Smoking cessation and prevention remain the most impactful, cost-effective interventions in medicine, but the global burden of smoking is still growing. Could Tobacco Harm Reduction become a game changer? Should smokers be encouraged to switch to less harmful nicotine delivery systems? And how ethical is to put barriers to smokers that would benefit from a switch to less harmful products, a lesser benefit versus “quitting” altogether but still a lot better than continuing smoking?
The distinguished panelists who participated at the discussion moderated by Takis Vidalis, tried to answer all these questions, and discussed how ethical the avoidance of health authorities is to use harm reduction―an approach with proven value, implemented in other fields of public health―in tobacco control.
Ethics in public health is incredibly important, Professor David T. Sweanor started his speech since it has to do with truth and justice. If we don’t believe the information which comes from public health authorities, the results won’t be good, as we have witnessed recently with Covid and many other issues in the past, he explained. Unfortunately, there is a tendency within public health to tell noble lies, to lie to people because they think it is for their good, and this way the public health authorities have destroyed their credibility. Today, in many countries of the world, there is no trust between public health authorities and citizens, because people have received misinformation from the authorities in the past, Professor Sweanor added. There are ethical frameworks for public health, he said. Unfortunately, in the field of nicotine and tobacco, we have a clear failure on issues of ethics. Even the goal is no clear, Professor Sweanor underlined, since some people claim that it should be a public health goal, to reduce harm to the overall population within an ethical framework and with respect to the human rights, while other people believe that the goal should be to attack the industry or nicotine. This is common in public health, he explained. The debate between those who support a scientific pragmatic public health agenda and those who claim that we need a more realistic one, is not new. And of course, he added, another crucial issue is to evaluate our strategies and policies’ effectiveness, as well as the burdens created to people by their implementation. Coercion is not the best strategy to promote health, it would be better to encourage people to change their behaviour by themselves because they know that this change will improve their own health, he said. Ethics in public health requires to move from coercion to empowerment of people, the speaker stated. By not giving people all the information or by misinforming them because we don’t believe they are not capable to make the right decision, we destroy trust, Professor Sweanor pointed out. When we don’t give people who cannot quit smoking alternatives to help them to minimize the burden of smoking to their health, he concluded, we cannot hold them responsible when they get sick.
Ethics requires sincerity, Professor Dr. Panos E. Vardas said. According to WHO recent views, human being should abstain fully from smoking and alcohol consumption, reduce to a significant degree salt use, and walk 10,000 steps per day. Apparently, this is an ideal goal, and not a realistic one, since it doesn’t consider the fact that human being was always and remains a hedonistic creature, that likes the pleasures even when they are risky, Professor Vardas commented. So, in smoking control, the dilemma we face is whether we should insist to complete smoking cessation only or we should also think about alternative ways to reduce the risk in those who cannot or refuse to quit, Professor Vardas said. No doubt the ‘Holy Grail’ is the complete smoking cessation, he emphasized, but if we want to be ethical we have to be based on real scientific data. If nicotine-containing alternative products are working and if the clinical data are indicative of less harm caused, there is no reason not to use them as a complementary strategy to our smoking cessation and prevention efforts. Recently, FDA based on this ideology has chosen to recognize some of these products as possible alternative ways to reduce the risk of smoking. Of course, in order to cast out all doubts we need more clear data supporting the less harmful effects of these alternatives, Professor Vardas said. We must be pragmatic, but we need to see well-organized, randomized, large scale trials to understand the expected real effects of these new products. The truth is that we have to compromise our ethics with the reality, he said, and the reality is that smoking cessation and prevention measures are not sufficient to reduce the still high prevalence of smoking.
Harm reduction is acceptable and applied in many aspects of our living, such as driving, sexual behaviour or even medicine, Professor Konstantinos Farsalinos noted, but when it comes to tobacco the same strategy is not acceptable. Over the last several years, we are seeing a battle between idealism and pragmatism. But we need to be realistic, he continued, not trying to imagine how an ideal world would be without any traffic accidents, without any pollution, without smoking or exposure to any other environmental or non-environmental risk factor. In the past, there was an ethical theory named consequentialism, Professor Farsalinos said, according to which the morality of any action is completely determined by the end result and not by the way in which you are reaching the end result. This theory is the source of the famous phrase that “the end justifies the means”, he explained, and in some cases when dealing with smoking control and tobacco harm reduction this is what we are seeing. Consequentialism and the phrase “the end justifies the means” is not ethical, because it violates at least one of the principles of bioethics, autonomy, Professor Farsalinos underlined. It also violates the principle of justice, he added, but autonomy, which is based on full information, reliable balanced information and providing consent, is the main “victim” of the consequentialism theory. It is an irony that autonomy and justice were two principles of bioethics that were protected by WHO, which in 1986 has stated that “we need to provide all the means and all the information to people to take control of their own health”, he said. The “we know better for you than you” approach, which has been adopted by WHO as it concerns smoking and THR, goes against that statement and prevents people from being autonomous. Informed consent is created only by giving people reliable balanced information to make their own decisions, even if they are not the ideal, the speaker underlined. Misperception, misinformation, disinformation, and miscommunication are unethical and are preventing the creation of informed decisions, he explained. We need to think why we still have more than 1 billion smokers after 60 years of knowledge about the harmful effects of smoking, why we have failed to eliminate smoking, why people keep on smoking, why they cannot or don’t want to quit, Professor Farsalinos said. We should answer these questions and adjust our policies, so that our decisions are addressing the needs and preferences of the people, Konstantinos Farsalinos concluded.
Discussion
Speaking about the role of Law, Professor Sweanor pointed out that prohibition of informing people about the differences in risks between products is far away from an ethical framework. Several laws and regulations today seem to protect the cigarette business, he explained, by making difficult to have any alternatives to cigarettes. Truth and justice are fundamental if you really want to help people to make informed decisions for their own health, Professor Sweanor said.
According to the recent results of CardioResearch Society which conducted a one-day scan of all hospitalized patients in all Cardiological Clinics of Greece, Professor Vardas said, 27.5% of them, despite their disease, were still smoking. 27.5% not of the general population, but of hospitalized patients for cardiovascular reasons, he emphasized, continue to smoke despite the well-known harmful effects of smoking. These people could clearly benefit from the switch to an alternative nicotine containing product, and that’s why large-scale trials comparing cigarettes to these products are urgently needed.
Answering the question of Takis Vidalis if the whole THR discussion is characterized by a return to a kind of medical paternalism, Professor Farsalinos commented that the approach “we know better than you about you” and “we are more capable to make decisions about you without asking you”, the strategy of enforcing decisions by using punitive measures with total lack of empathy is clearly paternalism. Regulators and health authorities need to have more empathy, he said. We should all understand that quitting smoking is extremely hard for most smokers and many of them are eventually unable to quit, he concluded. We cannot leave all these people without alternative choices to minimize the harm caused to their health. THR is not a substitute for all other measures, but a complementary tool in our efforts to control the smoking pandemic.
We never have absolute knowledge on anything, Professor Sweanor commented. The question for regulators and policymakers is when you have enough knowledge to justify acting. But there is an ethical question too, concerning what information you should be telling people whose lives are at risk, what level of certainty you need, he added. Respecting people’s autonomy means to give them all the information you already have about the relative risks of the products, tell them that this is what we know until now, and empower them to make their own decisions.
Unfortunately, we have examples indicating that scientific evidence may be never enough for policymakers and regulators, Professor Farsalinos said. Snus, for example, is a product with the best long-term epidemiological evidence in humans for decades and yet it is banned in almost all the European Union, he explained, which is totally irrational when selling cigarettes is legal.
