This post is a submission for Open Philanthropy's Cause Exploration Prizes contest. Big thanks to Andrew Cutler, Steve Hunter, Adam Jacobi, Jonathan Lansey, and Violeta Vicario for their many helpful suggestions!

Summary

Cigarette smoking kills millions of people every year. We spend a lot of money trying to reduce this number, but much of it is ineffective because we’re focused on getting people to stop doing something they enjoy. It’s demonstrably better to help them use products they would like just as much as cigarettes, but don’t cause health problems. Most of the alternatives involve ingesting nicotine without burning tobacco, and donors have an opportunity to (1) advocate for removing restrictions on them, (2) inform consumers that they’re available and safer; and (3) fund innovation to improve them.

What is tobacco harm reduction?

While the definition of harm reduction is contested, this document will use the phrase in the sense articulated by Shaun Shelly: "meeting people where they are at, without judgment, and helping them achieve their drug use aims (including abstinence) in the way that causes the least harm to them, irrespective of the current legal and policy framework." I will use the phrase "tobacco harm reduction" (THR for short) to refer to the application of this approach to the use of both tobacco and nicotine products.

As tobacco researcher Michael Russell famously stated in a 1976 article in the British Medical Journal, “people smoke for nicotine but they die from the tar.” Accordingly, the majority of effective THR methods and the efforts to promote them involve the ingestion of nicotine without the combustion of tobacco. They include the use of heat-not-burn (HNB) devices which warm tobacco leaves without burning them, liquid-based vaping devices that aerosolize a solution of nicotine in propylene glycol and/or vegetable glycerin (also called e-cigarettes), smokeless oral tobacco products like snus, and pharmaceutical nicotine sources like gum and lozenges.

Importance

Tobacco smoking has been identified by 80,000 Hours as taking an "enormous toll on human health," causing more deaths per year than HIV, malaria, and tuberculosis combined. The health effects of smoking are also an increasing problem in some parts of the world, as smoking prevalence is on the rise in a number of countries and the total number of daily smokers in the world was estimated to exceed 1.1 billion for the first time in 2019. Several million of them die due to its effects every year.

While most policies around tobacco focus on efforts to reduce supply and demand for all tobacco products, harm reduction is also enshrined in the WHO Framework Convention on Tobacco Control, the largest supranational agreement related to tobacco. It defines tobacco control as a “range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke.” Prominent EAs have also supported THR. For example, Robert Wiblin has publicly expressed his view that the “idea that vaping isn't vastly vastly safer than smoking is among the most personally harmful falsehoods a person can believe.”

In practice, however, the WHO, while promoting certain THR tools (for example, by including nicotine gum and patches in its Model List of Essential Medicines) expends significant resources on opposing others, including public misinformation on the risks of e-cigarettes, awards to officials implementing vaping bans in developing countries, and recommendations against the use of smokeless oral tobacco.

In parallel, some of the best-funded philanthropic organizations attempting to address health problems related to smoking also neglect or are openly hostile to THR. The largest of these is Bloomberg Philanthropies, which in 2019 committed $160 million to a campaign against flavored e-cigarettes used by millions of vapers worldwide, and has not made any comparable investments in promoting THR to current smokers.

Inaccurate perceptions of the risks of nicotine in both the general population and among doctors specifically both result from and drive hostility to THR. More than 80% of doctors surveyed in one recent study falsely claimed that nicotine causes cardiovascular disease, COPD, and cancer. Among the general population, the US National Cancer Institute’s HINTS survey indicates fewer than 20% of Americans think e-cigarettes are less harmful than combustible cigarettes.

Tractability

There are several examples of countries where high prevalence of THR has had a direct and significant effect on the prevalence of smoking and smoking-related illness. Two of the clearest examples come from Sweden and Japan.

Sweden, at 7%, currently has the lowest rate of smoking in the European Union, less than ⅓ of the EU average of 23% and about half of the country with the next-lowest prevalence, The Netherlands at 12%. Sweden is also the only country in the world where women smoke more than men. The overall rate of tobacco use in Sweden is similar to other countries in Europe, as is the percentage of women who smoke. The main difference is that the majority of male consumers use snus, a smokeless, steam-pasteurized, non-carcinogenic oral product banned in the rest of the EU. Sweden thus has Europe’s lowest male death rate from tobacco-related diseases including lung cancer.

Japan has had one of the largest declines in cigarette smoking rates in the past decade of any country in the world, going from about 21% to 13% between 2012 and now. The total number of cigarettes sold has also seen a massive recent drop, going from 43 billion to 25 billion between 2016 and 2021. Tobacco control policies in Japan are similar to those of other wealthy countries that haven’t seen declines of this magnitude, and there has been no significant change in tobacco control policies during this period. What is different about Japan as compared to other wealthy countries is that it was the first place tobacco companies introduced the latest iteration of heat-not-burn (HNB) products such as Philip Morris’ IQOS, and continues to be the largest market for them, claiming about 85% of global sales in 2018. As a result, HNB now makes up nearly 30% of tobacco sales in the country. While the shift is too recent for a significant amount of evidence on health outcomes to have accumulated, although the extensive data the company submitted to FDA in the US led it to conclude that heating instead of burning “significantly reduces the production of harmful and potentially harmful chemicals” and authorized the company to accordingly make marketing claims about reduced exposure.

In the USA, there has also been a strong correlation between the popularity of THR and the drop in smoking. While there has been neither a decades-long cultural shift toward smokeless use, as in Sweden, nor a large industry deliberately promoting new products, as in Japan, the introduction of the first e-cigarette in 2007, the increasing availability of open-system vaping devices, and the proliferation of vape shops selling e-liquid and accessories has led to an increase in vaping prevalence to about 6% of the total population in 2021. Vapes and cigarettes are economic substitutes; particularly among young people, a dramatic rise in vaping has closely accompanied a drop in smoking.

Neglectedness

Smoking-related illness is not a neglected issue in global health in general, nor among EAs specifically. In the USA, state governments spent over $700 million on smoking-related efforts in the most recent fiscal year and the Centers for Disease Control provides over $1 million in annual funding for tobacco control to every state. Globally, Michael Bloomberg and Bill Gates pledged a combined investment of $500 million to fighting “the tobacco epidemic” in 2008. The World Health Organization lists tobacco as a top-level health topic and the first international treaty it negotiated (the aforementioned Framework Convention on Tobacco Control) was on this subject and ratified by 181 countries. 80,000 Hours has a problem profile specifically about smoking in the developing world.

However, very few of the efforts funded by governments and philanthropists support any form of THR. In fact, all of the non-EA organizations mentioned above have taken steps actively opposing it. Federal agencies, state legislatures, and local governments in the USA have promulgated regulations to restrict smoke-free products. The CDC has confused consumers about an outbreak of lung illnesses caused by Vitamin E Acetate in black market cannabis products, leading to wildly incorrect risk perceptions about nicotine vaping. Bloomberg recently earmarked another $160 million exclusively for efforts related to restricting the use and advertisement of e-cigarettes. The WHO has been criticized by the former tobacco control VP of the American Cancer Society, among many others, for their “efforts to destroy the one version of harm reduction whose potential far surpasses that of all others.”

The parties promoting THR consist mainly of two groups: businesses selling lower risk nicotine and tobacco products and consumer organizations advocating for the rights of their users. 

Businesses include large tobacco companies like Swedish Match, the largest manufacturer of snus, and Philip Morris International, which has spent significant funds setting up and funding a foundation specifically to promote non-combustible products. Consumer and pharmaceutical businesses like GlaxoSmithKline and Johnson & Johnson, makers of nicotine replacement therapy products, have generally stayed away from public lobbying (although they did sponsor a yacht racing team). Vape device manufacturers, e-liquid makers, and retailers, many of whom belong to a trade group, the American Vapor Manufacturers Association and are active in efforts to fight restrictions on the products they sell. Most consumer organizations operate at the national level and belong to an international group, the International Network of Nicotine Consumer Organizations (INNCO).

While each of these organizations have contributed to harm reduction efforts, they are often constrained by either reputational concerns, as many policymakers and philanthropists are either unwilling to engage or have specific policies against engaging in discussions with representatives of the tobacco industry, or funding issues, as THR is not a prominent cause even within harm reduction circles. For example, Harm Reduction International’s Global State of Harm Reduction 2020 report, one of the most comprehensive annual publications of its kind, does not mention tobacco at all in its nearly 200-page text.

Areas of Funding

There are several ways donors could support the promotion of THR. Three of the most promising avenues are advocacy, education, and research. I will not be recommending specific existing partners and projects as this exploration didn’t focus on evaluating their effectiveness, but will mention a few potential fundees in each area as a starting point for future exploration.

In the world of advocacy, the primary battleground in the past decade has been on laws regulating the use of e-cigarettes. National legislatures have enacted restrictions of various levels: full bans in Brazil, India, and Mexico; flavor bans in The Netherlands and a number of US states; prescription-only status in Australia. On the more permissive side of the ledger, The Philippines passed a law supported by consumers this year after furious lobbying and allegations of illegal donations to its Food and Drug Administration from the Bloomberg Foundation; the UK is considering abandoning the ban on snus now that Brexit allows it to diverge from the EU’s Tobacco Policy Directive. There are ongoing debates about regulation in many other countries, giving funders an opportunity to support efforts to enact pro-THR policies. Some of the existing organizations working on projects in this area include INNCO, CASAA, and AVM.

The importance of the dissemination of more accurate information about product risks, to key decision makers and to the general public, is crucial to building legitimacy for pro-THR regulations. Legislators can be convinced to change their minds and advocate for liberalizing regulations they themselves passed before they learned more about the subject. 

Even more importantly, there’s a huge opportunity to inform smokers that THR exists and that it works. Some modeling on the effects of the initial information shock from the Surgeon General’s 1964 report on smoking suggests that this shock and subsequent social contagion caused most or even all of the subsequent reduction in smoking. By the same token, better-informed smokers can more easily make decisions that benefit their health. Simple websites with clearly presented information in New Zealand and the NHS in the UK can serve as a model for effective outreach. Filter Magazine serves as an independent media organization funding investigative journalism on harm reduction, and devotes regular space to THR. Attention Era Studios produced the feature films A Billion Lives and You Don’t Know Nicotine, both of which managed to attract significant media attention including appearances by the director on South Africa’s largest public broadcaster and CNBC. Knowledge Action Change funds the Global State of Tobacco Harm Reduction, a comprehensive overview of the regulatory landscape and public health impacts of THR. 

Finally, while non-combustible products have been around much longer than cigarettes, there is still room for innovation in the products themselves, as was made obvious by the explosive growth of vaping technology in the 21st century and the rapid changes in batteries, form factors, and e-liquid formulations. Donors could support further research into compelling alternatives to combustible products both through innovation in existing products and exploration of entirely new product categories.

A Note on Health Effects

A major crux of any discussion of THR is the health effects of various non-combustible nicotine and tobacco products, both in absolute terms and in comparison to those of cigarette smoking. It’s challenging to establish confident conclusions as a layperson due to the highly politicized history of the research around this question. Awareness of the strategy of extensive deception by cigarette manufacturers that began in the 1950’s is widespread - one of the best resources on the details of this topic is Allan Brandt’s The Cigarette Century. The extensive exaggeration of the risks of various forms of tobacco use - beginning with one of the earliest and most entertaining, King James VI’s A Counterblaste to Tobacco written in 1604 - is less well known, but no less relevant, as societal taboos surrounding the use of psychoactive substances have led to many shaky claims that aren’t based on credible evidence. The conclusions of epidemiological research on cigarette smoking like the British Doctors Study by Doll and Hill in 1951 demonstrating a causal link between smoking tobacco and lung cancer have been repeatedly confirmed. However, recent work has debunked commonly believed and widely disseminated claims about oral cancer and chewing tobacco, vaping and popcorn lung, and heart attacks and second hand smoke.

Due to the time necessary to properly explore this topic, this cause area overview doesn’t focus on detailed arguments about health effects of noncombustible products. However, two fairly uncontroversial claims can be made:

1. Inhaling concentrated smoke from burning plant matter is the cause of almost all health problems associated with smoking. This involves the well-understood carcinogenic effects of polycyclic aromatic hydrocarbons created by combustion and the effects of various components of smoke on mucociliary clearance and other defense mechanisms in the lung.
2. Research so far has failed to discover any causal link strong enough to shift our priors from “no effect” between the use of a currently available noncombustible product and a specific disease involving both a proposed biological mechanism and population-level correlation, as is the case for combustible products.

A number of utility calculations in the spirit of the EA “shut up and multiply” ethos have been attempted by economists and public health researchers. Even under fairly pessimistic assumptions, they indicate that promotion of THR is a net benefit under a wide range of assumptions, even for those skeptical of the two claims above. Estimates range from millions to tens of millions of QUALYs gained in the next few decades in the USA.

The assumptions made even in the optimistic scenarios of the analyses linked assume non-zero harms from the use of non-combustible products. It’s very plausible that some or all of them not only have no measurable harms, but confer a net health benefit, as downsides may be more than offset by the effects of nicotine on cognition and mood that could stave off the symptoms of mild cognitive impairment and Alzheimer’s disease. In this regard, tobacco may be more analogous to tea or coffee than to alcohol, despite being closer in the regulatory framework and cultural context to the latter.

Potential Objections

While I find the reasons to fund pro-THR work convincing, below are some possible reasons one could think it’s not a good use of a donor’s money and attention.

Objections to neglectedness

1. The large companies and governments currently selling cigarettes have an incentive to promote THR so that they are no longer selling deadly products. In some cases (e.g. PMI developing and marketing IQOS) they have already committed significant resources to this effort. They are well-connected enough to overcome regulatory barriers and have arguably captured, at least in part, some of the institutions posing the biggest roadblocks, like FDA in the US. Additional funding from EA-affiliated sources may not significantly affect the timeline of this transition.

Objections to tractability

1. Governments benefit extensively from cigarette sales - the largest tobacco company in the world is the China National Tobacco Company, fully owned by the Chinese state - and it may be too difficult and costly to influence their decisions. 
2. Taboos around psychoactive substances are as old as their use by humans. Similarly to the prohibition of other stimulants like cocaine or opiates like heroin, the impulse to prohibit may be too deeply rooted in feelings of sacredness, disgust, and in-group/out-group distinctions to be intentionally dislodged by arguments about health. The dynamic is similar to that of the larger “drug war.”
3. Many in the public health and medical fields  regard THR as illegitimate because it’s a non-medical solution to a problem they frame as a medical issue; in Carl Phillips’ words, “Those who spent their careers trying to get people to stop smoking [...] resent the possibility of smoking being substantially reduced in spite of their efforts rather than because of them.” It may be too difficult to overcome this bias enough to shift opinions noticeably.
4. Where most successful, THR has often been more an organic social phenomenon spread through social networks than a formal medical intervention. It may be too difficult to discover and implement a specific, repeatable set of actions that accelerates its growth.

Objections to importance

1. If new research discovers currently unknown health risks, the utility calculation could shift and estimates may need to be revised, perhaps even to the point where THR promotion becomes a net negative. If this ends up being the case, organizations funding such promotion could suffer reputational harms from being perceived as recklessly pushing dangerous behaviors.
2. Utility calculations assume that THR promotion results in a net reduction in the use of combustible products. This assumption could be wrong, and the gateway effect to smoking could outweigh the reduction in combustible use from people that switch to smokeless products. (I don’t find this and the previous point very convincing, but they are both pretty commonly argued - see a more detailed response.)