Tobacco harm reduction and e-cigarettes: setting a unified research agenda


Marisa de Andrade & Gerard Hastings

Institute for Social Marketing, University of Stirling

Recent discussions about an endgame for tobacco have built on a sense that we in the tobacco control (TC) movement know where we are going. The consistent application of evidence based strategies, from adbans to tax increases, was, it seemed, driving an inevitable progression towards a smoke-free world; the only question was ‘when would the prevalence line cross the X axis?’

Tobacco harm reduction (THR) has been a carefully modulated dimension of this debate. Now this balance has been unsettled by the sudden arrival onto the market of a wide range of e-cigarettes and other Nicotine Containing Products (NCPs). The development suggests both opportunities (such as greatly reduced harm for the heavily addicted) and threats (like the potential rehabilitation of the tobacco industry), and in the process throws up multiple research questions. This THR Research Agenda commissioned by Cancer Research UK presents a first attempt to map these questions.  It was informed by a review of the academic and grey literature and consultations with twelve TC experts.

It quickly became apparent that research questions could be grouped into four broad (and sometimes overlapping) areas: impacts on the individual; the tobacco control movement; the political environment; and philosophical issues.

A taxonomy of harm reduction research









A taxonomy of harm reduction research


According to the National Institute of Health and Care Excellence (NICE) draft HR guidance, e-cigarettes offer a cleaner vehicle for the delivery of nicotine as ‘the harm associated with cigarette smoking is almost entirely caused by the toxins and carcinogens found in tobacco smoke’. Ongoing evaluations of safety (short and long-term) are recommended by the health body, a call which a recent German Cancer Research Center report and presentation to the European Parliament also makes very strongly.

This research needs to be balanced with an examination of efficacy: how effective are NCPs and e-cigarettes as smoking cessation aids and at helping smokers cut down, and what impact does this have on quitting? We also need to know how NCPs are being used – for dual use, temporary abstinence, long-term as a tobacco substitute or part of a quit attempt – and by whom, covering age, socio-economic status, gender and ethnicity. By extension, potential impact on individual and population level inequalities also needs to be assessed.

More broadly there is a need to examine how key stakeholders, including smokers, non-smokers, policymakers, primary healthcare staff, journalists, children and young people, are perceiving HR, NCPs and all related commercial and social marketing activity.

Tobacco control

Developments in THR and e-cigarettes also raise strategic questions for tobacco control.  What priority should the TC community give to HR relative to other tobacco control approaches? We need to know how, if at all, HR interacts with these other approaches and specifically with complete cessation (eg do NCPs and/or e-cigarettes help or hinder quit attempts?) and youth prevention (eg could they act as a gateway to smoking?). In each case the net needs to be thrown wide to capture the effects not just of the products themselves, but the way they are presented and promoted in digital and conventional media.

The regulatory response is varying around the world and the efficacy and wider impact of these alternate models needs to be examined. In the UK, for example, where NCPs could soon be regulated by the Medicines and Healthcare products Regulatory Agency (MRHA), questions arise about how marketing will be overseen. What would the official channels be for reporting potential breaches, and how would this fit within the regulator’s remit? How well does this regime operate compared with other jurisdictions where tighter controls (eg complete adbans) are in place? More broadly, how did these different approaches arise?

The impact, if any, of HR and the use of NCPs on the denormalisation of smoking is currently unknown. Does e-cigarette use, for example, model smoking?  More specifically, to what extent, if at all, do the new products undermine smoke-free legislation, or the packaging, point of sale (POS) display and advertising of them undermine tobacco marketing controls? Potential conflicts with current regulation could also raise concerns relating to the Framework Convention on Tobacco Control (FCTC).  Specifically, how should Article 5.3 be interpreted and deployed when the tobacco industry (TI) is investing so heavily in HR and associated products?


The FCTC also raises political debates.  Is the TI using HR to engage in and influence health policy, perhaps via third parties (either commercial or public)? What, if any, conflict of interest does TI investment in reduced risk products present? Could it, for instance, undermine or remove public health gains from HR? And what is the TI’s business strategy with regard to NCPs and the implications for TC? Under what circumstances, if at all, could the TI come to be seen as a legitimate stakeholder? Is the tobacco TI using HR as a corporate social responsibility or stakeholder marketing strategy? If so, how is this happening and what are the potential dangers?

It is also necessary to know how research on HR and NCPs is being funded, and what impact will this have on TC. What, if any, similarities are there between TI interest in HR and its past activities around filtered, safe and low tar, cigarettes? What, if any, links will develop between the tobacco and pharmaceutical industry and what are the implications for TC?

International implications also need to be addressed.  What impact do decisions made in one country have on the rest of the world, and what can be learnt from countries where both smoking rates and HR activities are low?


More broadly still, HR and NCPs raise questions about the fundamental purpose of public health. Is it an acceptable and effective public health practice to promote an addictive product? How does this vary between cultures and classes? What, if any, impact does HR have on the individual’s sense of agency and his or her ability to address wider health behaviours?

Finally, does the resulting accumulation of corporate power present any threats to TC or public health more generally?


There is a new sense of uncertainty in tobacco control.  THR has been presenting alternate perspectives for some years in an appropriately cautious fashion, but the sudden arrival on the scene of heavily marketed e-cigarettes and other NCPs has greatly energised the debate.  It is vital that the tobacco control movement agrees a unified strategy to address these developments; amidst all the uncertainty there is one certainty: any divisions will be ruthlessly exploited by vested interest. This taxonomy of harm reduction research provides a first step towards this unified strategy.

  • Tom Gleeson

    Interesting questions. End game presumably being total nicotine abstinence then HR is not the way to go. In fact total nicotine abstinence is an impossibility their will never be a time when nicotine is not consumed by people as a recreational drug just as their will never be a time when caffeine is not consumed. If end game is defined as total abstinence then it’s a never never land that’s not achievable.
    If end game is the elimination of smoking related diseases to a statically insignificant level then HR is the missing piece of the puzzler.
    We have achieved all we can with the stick, time for the carrot.

  • Jon Krueger

    Which of the following sounds like harm reduction to you:

    Marlboro when you want it

    Rides alongside your smokes

    The foilpack fits perfectly alongside your smokes

    Whenever smoking isn’t an option, reach for Marlboro snus

    Made for smokers: Marlboro snus!

    If you said “none of them” you’re right. These are all Philip Morris advertising for their spit tobacco product. They all explicitly market dual use, undermining quitting, pretty much the opposite of harm reduction.

    If you want to know what the TI might do with e-cigarettes, look at what it did with snus.

  • cabbo

    Mainstream interpretation of electronic cigarettes seems to be that they are an attempt to give an exactly equal experience to ‘analog’ cigarettes. This is a misinterpretation, and the main focus of any attempt to capitalize on the harm reduction capabilities of these devices should be to discourage this outlook.

    Typically, devices made to look like real cigarettes are sub-par compared to those made by manufacturers that recognise ‘vaping’ as its own animal. Devices that look like personal vaporizers rather than cigarettes (even smaller, more mainstream ones like the popular and effective ‘ego’) are easily recognisable as a separate entity to smoking. These devices do not promote smoking, and the two should not be considered relevant to each other (I realise that seems paradoxical, but the experience of vaporizing does not feel similar to that of smoking).

    Any attempt to regulate the manufacture and sale of vaporizers should work with manufacturers like joyetech, smoktech, innokin, totally wicked and their ilk. I do not suggest in-house regulation, but I am certain that these and other manufacturers would jump at the chance to submit their products for honest clinical review.

    Treat this new harm reduction product as a safe alternative rather than a quick fix. Work with manufacturers who hold this outlook, make sure they actually are acceptably safe, then submit them to the mainstream as an equally or more satisfying alternative nicotine delivery solution without even mentioning smoking.