Public health is not an exact science. The research is messy, which makes the practice even messier. And this messiness also means that leading health organizations sometimes make the wrong decisions or take the wrong positions. Eventually, the guidance from these organizations usually changes, but, until then, extensive damage can occur to the public’s health. One example is the World Health Organization (WHO)’s early guidance against masking during COVID-19, and their need to amend the guidance when cases soared. Conversely, the WHO stubbornly refuses to change their stance on the utility of electronic nicotine delivery systems (ENDS), despite growing evidence that these products are significantly less harmful than combustible cigarettes and can help smokers quit.

On July 27, 2021, the WHO released the WHO Report on the Global Tobacco Epidemic, 2021: Addressing New and Emerging Products. The report urges the continued uptake of the WHO’s tobacco control guidelines, known as MPOWER, while simultaneously denouncing the presence of ENDS in the marketplace.

Doubtlessly, some of the WHO’s concerns about ENDS are valid; however, the WHO’s complete rejection of ENDS as a tobacco harm reduction tool disregards a growing body of literature that shows how ENDS can contribute positively to the tobacco control landscape. The U.S. Food and Drug Administration (FDA) has stated that tobacco products exist on a continuum of risk. The Royal College of Physicians report that e-cigarettes are unlikely to exceed 5 percent of the risk of smoking. And studies continue to show that biomarkers of exposure to harmful constituents are lower among ENDS users than smokers, and in many cases are nearly as low as those seen in non-smokers.

Nevertheless, the WHO states, “There is growing evidence to demonstrate that these products [ENDS] are not harmless.” Most tobacco harm reduction proponents do not claim that ENDS are harmless. As the term “tobacco harm reduction” implies, the idea is to transition people who use tobacco products to less harmful ways of consuming nicotine. Tobacco harm reduction recognizes that not using tobacco products is the ideal; however, it rejects the rigidity of the WHO’s cessation definition in favor of decreasing the health effects of the most harmful forms of tobacco products.

On the subject of cessation, the WHO speaks as though it envisions a world free of tobacco use: a noble goal. However, they rely on a definition of cessation that makes it clear that what they really envision is a world free of nicotine use. In their report, they state, “Cessation is defined in the Guidelines for implementation of Article 14 of the WHO FCTC [Framework Convention on Tobacco Control] as ‘the process of stopping the use of any tobacco product (…)’ and it is, therefore, implausible to claim this may be done by switching to another tobacco product.” Relying on this definition of cessation is an ideal. Only 7.5 percent of smokers in the United States successfully quit smoking in 2018. The advent of smoke-free ENDS and other nicotine delivery products opened an opportunity for people to use nicotine without the harmful effects of combusting or chewing tobacco leaves.

One of the primary arguments the report makes against ENDS is that the health effects of long-term use are unknown. While this is true, it minimizes the strong evidence that ENDS are less harmful than combustible cigarettes in the short term, which would suggest that they are also less harmful than combustible cigarettes in the long term. The report states, “The exact harm or level of risk that ENDS will have on population health in the future is not known, but currently the number of people using these products is only a fraction of the number exposed to the known harms of tobacco.” This is exactly the point of promoting ENDS as a tobacco harm reduction strategy. We know that millions of people who use combustible cigarettes will continue to die from toxic chemicals created through combustion, since very few are able to quit successfully each year. While it will take decades to produce the long-term epidemiological studies needed to assess the risk of a lifetime of ENDS use, what is clear now is that the composition of ENDS aerosol contains significantly fewer harmful constituents than combustible cigarette smoke suggesting that ENDS are significantly less harmful that combustible cigarettes.

The WHO is a leading voice in global public health, and their continuing crusade against ENDS products is an example of a health organization making the wrong decisions based on messy data. Sometimes public health authorities rely too heavily on the precautionary principle, the idea that in circumstances of imperfect information, protective action should be supported. That is the case with ENDS. Protective action is needed against the paramount harm of combustible cigarettes, and ENDS offer just that.

Image credit: PiyawatNandeenoparit