Towards a smoke-free future: Lessons from Japan

Smoking causes a number of serious diseases (including cardiovascular and pulmonary diseases and cancer) and increases the risk of early death. With around eight million attributed deaths every year, cigarette smoking is a formidable public health challenge for governments, regulators and public health authorities worldwide.

Tobacco control measures aimed at preventing smoking and supporting quitting play a key role in reducing the harm caused by smoking. Clearly, the best option for a smoker is to quit smoking, but the reality is that many won’t. According to the World Health Organization estimates, more than one billion people continue to smoke worldwide, and the number of smokers is unlikely to decline in the foreseeable future.

But for those adult smokers who do not quit, the opportunity to switch to scientifically substantiated, less harmful alternatives has the potential to accelerate the decline in the number of people smoking cigarettes. This is the principle of tobacco harm reduction.

Many people believe that nicotine is the main issue when it comes to the harms of smoking, but the evidence tells us this is not correct. Nicotine is not without risk and is addictive, but it is not the primary cause of smoking-related diseases. In fact, it is the toxic chemicals in the smoke that is generated when tobacco is burned — and not the nicotine — that is the main problem. Over 6,000 chemicals are produced when the tobacco in a cigarette is burned, around 100 of which are associated with smoking-related diseases, impacting public health.

In recent years, the role of tobacco harm reduction has been stimulated by the development and commercialisation of novel nicotine and tobacco products, including e-cigarettes and heated tobacco products. These products do not involve the burning of tobacco, do not generate smoke and reduce the levels of toxic chemicals emitted when compared with cigarette smoke. While these products are not risk-free, when scientifically substantiated and regulated, they can be a better alternative for adult smokers who switch to them completely.

In several countries, the use of regulated novel nicotine and tobacco products is seen as an appropriate alternative for smokers who do not quit, and their use is encouraged by public health bodies. For example, Public Health England’s ‘Stoptober’ campaign recommends heated tobacco products to help cigarette smokers stop smoking. New Zealand’s

Health Promotion Agency has adopted a similar approach.

A country that merits attention is Japan, where a large number of smokers have switched to novel nicotine and tobacco products despite no formal tobacco harm reduction policy to encourage switching. Since the introduction of heated tobacco products in 2014, Japan has become the biggest market for heated tobacco products and accounts for an estimated 85 per cent share globally.

A study by researchers from the American Cancer Society mapped the growth of heated tobacco products against the decline of cigarette sales in the Japanese market, which found that cigarette sales began to decline following the launch of heated tobacco products in the country. Furthermore, the study found that the decline started sooner in those prefectures where these products had been introduced earlier.

Researchers applied multiple alternative causation models to the sales figures, including pricing and legislation, but found it difficult to explain the decline in cigarette sales without factoring in the introduction of heated tobacco products in the country. The study concluded that heated tobacco products ‘likely reduced cigarette sales in Japan’. However, the authors cautioned that the study assessed the reasons for the decline in cigarette sales and not the health impact of heated tobacco products.

A second, independent study, reported that between 2015 and 2019, total cigarette sales dropped by 34 per cent in Japan, while the sales of heated tobacco products increased from 5.1 billion sticks to 37.1 billion. The study concluded that “the accelerated decline in cigarette-only sales since 2016 corresponds to the introduction and growth in the sales of heated tobacco products.”

The decline of cigarette sales in Japan can inspire other countries looking to decrease the sale of cigarettes among their population. As seen in Japan, smoke-free products canplay an important role in replacing cigarettes with legal age smokers. With the right regulatory encouragement, support from civil society, and innovative science-based reduced harm alternatives, a future without cigarettes is possible.

This article is sponsored by Philip Morris Management Services (ME).