Africa: AHAS 2024

The 2024 edition of Africa Healthcare Summit was held in Accra on April 22-23, 2024. Organized by Zenith Global Health, this year’s theme was ” Advances in Public Health-Tackling Inequities and Access: A One Health Approach”.  The organization’s mission is to foster partnership, collaboration and share learning, thereby bridge the global south/north divide and form partnerships (PPP) involving all stakeholders, policy makers in positive and meaningful engagement to ensure health equity and access.

Speaking at the event, South African Dr Kgosi Letlape, President of the Africa Harm Reduction Alliance addressed in an interview, the critical challenge of adopting harm reduction practices.

 Public health concerns everyone, how are different stakeholders, including governments, public health organizations and industry players, collaborating to address tobacco harm reduction?

It is very difficult. Harm reduction is in the innovation space, it’s about innovating on alternative ways of getting nicotine. There’s a lot of private sector activity. E-cigarettes in particular were started by small businesses; it is an independent pharmacist that has created the modern-day e cigarette. It was not started inside the tobacco industry but given its disruptive nature to the industry and given the behaviour of public health, it’s been driven into big business and adopted by the tobacco industry. So now a lot of the e-cigarette’s companies have been bought by big tobacco. There are other technologies that come from inside big tobacco, using a technology called heat -not -burn that are smokeless but still contains tobacco.

The unfortunate situation is that for some reason, the World Health Organization (WHO) has always recognized that the problem is not nicotine, the problem is the other chemicals that are produced by combustion. But of late, the WHO seems to have lost that knowledge that nicotine doesn’t cause cancer. The problem is not nicotine, that’s why we have nicotine replacement therapy. And because of that position of the WHO, it’s really confusing for governments to come up with appropriate regulations and policies that are based on science and that will save lives and create a net public health benefit.

 What is the most effective strategy for promoting tobacco harm reduction, among different demographics?

It’s about science and truth. It’s akin to the Spanish Inquisition, when people said to the Church the earth was round and not flat, those people were killed! When we say that there are less harmful ways of getting nicotine, the WHO acts like a church and burns at the stake anybody that will bring the science forward. Not all products are the same.

If we look at the Swedish experience with snus, it was rejected by the WHO. Today we have nearly 50 years of epidemiological evidence in Sweden but the WHO is still not accepting that the position should be different, even in the face of science.

On many things, people will say that we don’t know the long-term effects. Let’s remember during COVID 19 pandemic, anti-vaccine people were saying that we don’t know the long-term effects of vaccines, but on the balance of probability, there is more benefit than harm. When it comes to nicotine, the WHO is not looking at the science and the balance of probability, upside versus downside. They are becoming like theocrats instead of being a science-based, evidence- driven Organization.

 How can we address misinformation and misconceptions surrounding tobacco harm reduction, particularly among policymakers?

It is difficult because when there is misinformation, and an Organization that is part of the misinformation, it becomes a serious challenge. When the WHO chooses to be part of the problem and part of the solution, it makes it extremely difficult. So, it’s going to be a matter of education. Education in low- and middle-income countries is key, looking at the fact that high income countries are looking at the evidence and basing their own policies on evidence, rather than the rhetoric that comes from the WHO in relation to tobacco. People have to understand that the combustible cigarette is still the most cost-effective way of getting the nicotine. But combustible cigarettes will kill one in two of its users in their lifetime. Smoking causes more than 8 million deaths per annum. 1.3 billion people on the planet continue to smoke despite the knowledge about the dangers of cigarettes. In such a situation, that’s where harm reduction becomes important.

Article 1D of the WHO’s Framework Convention of Tobacco Control (FCTC) talks about harm reduction, but at the time that it was written in 2003, there wasn’t really any product portfolio for ham reduction. Now that there is a plethora of alternatives and reduced risk products, they are not accepting harm reduction for tobacco.

On all other aspects WHO has been a champion of harm reduction whether it was about changing their minds about needle exchange programs, whether it was about using methadone for heroin addicts, whether it was about promoting safe sex and condom use and distribution, they’ve come to the party.

But when it comes to tobacco, for multiple reasons, they’re not coming to the party. Harm reduction is not well financed, so it is now being financed by ideologues. Organizations like Bloomberg are not philanthropists that would just give funding to do the job without dictating how to do the job. And it’s quite sad when a structure like WHO has lost the authority of being the voice of reason when it comes to tobacco, because they’ve taken a position rather than looking at the science.

 What is the role of technology and innovation in the tobacco harm reduction approach?

Technology is a key part of tobacco harm reduction. We’ve always known that people who smoke die from the tar, from more than 7000 chemicals that are produced some of which are carcinogenic, as evidenced by the list of the WHO or the FDA (Food and Drug Administration). It was always known that the problem comes from combustion. With nicotine replacement therapy and technology from pharmaceutical companies, they said users can get their nicotine through a patch, through tablets, through inhalers, through gum. It was medically driven, it was therapeutic, it was nicotine replacement therapy. Now that there is innovation that is giving over-the-counter products with more acceptance than nicotine replacement therapies from the users, suddenly there’s demonization of nicotine.

Innovation has come in, to make it something more acceptable to the users, to allow them to shift from the most harmful ways to the less harmful ways of getting their nicotine. Technology is key and everyday things change. The electronic cigarettes have gone through many iterations, what was available in 2013 is no longer on the market today in 2024. We are now talking about 5th, 6th generation of electronic cigarettes. So, innovation keeps coming, it keeps moving.

Nicotine vaporizers are getting better, they are getting sophisticated with dosing control, puffs measurement systems, that users can link to their smartphones and reduce the dose progressively.

Some of the heat-not-burn products are on the 4^th version, because they are responding to challenges, consumer needs, cleaning, safety of delivery without overdosing on puffs etc. Technology is a very keyway of keeping this alive.