Earlier this year, the World Health Organization (WHO) issued a new paper on the use of taxation as part of its MPOWER global strategies for reducing disease and death caused by the use of tobacco. More recently F. Chaloupka, K. Warner, and D. Sweanor had a piece in the New England Journal of Medicine (NEJM) discussing how differential taxation could be used as a harm reduction strategy ( www.nejm.org/doi/full/10.1056/NEJMp1505710 ). And even more recently the International Association for the Study of Lung Cancer (IASLC) issued new tobacco control recommendations ( www.iaslc.org/sites/default/files/wysiwyg-assets/News/iaslc_2015_tobacco_statement_long.pdf ) which contained a provision that in part called for the ‘adoption of policy measures that recognize probable differences in the lung cancer risks of alternative nicotine delivery products’. All this has prompted me to think about how the WHO could and should bring itself into the 21st century by developing more effective and flexible strategies for dealing with the global smoking epidemic. This is not so much a criticism of its current efforts but rather an observation about how WHO has unfortunately 'boxed' itself in by relying and focusing on limited strategies that were designed over a decade ago. This approach is also something that has plagued and prevented NGO's in the US who have called for 'doing what we have been doing' as the only avenue for reducing disease and death from tobacco use.

I have spent many years working in tobacco control and was around when all of the components of the MPOWER program were developed as strategies to combat the use of tobacco here in the US (taxation, advertising and marketing restrictions, clean indoor air laws, smoking cessation etc.) That was over 20 years ago. Today the same approaches are being applied to efforts around the world. But is that all we should be doing and thinking about? My answer is 'NO'! Absolutely not!

One of the short comings of relying on programs and strategies that are seemingly cast in stone (no matter how effective or well-intentioned they were at the time they were developed) is that environments change. Some of the strategies might stay the same but might need to be modified, while newer ones need to be considered, tested and implemented. In my forty years working in tobacco control I do not recall a time where there was so much uncertainty and in some cases anxiety about what lies ahead. But I remain optimistic just the same.

Regulation, science, technology, innovation, consumer preferences, competition, incentives and new entrants into the market place can all play a role in deciding and shaping what our goals and objectives should be. Are we trying to eradicate 'tobacco' from the face of the earth or are we trying to reduce disease and death caused by tobacco use--especially disease and death from the deadly cigarette? The changing environment presents new challenges but more importantly new opportunities for consideration. The tobacco epidemic that we are experiencing has been caused by the development of the mass produced and very profitable ‘cigarette’. This epidemic is ‘manmade’. Technology caused this epidemic and technology and the use of new technologies can help eradicate it. Today there are products that can help reverse this devastating epidemic and there are many more in the pipeline. Unfortunately however, many in tobacco control remain stuck in the past and see things not as opportunities but for a continuation of the 'tobacco wars'.

We all know the devastating facts that tobacco use takes the lives of 5.3 million people each year globally. What we continue to ignore however, is that the overwhelming majority of those deaths are caused by the deadly cigarette. We have become far too comfortable with the simplistic view of suggesting that all tobacco (and now nicotine) is equally harmful. The reality is that it’s not the tobacco that causes the overwhelming disease and death but what is done with it or what we allow manufacturers and users to do with it. Burn it and it produces a deadly cocktail of substances. We can significantly reduced the risks of products by taking steps all along the 'tobacco chain'. How tobacco is grown, cured, processed, manufactured, advertised, marketed, regulated and used are all variables that can be changed. Tobacco is also considered the 'white rat' of the plant world and can be used in the development of industrial enzymes and drugs - a recent example of which is the development of a vaccine for Ebola. So let's think about the future and eradicate our antiquated thinking of the past.

So what is MPOWER?

According to the World Health Organization:

"The WHO Framework Convention on Tobacco Control and its guidelines provide the foundation for countries to implement and manage tobacco control. To help make this a reality , WHO introduced the MPOWER measures These measures are intended to assist in the country-level implementation of effective interventions to reduce the demand for tobacco, contained in the WHO FCTC." ( www.who.int/tobacco/mpower/en/ )

One of the biggest limitations to the implementations of these efforts is that they refer to ‘tobacco’ and all tobacco products as being equally harmful. They are not. This approach had its heyday in the US during what is commonly referred to as the 'Tobacco Wars', when Big Tobacco dominated and controlled the market place and aggressively and deceptively worked to ensure that laws and regulations did not adversely affect their profitability. But in today's environment it is not so simple or black and white. Today it is generally accepted that many 'smoke-free' tobacco and nicotine products are at least 95% plus lower in risk than the deadly toxic cigarette. And with the development of new lower risk products including e-cigarettes, we can no longer simply refer to all products that contain tobacco and/or nicotine as being 'tobacco products'.

The current six components of MPOWER are:

M onitor tobacco use and prevention policies;

P rotect people from tobacco smoke;

O ffer help to quit tobacco use;

W arn about the dangers of tobacco;

E nforce bans on tobacco advertising, promotion and sponsorship;

R aise taxes on tobacco.

Each of these areas are given greater details by the WHO in various backgrounders.

But what should MPOWER be focused on today?

Without straying from the use of the MPOWR letter designations I want to suggest some language that would be more appropriate to the current environment and provide policy makers, public health advocates, consumers, health care professionals and even manufacturers some greater flexibilities and opportunities for reducing disease and death caused primarily by smoking and the use of cigarettes. So here is what I propose the MPOWER components be:

M onitor all tobacco and nicotine use and implement policies that seek to regulate products based on risks, relative, risks and intended uses;

P rotect children and adolescents from being able to buy, obtain and use tobacco and nicotine products and protect all people from the adverse health effects of tobacco smoke;

O ffer help to quit cigarette and other high- risk tobacco use by developing effective prevention and cessation programs and making available significantly lower- risk alternative tobacco and nicotine products to users;

W arn and provide truthful and accurate information about the risks, relative risks and intended uses of all tobacco, nicotine and alternative products;

E nforce laws and regulations governing the sale, distribution, marketing, promotion and sponsorship of all tobacco, nicotine, and alternative products but set regulations that are based on risks and relative risks;

R aise taxes on products that cause the greatest level of harm and set lower taxes (or even no tax) on products that are significantly lower in risk than the cigarette.

How can WHO provide some new leadership?

I write this in the hopes that rational and well intentioned stakeholders can look to a future where we can significantly reduce disease and death from the use of the deadly cigarette. The World Health Organization has an important role to play but it must be willing to 'learn and lead'. It can start by having a thorough review of its MPOWER program and make modifications to it that deal with the both the challenges and opportunities of the future. It can come to the table in a 'safe haven' environment such as is being done at the University of Virginia as part of the 'Morven' tobacco nicotine, and alternative products harm reduction dialogues, and it can lead by facilitating its own discussions, dialogues and consultations that deal directly with challenges but more importantly new opportunities. (The Core Principles Statement released by the University of Virginia in January 2015 - www.bitly.com/coreprinciples provides some guidance on how individually and collectively we might get there. This is a 'New Era' and organizations like the WHO have a responsibility to lead and not merely perpetuate past practices.

November 2015

Scott D. Ballin, JD
Health Policy Consultant
Mobile: 202 258-2419
Email: [email protected]