatives to cigarettes, thereby reducing the associated health impact of smoking.^*† Building a bridge between these perspectives can lead to progressive policies that not only discourage smoking initiation and promote cessation but also offer practical solutions for smokers who would otherwise continue to smoke. This balanced approach can harness the full potential of both schools of thought, ultimately leading to a more substantial and sustainable decline in smoking rates and smoking-related health morbidity and mortality.

Those opposed to incorporating Smokeless Products into a harm reduction strategy express a variety of concerns, including that there is insufficient scientific knowledge to determine that Smokeless Products are reduced risk^*† and whether they might introduce new risks. They argue that because such products typically contain nicotine they maintain addiction, and that the products may both stop adult smokers from quitting and encourage underage people to start smoking. These important issues, and others listed below, are recognised by those who believe Smokeless Products are a critical component of a harm reduction strategy, but they tend to think that the potential benefits of Smokeless Products outweigh the potential risks, taking a weight-of-evidence approach to the existing data. They believe that many outstanding issues can be resolved by additional research and by monitoring usage patterns^[9],[10].