Between the sledgehammer and the anvil - smokers, e-cigarettes and tobacco companies

The debate on harm reduction and e-cigarettes is a heated one. Not least since the tobacco companies got involved. But what do they really want? And why do cigarette manufacturers care about e-cigarettes? Vejpkollen visited Philip Morris.

The world of tobacco and harm reduction, especially e-cigarettes, is like a minefield. A playing field where every step risks triggering an explosion. 
It is very difficult to get it right.
It is very easy to make mistakes.
I think about that as I stand in the lobby of Philip Morris - one of the world's largest tobacco companies. It's a pretty fancy office, but not as flashy as you'd expect from one of the world's biggest companies. A few armchairs, a table, a coffee machine sighing in the corner. Nothing over the top. Very quiet. 

Something undesirable

In the middle of the room, however, is one of the reasons why the debate on harm reduction and e-cigarettes is so complicated. A glass case containing Philip Morris' own version of a vejp product - IQOS - an electronic system for heating tobacco.

In all its simplicity, it is a product that reduces the risks of inhaling nicotine. But it is also a product that divides politicians, health researchers, activists and, for that matter, vejpers into several opposing camps. On the one hand, those who see all the benefits of harm reduction as something welcome. On the other hand, those who see everything coming from a tobacco company as something undesirable.

The doctor who changed sides

I am here to meet Claude Guiron, Scientific Director of Philip Morris' Nordic operations. A cardiologist by training, he comes straight from the pharmaceutical industry and is now employed by PMI to deliver a specific message: a smoke-free society is possible, harm reduction works and tobacco companies have some of the solutions. IQOS, electronically heated tobacco, is one of them. Traditional e-cigarettes, snus and nicotine pouches are others.

"We have the technology today and several smoke-free products have been developed rapidly, just in the last five years. PMI's goal is to become a smoke-free company, but to do that we need to get smokers to stop smoking. We also know that current smoking cessation medicines do not work for everyone. Many smokers want to continue using nicotine, so snus, nicotine pouches and e-cigarettes are important alternatives. " says Claude Guiron.

Called the angel of death

Claude Gurion is the doctor who changed sides. From drugs to tobacco. From saint to heretic. I don't know if the parable is fair. But there is no doubt that others like to use biblical terms to describe Claude Guiron. He and Philip Morris were recently called "the angel of death" by Aftonbladet columnist Peter Kadhammar. It is a strong expression that would normally be removed by any responsible publisher. But not in the case of Claude Guiron and Philip Morris. It is gloves off. Any message from the tobacco industry is by definition dangerous. That includes anyone on their payroll. 

Stigma

Claude Guiron is aware of that too. Managing it is a bit of a job description.

"There is a huge stigma around smoking. And the tobacco companies don't have a good reputation, of course. You have to step back and think, why are we doing this? It's about offering smokers an acceptable alternative to cigarettes. And it's incredibly inspiring to be part of. It will take time to build trust, of course. But it makes the job meaningful too," says Claude Guiron.

Want to ban cigarettes

Phillip Morris attracted worldwide attention when CEO Jacek Olczak suggested that all cigarette sales in the UK should be banned within 10 years. A somewhat unexpected move by one of the world's leading cigarette companies. And quite problematic. Why would a company want to ban the product they make billions from?
The answer: alternative products: e-cigarettes, nicotine pouches, snus. And IQOS.

Harm reduction in politics

It was no coincidence that the PMI focused on the UK. Harm reduction is an integral part of UK tobacco policy and e-cigarettes have taken their place as a cutting-edge technology to phase out smoking, alongside traditional medicines.

"E-cigarettes are not risk-free but significantly less harmful than cigarettes. Smokers should therefore consider switching to vejpning." British health authorities repeat time and again in public statements.

We see similar strategies in New Zealand and to some extent USA, where IQOS, was recently classified as a harm reduction product (Swedish snus has also received such a classification).

Set an expiry date for cigarettes

Claude Guiron argues that Swedish politicians should also consider the issue.

"Set a date. A date when the last cigarette will be sold. Until then, raise the tax on analog cigarettes and keep it down for the alternatives. Allow less harmful products to become more attractive to smokers. Allow manufacturers to provide information on relative harm risks. For smokers - not non-smokers"

Nicotine

Claude Guiron sounds like any other harm reduction activist. It's all about relative risksto ensure that smokers are properly informed about the harmful effects of nicotine versus smoke. That a smoke-free life does not have to mean total abstinence from nicotine - that nicotine is not the enemy.

"There are several ways to help smokers quit. For smokers where medication and therapy don't work, there must be more alternatives" says Claude Guiron.

The enemy with a capital F

The difference, of course, is that Claude Guiron represents something different. He is not a leftist vejpshop owner or a passionate ex-smoker puffing on an e-cig. He represents a big tobacco company. Big Tobacco. With all that entails.
For many, he is the enemy with a capital F. 

Harm reduction - a new target

Since tobacco companies started using the word 'harm reduction', the term itself has become a target, almost more than smoking itself. Activist groups like Non Smoking Generation, Tobaksfakta - both funded by Public Health Agency of Sweden, calls tobacco harm reduction a myth - a Trojan horse that could benefit tobacco companies if we let the philosophy seep into policy. 

Harm reduction in other areas

At the same time harm minimizationIn drug and sexual policies - needle exchanges and condoms are examples of harm reduction. In traffic, we see bicycle helmets and seat belts - innovations that make risky behavior less dangerous. No one seriously believes that we will stop cycling and driving just because it can lead to fatal accidents. Still less will young people stop having spontaneous sexual relations just because it could lead to unwanted pregnancies or STDs. Nor will all drug users stop using drugs just because it is 'best' not to. They have a lot to gain from clean needles and an open door to care and support.
Most people agree that harm reduction can save lives. 

A myth?

But it does not apply to smoking. At least not in Sweden.
"Tobacco harm reduction is a myth spread by tobacco companies. Today, there is better help available through medicines and support through health care for those who want to quit smoking," said the Public Health Agency of Sweden's head of unit Josefin P. Jonsson during a seminar in Almedalen as late as 2021.

So who can be trusted? Experts contradict each other, interpret science differently. It's easy to get it wrong, hard to get it right. For smokers and politicians alike.

An established concept

Claude Guiron is convinced that there is no stopping this trend. E-cigarettes, the vejping of nicotine, basically an innovation that grew from the grassroots. But it is here to stay. At the same time, tobacco companies are not going away, they are adapting to a market where fewer people want to smoke. They are taking their place, if only because of their enormous financial capacity. And to exclude them from the discussion on reducing the harm caused by smoking is naive, he says. 

"Harm reduction is a concept that has been established in research and proven to be an effective way to reduce the harm of a deadly product," says Claude Guiron. "It's not just us saying this. There is plenty of independent research and clear examples of harm reduction working. Sweden is a good example, where alternatives such as snus and nicotine pouches have long been available. Here smoking rates are down to 6%. In the UK, where e-cigarettes have taken hold, smoking is falling rapidly. In Japan, where sales of heat-not-burn products are increasing rapidly, smoking is falling even more."

Alternatives to cigarettes

Claude Guiron says that many companies and authorities around the world have their eyes on Sweden. "And it's not about our tough rules for tobacco products. It's about the fact that tobacco sells well here, while tobacco-related harm is relatively low.

"They see that it is not only restrictive legislation that works. In countries that don't allow alternatives, it turns out that smoking rates are much higher. Finland and Denmark, with stricter legislation on e-cigarettes and snus, has a higher proportion of smokers (14%) compared to Sweden and Norway" 

Economic calculation in the background

Snus has been a key product, says Claude Guiron. It is a phenomenon that has de-normalized smoking right from the start. The public health authorities and the anti-tobacco movement certainly do not agree with this analysis. But many tobacco companies, which base almost everything they do on economic realism, see opportunities to broaden their portfolio with less harmful products. That actually sell.

Want to reduce cigarette sales

PMI wants to be at the forefront of that development, of course. But competitors such as British American Tobacco and Japan Tobacco are on board, at least as motivated. In addition to IQOS, PMI has invested in snus, nicotine pouches and e-cigarettes. Some products are available on the Swedish market, others are not. 

"Tobacco companies are not the fastest innovators in the world. What we are very good at is spreading products for mass consumption through efficient distribution. We don't develop everything ourselves, we also buy technology, develop it further and make it available globally. It doesn't really matter what type of product it is - cigarettes, e-cigarettes, snus or nicotine pouches. But there is always an economic calculation in the background, of course," says Claude Guiron. "Today, 30% of PMI's revenue comes from smoke-free products. The goal is for everything to do so. But it will happen gradually, by 2025 it will be 50%. But all launches are preceded by an economic calculation. Will it be possible to sell the products?"

Tobacco industry stopped by WHO

But selling requires more than just good arguments. Marketing of nicotine and tobacco products is currently severely restricted. This includes traditional lobbying and information on research findings that would increase interest among smokers. But according to The WHO Tobacco Convention from 2003, the tobacco industry should not be allowed to influence health policy in signatory countries. So no matter what Phillip Morris, or any other tobacco company, says, they MUST by definition speak to deaf ears. This is also the case in Sweden.

"It is of course very frustrating. The WHO statement comes from a different time" says Claude Guiron "A lot has happened since 2003. We've seen incredible innovation in products that deliver nicotine in a less harmful way. And authorities are struggling to keep up, partly because the Convention prevents communication with companies. After all, we are the experts on the products we have developed. We also see this when we examine the knowledge about smoking and harm reduction among smokers. It is very poor. The only thing we can do is to be more transparent, write opinion pieces and invite people to open lectures. But it's very skewed."

Smokers do not receive accurate information

The bias is reflected in the information that reaches the target audience for harm reduction interventions, says Claude Guiron. Smokers. When the UK Public Health Agency 2020 smokers asked what they know about e-cigarettes, it became clear that something is not right. Nearly half of all smokers believed that vejping, that is, e-cigarette use, was as, or more, harmful than smoking. The science, according to UK authorities, clearly shows that it is the other way around. Using a regulated e-cigarette means that smokers expose themselves to a significantly lower risk, almost 95% lower. 

"It's the smoke, the combustion that kills smokers. Knowledge of this is actually quite low, even among doctors and those who work with smoking cessation. Worse still, 30% of smokers who have a heart attack continue to smoke afterwards. And nearly 40% of patients with COPD continue to smoke, even though it makes the disease worse," says Claude Guiron. 

IQOS - more research needed

IQOS also has a harm profile similar to traditional e-cigarettes. However, it British health authorities notes that the technology is much newer and that much of the research on IQOS comes from Philip Morris.

"More independent research is needed. Using IQOS is less harmful than smoking cigarettes, but whether it is 95% less dangerous, we strictly do not know today" admits Claude Guiron.

"Faster if everyone pulls in the same direction"

But who really listens to the "angel of death"? Tobacco companies still make the big money from cigarette sales. And although smokeless products such as nicotine pouches and electronic cigarettes are growing at an ever faster pace, it is still smoking tobacco that is in greatest demand. But smokers are the key, says Claude Guiron. Their choices can change an entire industry, he says.

"We still have 500,000 daily smokers in Sweden. Many of them do not want to quit smoking. This is a large group that can be helped by new technologies, such as e-cigarettes or heat-not-burn products. The problem is, if we stop selling cigarettes, someone else will sell them instead. So it's not very likely that someone will stop selling cigarettes overnight. We need to change a whole industry. Then it's about phasing out smoking. Smoke-free products will take more space little by little. PMI is investing heavily in the transition. But it would be quicker if authorities and politicians worked in the same direction"

Flavourings - a source of concern

Back in the foyer. With IQOS, Claude Guiron and an unclear future. In the spring, the Swedish Parliament will discuss harm reduction within the new strategy for alcohol, drugs, doping, tobacco and gambling (ANDTS). Later also a possible taste ban for e-cigarettes and e-liquid. Claude Guiron says it's a complex issue that requires reflection.

"Flavoring is of course a concern for politicians. But if products are to work for harm reduction, they must be attractive to smokers. It is debatable whether some flavors appeal to young people more than others. But instead of a sweeping ban, perhaps it is appropriate to allow certain flavours to be sold only in specialized vejp shops? The most important thing is that we keep age limits and that we have a regulatory framework that guarantees quality and safety. We see such a system in New Zealand, for example, where only licensed specialist shops are allowed to sell flavors other than tobacco, menthol and mint" says Claude Guiron.

The Angel of Death

I leave Philip Morris and head out into the Stockholm dusk. Someone has thrown a burning cigarette on the sidewalk. It lies there among other cigarette butts. A different kind of minefield. I think of Peter Kadhammar and the angel of death. About power and who takes the right to use it. Another minefield where the slightest misstep triggers an explosion. It's easy to make mistakes - when lives are at stake. Isn't it?

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