The Global State of Tobacco Harm Reduction

Transition to Safer Products Underway: Report

A new report from Knowledge Action Change (KAC) describes the extent to which safer nicotine products (SNP) are replacing and substituting for combustible and risky oral tobacco products.

Co-authored by experts in harm reduction, data science and economics, The Global State of Tobacco Harm Reduction 2024: A Situation Report (GSTHR 2024) considers what is driving these changes, how different regulatory environments have developed, and the complex interplay between products, consumers, and policy and regulation.

The latest market data shows that while sales of combustible tobacco remain significantly higher than sales of SNP, two key shifts are occurring in the tobacco and nicotine market: first, the total market share of SNP is increasing, and second, inflation-adjusted combustible tobacco sales are declining, while SNP sales are experiencing rapid growth.

Although the nominal value of combustible tobacco sales increased from $752 billion in 2015 to over $1 trillion in 2024, when adjusted for inflation (and assuming a constant currency value), combustible tobacco sales actually decreased to $685 billion in 2024—an 8.9 percent decline. Meanwhile, inflation-adjusted SNP sales grew nearly sixfold from 2015, reaching, in non-adjusted terms, $96 billion in 2024.

Further analysis shows, however, that Chinese data skews these figures. China’s tobacco market accounts for an astonishing $344 billion of the $1 trillion global combustible tobacco market. Despite being the global center of production for nicotine vapes, the Chinese market for all SNP is extremely small, at less than 1.2 percent of its market for combustibles. GSTHR analysis removing China from the calculations reveals the true scale of the acceleration in the global SNP market: it has reached 12.3 percent of the total tobacco and nicotine market in 2024, up from virtually zero in 2004.

The evidence from this report shows that when safer products are appropriate, acceptable, accessible and affordable—people will switch.

Gerry Stimson, founder, KAC

According to KAC, legal access to a range of SNP will be essential for the billion people who smoke worldwide to benefit from tobacco harm reduction (THR). Research undertaken for GSTHR 2024 shows that more than two-thirds of the world’s adult population can now legally access at least one form of SNP. Access to combustible tobacco products, by contrast, remains legal for 100 percent of the world’s adult population. The report also reveals that the global number of vapers has increased from 58 million in 2018, to reach an estimated 114 million in 2023. With 30 million people using other safer nicotine products, this means the GSTHR estimates there are now around 144 million users of SNP worldwide.

“Harm reduction is often thought about as policies and strategies, driven by public health. But it isn’t only this. It’s also what people do themselves to reduce risks and improve their own health,” said KAC Founder Gerry Stimson in a statement. “Governments and both international and national health organizations, need to help create an environment in which people can be informed and empowered to make those safer choices. And the evidence from this report shows that—when safer products are appropriate, acceptable, accessible and affordable—people will switch, in fact they are already switching, in their millions.”

November 18, 2024

Paper Explores British Harm Reduction Success

The latest briefing paper from the Global State of Tobacco Harm Reduction (GSTHR), a project from public health agency Knowledge Action Change (KAC), focuses on the remarkable shift from smoking to vaping that has taken place in the United Kingdom in recent years.

“A smokefree UK? How research, policy and vapes have cut smoking rates” explores some of the reasons behind the U.K.’s rapid and growing embrace of vaping and provides a case study showcasing the potential of tobacco harm reduction through the adoption of safer nicotine products, following KAC’s recent briefing paper on the effect heated-tobacco products have had in Japan.

One of a number of positive country profiles set to feature in the fourth biennial Global State of Tobacco Harm Reduction report, published later this year, this briefing paper shows the number of people who smoke has fallen by nearly 50 percent since the introduction of vapes nearly two decades ago (from 23.7 percent of adults in 2005 to 12.9 percent in 2022).

KAC’s newest publication also includes a significant forecast, based on the latest available data from the Office for National Statistics and Action on Smoking and Health, that reveals the number of adults who smoke will continue to fall to just over 10 percent in 2025. In contrast, the number of adults who vape will keep rising from the 11 percent recorded in 2024, meaning vaping will overtake smoking for the first time in the U.K. According to KAC, these changes provide further evidence that when consumers have access to safer nicotine products that are acceptable and readily available, they will make the decision to switch in ever-increasing numbers.

While this briefing paper, which will be available in 12 languages as well as English, tells a story of consumers leading the way by adopting a new technology in a bid to improve their health, it also showcases the impact that scientific research and proactive governments can have on public health policies, according to KAC.

The U.K. has played host to some significant milestones in the study of smoking and safer nicotine products. The link between smoking and cancer was first established in the U.K. in 1950 and these studies led to the publication of the Royal College of Physicians’ landmark report “Smoking and Health.” It was the first to widely publicize information about the negative effects of smoking on health, and it is considered to be a turning point in the history of public health in the U.K. Moving forward to 2015, the predecessor of the Office for Health Improvement and Disparities, Public Health England, published an independent evidence review that concluded nicotine vapes were around 95 percent less harmful than smoking. Now referenced around the world as the foremost example of the relative safety of vaping, this report concluded vapes had the potential to help people quit smoking.

Armed with such strong and reliable evidence supporting the role it could play in reducing smoking rates, successive U.K. governments have continued to endorse vaping. Not only are vapes easy to access for those aged over 18, the government and the National Health Service (NHS) have encouraged people to switch from smoking to vaping. One of the most radical ideas came in 2023 when the government announced that 1 million people who smoked would be encouraged to switch from cigarettes to vapes. As part of the “swap to stop” campaign, a world-first national scheme, around one-fifth of those who smoked would be provided with a vape starter kit, alongside behavioral support, to help them quit. For its part, the NHS provides a wealth of evidence-based advice to those who smoke about the relative safety of vapes compared to cigarettes, though it does emphasize that the full benefits of vaping are only achieved by those who manage to stop smoking cigarettes completely.

“In a similar vein to that seen in Japan, the fall in smoking rates in the United Kingdom reinforces just how rapidly situations can improve when people already consuming nicotine by smoking can access a safer alternative like vapes,” said KAC Director David MacKintosh in a statement.

“When vaping overtakes smoking next year in the U.K., it will not be simply the consequence of a consumer-led revolution, although this has been significant, it will also be the result of successive governments making pragmatic policy decisions based on the evidence in front of them. Maintaining a clear focus on reducing the use of combustible cigarettes provides an opportunity to achieve the ambitious 2030 ‘smoke-free’ target.”

October 1, 2024

New Briefing Details THR Success in Japan

Knowledge Action Change (KAC) has released a briefing paper on the rapid fall in cigarette sales in Japan following the introduction of heated-tobacco products (HTP).

Titled “Cigarette Sales Halved: Heated-Tobacco Products and the Japanese Experience,” the paper explores some of the social and cultural factors that have made Japan particularly suited to HTP and provides a case study showcasing the potential of tobacco harm reduction through the adoption of safer nicotine products.

As well as referencing a number of peer-reviewed science papers, the briefing paper, available in 12 languages, also includes some new Global State of Tobacco Harm Reduction research, which compares up-to-date sales figures that emphasize the changing nature of cigarette and HTP consumption.

According to KAC, the success of HTP in Japan offers significant hope of their potential to reduce cigarette sales in other similar countries.

“The speed and scale of the change in Japan shows just how quickly things can improve when those people already consuming nicotine are given access to a safer alternative,” said KAC Director David MacKintosh in a statement.

“This is not the result of a specific government policy or initiative, yet the benefits to individuals and society are significant. There are lessons to be learnt from Japan by all those who wish to see the use of combustible tobacco consigned to the history books. Harm reduction is about giving people the opportunity to improve their own health and the health of those around them. Given the chance, most people will do just that.”

May 15, 2024

Briefing Explores THR for the Homeless

A new briefing paper from the Global State of Tobacco Harm Reduction (GSTHR), a project from U.K.-based public health agency Knowledge Action Change (KAC), examines the significant potential of the approach to help people experiencing homelessness.

Surveys consistently estimate that between 76 and 85 percent of U.K. homeless people smoke—six or seven times the smoking prevalence seen in the general population, which is now at an historic low of 12.9 percent. On average, U.K. homeless men die at 44 years of age, compared to 76 in the general population and homeless women at 42 years, compared to 81 in the overall population.

Tobacco harm reduction helps people quit smoking by giving them the choice to switch to safer nicotine products. A 2019 study found that at least two thirds of rough sleepers who smoked would be willing to switch to vaping if a device was freely available, and would take up smoking cessation support offered at their homelessness service.

Tobacco harm reduction initiatives developed in London, Manchester and Edinburgh included the provision of free vape starter kits to homeless people. As well as the longer term health improvements offered by switching, the leaders of those projects also noticed more immediate benefits; Covid-19 infection risks associated with sharing or smoking discarded cigarettes were reduced, along with the risk of eviction by breaking no smoking policies, and the risk of breaking lockdown to go out and purchase—or look for discarded—cigarettes.

“Homeless populations have long been disproportionately impacted by smoking, and therefore stand to gain enormously from effective and pragmatic harm reduction routes to quitting tobacco,” said KAC Director David MacKintosh in a statement.

“The sustainability of this type of intervention must be approached carefully, but there is real potential here and it should be explored. On average, homeless people in the U.K. live half a life compared to the general population. Reducing their high rates of smoking is one way to start addressing this tragedy.”

December 11, 2023

Consumer Groups Critical to THR: Paper

Consumer advocacy organizations play a critical role in ensuring safer nicotine products are available as alternatives for those who use high-risk tobacco products, according to a new briefing paper by the Global State of Tobacco Harm Reduction (GSTHR).

The absence of consumer perspectives from 10^th Conference of the Parties to the Framework Convention on Tobacco Control–which was scheduled to be held in November but has been postponed due to social unrest in the host nation, Panama—will hamper collective efforts to bring an end to the smoking epidemic, according to the GSTHR.

Consumer advocacy groups are also overstretched and under-resourced, according to the report. During the 12 months prior to the study, the total funding for all of the groups surveyed was only $309,810. None of this money came from tobacco or pharmaceutical companies, despite oft-repeated allegations from opponents of tobacco harm reduction. By contrast, the Campaign for Tobacco Free Kids received $160 million from Bloomberg Philanthropies in 2019 to oppose flavors in nicotine vapes.

Despite the lack of funding, tobacco harm reduction consumer advocacy organizations have achieved a lot. “From the very early days of simply sharing information on products with peers who hoped to quit smoking, through to the emergence of more organized advocacy efforts, consumers have been central to the development of tobacco harm reduction,” said Jessica Harding, director of external engagement at Knowledge Action Change, in a statement.

“Consumer advocacy groups play a vital role in maintaining access to safer nicotine products throughout the world and, despite the many obstacles they face, their achievements are impressive.”

“People who use safer nicotine products and people who smoke are significantly affected by policy responses to tobacco and nicotine, broadly described as ‘tobacco control,’” said Gerry Stimson on behalf of the GSTHR project.

“They are also the people who would most benefit from tobacco harm reduction. As in other comparable areas of public health, there must be a recognition of the contribution consumer advocacy groups can make to inform decisionmaking at meetings such as COP10. Their experiences are testament to the potential of harm reduction, and they should be heard.”

Tobacco Reporter’s Stefanie Rossel recently explored the role of consumer advocacy groups in her article “Persistence Pays.”

November 10, 2023

KAC: Seize Potential of Safer Nicotine

Knowledge-Action-Change (KAC) has published The Global State of Tobacco Harm Reduction 2022: The Right Side of History. The Global State of Tobacco Harm Reduction (GSTHR) publication charts the history of tobacco harm reduction and considers the future of a strategy that can hasten the end of smoking and drastically reduce smoking-related death and disease worldwide.

According to the report’s authors, the emergence of new safer nicotine products has caused substantial disruption to nicotine use, public health and tobacco control institutions and the traditional tobacco industry. However, mistrust and ideological opposition is hampering widespread adoption of a strategy that could help 1.1 billion adult smokers failed by existing tobacco control interventions.

“Technology helped smoking become one of the world’s biggest health problems,” said Harry Shapiro, author of The Right Side of History, in a statement. “Now, technological innovations from beyond both the tobacco industry and public health have combined to produce safer nicotine products, and millions of people who smoked have already chosen to switch. Yet progress is being hampered. Although disruption is not always comfortable, the genie is out of the bottle—these new technologies demand the development of new policies and new thinking.”

“A failure to recognize and exploit the potential of tobacco harm reduction will mean millions more avoidable deaths each year.”

Gerry Stimson, project lead, GSTHR

“A failure to recognize and exploit the potential of tobacco harm reduction will mean millions more avoidable deaths each year and contribute to an ever-growing burden of disease that disproportionately affects the most vulnerable countries and communities,” said Gerry Stimson, GSTHR project lead and emeritus professor at Imperial College London.

“Tobacco control’s lack of evolution, despite its very limited gains, means that many aspirational targets to achieve smoke-free status by 2030 or within the next generation are no more likely to be met than former aspirations for a drug-free world. Tobacco harm reduction offers us an historic opportunity. We must not let it slip away.”

The Right Side of History is the third in the biennial series of GSTHR reports, following No Fire, No Smoke in 2018 and Burning Issues in 2020. A summary of the most recent report is here. The GSTHR project is produced with the help of a grant from the Foundation for a Smoke-Free World.

November 16, 2022

Sub-Saharan Africa Urged to Embrace THR

With more than 200,000 smoking-related deaths each year in sub-Saharan Africa, there is an urgent need for the region to embrace tobacco harm reduction, according to a new briefing paper published by Knowledge Action Change (KAC).

KAC argues that tobacco harm reduction could generate significant public health gains for the countries in sub-Saharan Africa and is particularly crucial at a time when the number of tobacco users across the continent as a whole is set to increase to 62 million by 2025.

“Many people either cannot or do not want to quit nicotine use, but smoking is deadly,” KAC wrote in a press note. “Tobacco harm reduction offers smokers the choice to switch from combustible cigarettes to safer nicotine products that pose fewer health risks, including nicotine vapes (e-cigarettes), tobacco-free nicotine pouches, Swedish-style snus (an oral tobacco) and heated-tobacco products.”

Authored by THR Malawi founder Chimwemwe Ngoma, Tobacco Harm Reduction in Sub-Saharan Africa investigates the current status of tobacco harm reduction in the 48 countries of sub-Saharan Africa.

As well as considering the economic role of tobacco in the region, the paper provides a country-by-country guide on the availability and legal status of safer nicotine products. It notes progress is being made with tobacco harm reduction across sub-Saharan Africa, highlighting the work of consumer advocacy groups offering tobacco users accurate information about combustible cigarettes and safer nicotine products.

However, the availability and accessibility of products such as nicotine vapes remains poor in many countries while appropriate regulation is needed for product safety. Many smokers cannot access smoking cessation support. Some governments are unable to meet basic requirements for a robust healthcare system, and there is a lack of funding to prevent the noncommunicable diseases linked to smoking.

There is also widespread and deliberate misinformation circulating about safer nicotine products, and many consumers, healthcare institutions and governments in sub-Saharan Africa remain unaware of tobacco harm reduction’s potential.

“To become smoke-free, sub-Saharan Africa needs safer nicotine products that are locally feasible, affordable, appropriate, accessible and culturally acceptable, supported by sensible product regulation,” says Chimwemwe. “For this to happen, governments in Africa should strive to remain independent, conduct their own social economic impact assessments and make science-based policies that embrace tobacco harm reduction.”

The new briefing paper is part of KAC’s Global State of Tobacco Harm Reduction project, funded by a grant from the Foundation for a Smoke-Free World.

September 16, 2022

New Papers On Tobacco Harm Reduction

Knowledge Action Change (KAC) has launched the latest in a series of briefing papers as part of its Global State of Tobacco Harm Reduction project. Titled What is Tobacco Harm Reduction?, the publication provides a detailed introduction to the principles, history and evidence for this vital public health strategy.

For the 1.1 billion people across the world who smoke combustible cigarettes, tobacco harm reduction is a potentially life-saving approach. Like other forms of harm reduction, it recognizes that simply quitting isn’t possible for all smokers. People smoke for the nicotine, but nicotine itself does not cause smoking-related death and disease—it’s the chemicals inhaled in tobacco smoke. Removing combustion reduces the risk. For those people who can’t or don’t want to quit nicotine, tobacco harm reduction offers a chance to switch to safer nicotine products including nicotine vapes, tobacco-free nicotine pouches, Swedish-style snus, many U.S. smokeless tobaccos and heated tobacco products.

Many of these products have only been developed in the past 10-15 years, but they are proving increasingly popular. Research published in March by the GSTHR estimates there were 82 million vapers worldwide in 2021. This represents a 20 percent increase on the figure for 2020 (68 million), meaning safer nicotine products are now being used by 112 million people worldwide. A striking example of tobacco harm reduction’s potential can be found in Scandinavia. Sweden now has the lowest rate of tobacco-related disease in Europe, thanks to Swedish men switching from smoking to snus, and in Norway, 12 percent of women aged 16-24 use snus daily while only 1 percent smoke.

In England, tobacco harm reduction can play a key role in the government’s bold ambition to make the country smoke-free (defined as a prevalence rate of under 5 percent of the population) by 2030, according to KAC. The uptake of vaping has been accompanied by a rapid decline in smoking. Vapes are the most popular way to stop smoking, with 3.6 million people vaping in Great Britain, of whom 2.4 million have completely quit combustible cigarettes. But tobacco is still the single largest cause of preventable mortality in England with nearly 75,000 smokers dying from smoking in 2019 and figures show nearly one in 10 pregnant women are smoking at the time of delivery.

An end to smoking is possible—but the widest range of harm reduction products, from nicotine vapes and heated tobacco products to non-tobacco nicotine pouches and Swedish-style snus, should be available, accessible, appropriate and affordable to all.

Gerry Stimson, director, KAC

Continuing to drive down smoking rates is crucial if the U.K. government is to tackle the health disparities caused by smoking that currently see a disproportionate burden falling on the most disadvantaged families and communities. Smoking rates vary significantly across the country—for example in Blackpool about one in five people smoke (19.8 percent), compared to about one in 20 in Richmond upon Thames (6 percent). Rates are also very high among people who experience drug and alcohol problems (56 percent of those entering treatment smoke), people who are homeless (of whom 77 percent in England smoke) and people who live with mental health problems (of whom 26.8 percent in England smoke).

But adopting tobacco harm reduction will not just help the U.K. counter the impacts of smoking, according to KAC. It has huge potential as a global public health solution. Smoking is responsible for 7.7 million deaths a year and current tobacco control measures are failing to reduce the death and disease caused by smoking fast enough.

Translated into Spanish, Russian, Mandarin, French, Portuguese, Indonesian, Swahili, Japanese, German, Polish, Hindi and Arabic, this GSTHR briefing paper is intended to start conversations in countries across the world where harm reduction has yet to be recognized.

“An end to smoking is possible—but the widest range of harm reduction products, from nicotine vapes and heated tobacco products to non-tobacco nicotine pouches and Swedish-style snus, should be available, accessible, appropriate and affordable to all,” said Gerry Stimson, director of KAC and emeritus professor at Imperial College London.

“Strong government support is also needed to ensure access for marginal and vulnerable groups. The gains will be evident in the lives saved and the communities protected. Crucially, tobacco harm reduction is an extremely low cost yet effective strategy—a rare example of a health intervention that doesn’t require significant government expenditure, as consumers bear the cost. An end to smoking is possible—and tobacco harm reduction is the key.”

May 27, 2022

KAC: Number of Vapers up Significantly

The number of vapers worldwide increased by 20 percent from 2020 to 2021, according to the latest research by the Global State of Tobacco Harm Reduction (GSTHR), a project from Knowledge Action Change. The organization estimates that there are now 82 million vapers worldwide.

The updated calculation was made possible by the release of a range of new data, including the 2021 Eurobarometer 506 survey, and is revealed in a new GSTHR briefing paper. The figure is based on 49 countries that have produced viable survey results on vaping prevalence.

To address the problem of missing data, the GSTHR used an established method of estimating vaper numbers in countries that currently have no information by assuming a similarity with countries in the same region and economic condition for which data points were available.

This estimate considers three factors—sales regulation status, World Health Organization regions and World Bank income groups—along with the Euromonitor data on vaping product market size from 2015 to 2021.

This [increase in vapers] is in spite of prohibitive policies in many countries who follow the World Health Organization’s anti-scientific stance against tobacco harm reduction, thanks to Michael Bloomberg’s billions and his personal zeal for a war on nicotine.”

Gerry Stimson, director, KAC

“As well as the substantial growth in the number of vapers globally, our research shows there has been rapid uptake of nicotine vaping products in some countries in Europe and in North America,” said Tomasz Jerzynski, data scientist at GSTHR. “This increase is particularly significant, because in most markets, these products have been available for only a decade.”

Indeed, the rise in the number of global vapers comes despite the GSTHR’s database showing nicotine vaping products are banned in 36 countries, including India, Japan, Egypt, Brazil and Turkey.

The new data also shows the U.S. is the largest market for vaping at $10.3 billion, followed by Western Europe ($6.6 billion), Asia-Pacific ($4.4 billion) and Eastern Europe ($1.6 billion).

“As this updated data from the Global State of Tobacco Harm Reduction shows, consumers find nicotine vaping products attractive and are switching to use them in increasing numbers worldwide,” said Gerry Stimson, director of KAC and emeritus professor at Imperial College London. “This is in spite of prohibitive policies in many countries who follow the World Health Organization’s anti-scientific stance against tobacco harm reduction, thanks to Michael Bloomberg’s billions and his personal zeal for a war on nicotine.”

March 9, 2022

Tag: The Global State of Tobacco Harm Reduction