Are safer nicotine products a viable option for smokers in low and middle income countries?

UK based public health agency Knowledge Action Change launched launch of Burning Issues: The Global State of Tobacco Harm Reduction (GSTHR) 2020, the latest in a landmark report series at an open access virtual conference on the 4^th of November, 2020. Unlike many other Tobacco Harm Reduction efforts generally steered by developed countries, the conference featured many speakers and panelists from low and middle income countries including Malawi.

Tobacco Harm Reduction (THR) supports people to quit smoking by using safer nicotine products (SNP) including vaping devices (e cigarettes) and pasteurised oral snus, improving health and reducing deaths by enabling people to use nicotine without the smoke that causes disease. For the average Malawi smoker, alternative smoking products remain unheard of. Whilst we have witnessed a number of awareness anti-smoking campaigns, THR products have not been highlighted as a possible solution.

One of Malawian Speakers at the event, Chimwemwe Ngoma, a THR advocate who runs an information disseminate project on Tobacco Harm Reduction and Nicotine Science, THR Malawi, presented to the audience that there is a lack of knowledge and limited access to THR products among the local smoking population. He added that in most low to middle income countries (LMICs), THR products are very expensive compared to easily accessible combustible cigarettes.

In an interview with Victor Mithi, President of the Medical Society of Malawi, he was of the view that smokers should be encouraged to quit as opposed to seeking less harmful options.

“We do not have enough local scientific data on the impacts of tobacco smoking but we would be more inclined to encourage smokers to quit smoking completely instead of opting for other tobacco products,” said Mithi.

The Burning Issues report reveals that there’s only an estimated 9 Safer Nicotine Products (SNP) health crisis of smoking is ongoing and deadly. 1.1bn people smoke worldwide, a figure that has remained unchanged for two decades despite billions spent by governments and the World Health Organization (WHO) on tobacco control.

Although the use of SNP seems to be slightly rising, especially after the US Food and Drug Administration’s approval of Phillip Morris International’s SNP IQOS as a modified risk tobacco product, the reports notes that there is a still worrying poor THR support and awareness in LMICs.

Accoring the the report, 80% of the world’s smokers live in LMICs, and eight million people die due to smoking-related disease every year. The WHO estimates that one billion people will die of smoking-related disease by 2100.

“There is an urgent need to find new approaches is clear, especially in LMIC, where tobacco control measures are often poorly or partially implemented, smoking rates are high or plateauing, population growth is increasing the number of smokers, and health systems are least able to treat smoking-related disease effectively or offer smokers support to quit,” said David Nutt, one of the main speakers at the conference and founder of Drug Science, a leading independent scientific body on drugs in the UK.

According to the Burning Issue report, Since SNP have become available, accessible and affordable in countries such as Japan, the UK and Iceland, existing declines in smoking rates have accelerated yet despite the emergence of products that are demonstrably safer than combustible cigarettes, proven to be effective in smoking cessation and attractive to adult consumers, many public health organisations have turned the war against smoking into the war against nicotine.

But are safer nicotine options a viable option for Malawian smokers?

“The failure rate for smokers trying to quite smoking is very high. Some smokers fail to quit smoking even after a life threatening disease. E-cigarettes and Nicotine Replacement Therapy products are definitely better options and less risk. E-cigarettes are only 5% harmful compared to burning cigarettes because the tar in burning cigarettes is very dangerous,” Internal Medicine Specialist Dr. Noel Kayange, who runs a private practice in Blantyre said in an interview.

Kayange also added that the risk for smokers is even higher in developing countries like Malawi because some smokers use non-filtered cigarettes which are an even bigger health risk. He however noted that whilst he recommends THR products to his patients, these are very expensive and not always available making them a non-viable option at times.

Grace Kamphale, a local smoker, says she used e-cigarettes in 2015 and would spend an estimated MWK40,000.00 ($53) a month on the gadget and supplies. In the year 2020, she spends nearly MWK65,000 ($86) on the same. She bemoans that THR products are generally expensive and difficult to manage compared to regular cigarettes.

The average Malawian earns $60 a month indicating that one of the biggest bottlenecks to access to THR products for Malawians would be the high cost.