The pro-vaping assault on the World Health Organization

The Framework Convention on Tobacco Control is the treaty negotiated among members of the World Health Organization to establish international standards for tobacco control interventions. Negotiations began at the turn of the century, and the treaty came into force in February 2005. The vast majority (182 of 194) countries which participate in the World Health Organization have joined this treaty process,

The governments and civil society organizations that are involved in the treaty process are now preparing for the FCTC's 9th Conference of the Parties, which will be held virtually during the second week of November. The item that seems to be gaining the most attention, however, is one that the FCTC Bureau (its management committee) has removed from this year's agenda: discussion of how to manage new nicotine products, like e-cigarettes and heated tobacco products. Removing this issue from the agenda has not, however, stopped the attacks on the WHO for the background work it has done on this topic.

This post reports on some recent activities by the World Health Organization related to electronic nicotine delivery systems (ENDS) and on activities by those opposing these efforts.

1 The action:
WHO's evolving knowledge and recommendations on alternative nicotine products 

The FCTC has grappled with how to address e-cigarettes (electronic nicotine delivery systems, ENDS) for several years, and countries have repeatedly sought advice from WHO on how to respond to the new products. Examples of these are consensus decisions taken in the 2014 and 2016 meetings of the Conference of Parties ( FCTC/COP/6/10 Rev.1, FCTC/COP7(9)). 

In 2018, the parties requested WHO to engage independent scientists to study the issue of e-cigarettes and other "novel and emerging tobacco products" and their potential benefits and risks  (FCTC/COP8(22)). They also asked the FCTC secretariat to prepare suggestions on how to adjust the treaty in response to this changing market. It was expected that these documents would provide a foundation for a negotiation during COP 9 (originally scheduled for 2020 and then delayed to 2021) on whether or how to include these products in the treaty.

As requested, the WHO, the secretariat and its advisory committee on tobacco regulation (TobReg) commissioned a series of scientific reviews and hosted a meeting of approximately 50 regulators and experts to discuss the findings (including some from Canada). The meeting took place a year ago (September 28-October 2 2020). The first indication of the advice that would be provided from this review came in an overview of expert meetings that was circulated to WHO's Executive Board in December. (EB148/47). 

The recommendations circulated in advance of this meeting covered two categories of electronic products: heated tobacco products and vapour products. The recommendations for heated tobacco products (such as the IQOS product now sold in Canada) were for them to be regulated as strictly as other tobacco products, that manufacturers be barred from making health claims and that advertisements be banned. Recommendations specific to e-cigarettes included banning open systems (where users can modify the liquids), regulatory requirements which prohibited e-cigarettes from providing more nicotine than conventional tobacco and a prohibition on the sale of other pharmacologically active substances (eg cannabinoids) in vaping liquids. 

In May 2021, the full report of WHO's scientific advisors and the background research was made public. In over 300 pages, this eighth report of the WHO study group on tobacco product regulation (Tob Reg) addressed evidence concerning product toxicants, addictive potential, patterns of use, individual and population risk, flavours and forms of nicotine. In addition to the recommendations that had circulated earlier, there was detailed policy advice in each of the 12 separate chapters.

In July, WHO released its 8th MPOWER report, which included, for the first time, data on e-cigarettes (electronic nicotine delivery systems, ENDS). The report reviewed WHO's involvement in the issue (see figure below), and clearly recommended that e-cigarettes and "new and emerging products should be included in a comprehensive approach to tobacco control". The WHO concludes that children who use ENDS are more likely to later smoke tobacco, and that the "evidence on the potential role for ENDS in cessation is still inconclusive."

Also in July, the FCTC Secretariat provided countries with its assessment of the situation in two background documents. One (FCTC/COP/9/9) outlined the key findings of the 8th TobReg report with respect to heated tobacco products (HTP, eg IQOS). The other (FCTC/COP/9/10), addressed specific challenges in regulation. The Secretariat's unequivocal advice was that HTP products should be regulated in the same way as conventional tobacco products, and that Parties should be mindful of their FCTC obligations in making this happen.

By the time these documents were released, however, the decision had been reached that "substantive discussions" on the topic should be postponed until COP10, likely in 2023.

2. The re-action:
Calls for WHO to be de-funded and for an independent review of its scientific review.  

The circulation of WHO's recommendation on e-cigarettes in December 2020 triggered attacks on the institution in several in important quarters. 

Not "fit for purpose"

United Kingdom politicians working under the banner "All-Party Parliamentary Group for Vaping Inquiry" hosted hearings in the winter, with an objective to "collect evidence and issue a report on the FCTC's Conference of Parties 9". (copinquiry.co.uk) In it's report this unofficial parliamentary committee concluded that the FCTC is " no longer fit for purpose" and called on the British government to cut funding to the WHO unless a more pro-vaping position was adopted. In their report (and subsequent Twitter posts), they have exhorted the United Kingdom to flex its post-Brexit muscle and push for a pro-vaping resolution at COP9. 

The "fit for purpose" attack has been joined by several industry-friendly groups. These include the Consumer Choice Centre, which says the "the FCTC protocol [sic] has become more of a tool for political power and control rather than considerate public health policies."

In a report focused at the upcoming COP, the UK Institute of Economic Affairs repeated this assertion. "The FCTC Secretariat and the COP meetings are not fit for purpose. In their relentless opposition to vaping and other reduced risk products, they have become a threat to global health."  (In support of this position, the IEA directly attributes the decline in smoking in Canada to increased vaping.) 

As COP9 approaches, the campaign to up-end WHO's advice has intensified, with a particular focus on encouraging the U.K. government to flex its post-Brexit independence to influence FCTC decisions.  

In September, the Global Tobacco and Nicotine Forum held a session on "Transforming the FCTC". (The GTNF is an annual meeting established by tobacco companies to promote communication between government and industry)  At a press conference the next day, speakers from the conference accused the WHO of being "negligent and incompetent" and called for the British government to have a “big independent voice” at COP9 and to push for e-cigarettes to be treated as an acceptable tobacco alternative. 

Another event in the pre-COP9 campaign took place this past week, when a letter signed by 100 "experts" was sent to country representatives to the FCTC meeting. Among these were individuals who are known to be funded by the tobacco industry and also some who are known to not be associated with it. These individuals called for an independent audit of WHO's scientific analysis of heated tobacco and ENDS: "Initiate an independent review of WHO and the FCTC approach to tobacco policy ...the interpretation and use of science, the quality of policy advice, stakeholder engagement, and accountability and governance."  

The letter is an apparent follow-up to a letter to WHO leadreship sent on World No Tobacco Day by the same organizers.  

Next week, another pro-industry group, the Global State of Tobacco Harm Reduction, will launch another attack on WHO's approach to e-cigarette and on FCTC decisions. "Fighting the Last War challenges the direction of travel of the Framework Convention on Tobacco Control (FCTC) ahead of the forthcoming Conference of the Parties (COP 9). Over recent years, these meetings have moved away from the fundamental aim of the treaty, which was to prevent disease and death linked to tobacco smoking. Instead, leaders in tobacco control have sought to undermine the growing evidence supporting the efficacy and effectiveness of safer nicotine products and their public health potential."

3. The road ahead

When delegates to COP9 meet in early November, they will do so on computer screens. Face-to-face meetings (with the ability to negotiate in informal settings and to gain information through corridor chats) will be postponed until COP10 in 2023. 

Only a few FCTC members have adopted policies which promote harm reduction and e-cigarette use. The majority of member states see these products as part of the problem, not part of the solution. Many interpret the FCTC obligations in Article 5.2 as guidance to maintain a focus on reducing nicotine addiction, not just tobacco use. (As shown below, parties are obliged to adopt measures for "preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke.")

Because the FCTC operates by consensus and because a consensus does not appear to be in the cards, there is little advantage for either vaping enthusiasts or vaping doubters to force the issue to come to the floor for discussion.

Meanwhile, tobacco and vaping companies will continue to amplify the voices of those who want a permissive regulatory approach to these products. Less certain is whether the silent majority of governments and tobacco control activists will continue to remain silent as WHO continues to come under attack.