Opening Substack post: an interview with me

This is my introductory Substack post. I hope this interview will help readers see where I am coming from and why I hold the views I do. I hope it may even persuade those who disagree to engage.

This post is based on questions from an interview I did with an investment bank a while back. I have updated my responses and would like to use this to introduce my Substack and my views. My intention is that future posts will be shorter (1,500 words or less). Please be forgiving while I learn this new system!

Can you discuss how your early engagement with regulation shaped your perspective on tobacco control?

I started as Director of Action on Smoking and Health (UK) in 1997, coinciding with the election of Tony Blair’s Labour government, which took office committed to addressing smoking. The goal was to secure a fairly broad set of measures to rein in the tobacco industry and bear down on smoking - advertising bans, stronger warnings, higher taxes, control of illicit trade, restrictions on smoking in workplaces and public places, public anti-smoking campaigns and so on. This was quite a bare-knuckle fight at the time (the tobacco companies are far less aggressive today), and we took some hits over tobacco sponsorship of Formula 1.

I believed then, and I believe now with more conviction, that you have to take the public with you and win reasonable consent for such measures. At the time in 1997, I was wary of a complete ban on smoking in public places, for example. It eventually came into effect in 2007. The idea behind the WHO FCTC, negotiated between 1999 and 2003, was to generalise a package of measures worldwide and build support and solidarity for it. Having spent time between 2003 and 2013 as a civil servant, I now look at tobacco control measures with more scepticism - both for the potential harms the policies can do (often to the more vulnerable citizens) and also the scope for seemingly bold, idealistic policies to have painful unintended consequences.

How did you become interested in tobacco harm reduction?

I was committed to tobacco harm reduction as soon as I understood the idea, soon after starting at ASH in 1997. It was a privilege to be guided by leading experts in the field, such as Martin Jarvis and Ann McNeill, and to be encouraged by the late Mike Russell. THR is not a new idea, but the technology landscape has changed dramatically for the better in the last 15 years. For me, there were four formative experiences:

1. We saw the potential for NRT for tobacco harm reduction and campaigned to liberalise medicine regulation to allow for indefinite use. See, for example, McNeill A, Foulds J, Bates C. Regulation of nicotine replacement therapies (NRT): a critique of current practice. Addiction 2001;96(12):1757–68. [link]

2. We were horrified by the EU ban on snus (other than in Sweden) despite the evidence that it was a much lower risk than smoking, and it was possible to see health benefits - a proof of concept for tobacco harm reduction. That evidence and proof of concept have only strengthened over time. See, for example, Bates C, Fagerström K, Jarvis MJ, Kunze M, McNeill A, Ramström L. European Union policy on smokeless tobacco: A statement in favour of evidence-based regulation for public health. Tob. Control. 2003;12(4):360–367. [link]

3. We were active against bogus harm reduction claims and what we called out as the “light & mild scam” - see this ASH Report, Why low-tar cigarettes don’t work & how the tobacco industry fools the smoking public, March 1999 [link] and Bates C, McNeill A, Jarvis M, Gray N. The future of tobacco product regulation and labelling in Europe: implications for the forthcoming European Union directive. Tob Control 1999;8(2):225–235. [link]. This was a valuable education on nicotine, titration, compensation, and related topics.

4. Finally, I tried my hand at gazing into the future with this paper in 2000: Bates CD. What is the future for the tobacco industry? Tob Control 2000;9(2):237–238. [link] - I am quite proud of this as it anticipated (roughly) the products and controversies that lay ahead 10-25 years later.

I have always thought reducing ‘harm’ should be the dominant concern of tobacco control - not achieving a nicotine-free society, destroying the tobacco industry, or some other goal.

What do you mean by tobacco harm reduction?

Harm reduction is a widely used concept across public health and society more broadly. There should be no mystery or controversy about applying the concept to tobacco. There are harm reduction approaches used in illicit drugs, alcohol, sexual health, teen pregnancy, gambling, and other risky behaviours. They work because they are usually more pragmatic and effective than trying to eliminate harm by pressing for abstinence. For harm reduction, the threshold for success is lower and more attainable, and can be achieved through consent rather than coercion.

Harm has to be defined in the round, not just severe diseases later in life, but also in terms of day-to-day well-being, the adverse welfare impacts of anti-tobacco policies (like regressive taxation, stigma, illicit markets), and any imposed loss of adult autonomy that belittles people through state overreach. It is more than just declaring that abstinence is the preferred outcome or about using vapes as better smoking cessation meds. It is about helping people to manage their own risks and preferences, and, crucially, to work through informed consent rather than coercion. The approach is to meet people where they are and help them, not to insist they meet a standard they find unattainable or undesirable. I like the definition from Harm Reduction International: "What is harm reduction?"

Harm reduction refers to policies, programmes and practices that aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights. It focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that people stop using drugs as a precondition of support.

Is tobacco harm reduction part of tobacco control?

The goal of all tobacco policy is harm reduction - nothing else. That is coded into the objective (Article 3) of the FCTC

…to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.

People often focus on Article 1d, the definition of tobacco control, which also includes harm reduction, but the entire FCTC is about reducing harm. It should aim to reduce the widest range of harms to the greatest extent, as rapidly as possible, while maintaining public consent and sound ethics.

What is the goal of tobacco harm reduction?

Today, the primary challenge for tobacco policy is to facilitate or engineer a large-scale global migration of nicotine use from high-risk combustible to low-risk smoke-free nicotine products, while keeping the market lawful and regulated in the consumer interest. I would say mainstream tobacco control does not accept that this is the mission and, as a result, is not only failing to realise the potential gains, but now forms a major obstacle to progress, causing more harm than good.

I do not see tobacco harm reduction simply as a more effective or popular way of quitting smoking. It is about changing the way nicotine is used in society, and that includes among those who have never smoked. In some ways, “tobacco harm reduction” is an inadequate term: it is really about reducing the risks of nicotine use.

How feasible is tobacco harm reduction

The case for the feasibility of tobacco harm reduction is very compelling. The conventional model of smoking cessation works by persuading and pressuring a smoker to go from smoking to abstinence and provides behavioural support and pharmaceuticals to manage withdrawal, craving and loss - often with a high level of relapse. The model of tobacco harm reduction is quite different: the aim is to replace one ‘pleasure’ or consumer behaviour with another, but at a much lower level of risk. It is a change in the way of consuming nicotine. The idea is that switching to say vaping or heated products involves giving up much less, and therefore is more feasible. The user can continue to experience nicotine, sensory effects, flavour, hand-to-mouth motion, ritual, identity, etc. It is clear that the demand for nicotine itself is more robust or “sticky” than the demand for any particular way of taking it. This can allow very rapid changes to occur through switching or not starting, as we have seen in younger populations where the smoking habit is less deeply entrenched, or where governments get behind the idea, or at least do not get in the way.

So I tend to see smoking and vaping (etc) as presenting what marketers call rival ‘value propositions’ to new or existing nicotine users. Historically, tobacco control efforts have aimed to degrade the smoking value proposition through regulation, tax and communication. If we can maintain or enhance the vaping value proposition, then more smokers will follow this route.

Why is tobacco harm reduction controversial?

There is often controversy with harm reduction, especially if the underlying risky behaviour is frowned upon, like illicit drug use. Maybe in making it safer, the argument goes, you are also making it more acceptable. There is an element of that in tobacco. The clinching argument against nicotine use was “Smoking Kills”, and it does this and much else to harm the user. But what if the harms of non-combustibles are low or negligible? The “it’ll kill you” argument no longer applies. We ought to be glad about that, but also expect more people to use nicotine once the main reason for not using it no longer applies. Much of the backlash and the frankly desperate efforts of activists and academics to claim vaping and smoking have equivalent harm is to restore what they see as a clinching argument for not using tobacco or nicotine. However, they do not seem to realise (or care) that once the risk is down to the normal levels tolerated in a consumer society, there is far less reason for users to want to stop and far less justification for the state to use coercive powers to stop it.

Why are you advocating for harm reduction and not harm elimination?

There is a basic tension between what is ideal from a health point of view (abstinence or never-use) and what is attainable in practice, given what people want and respect for their autonomy, their motivation to quit nicotine, and any benefits (real or perceived) that people experience from nicotine use. The demand for nicotine is much more robust than any particular way of taking it - it has been in use for 12,000 years and is currently used by around 1.2 billion people, with many more starting each day. It follows that for many people, nicotine use will continue, but considerable health gains can be made by changing the way they use nicotine, primarily by eliminating smoking. A singular focus on nicotine abstinence, though usually with methods that fail, is not somehow superior to a harm reduction approach and diverts attention away from what works to stop smoking.

In my view, we should recognise that nicotine is a relatively innocuous and popular drug and about which the main concern so far has been its ‘dirty’ delivery system - smoke inhalation. Once we adjust to seeing nicotine as part of the collection of legal recreational drugs - alcohol, caffeine and increasingly cannabis - the job is to make the delivery system safe enough. Safe enough means within the normal boundaries of acceptable risk for consumer behaviour, not zero risk. I believe an effort to eradicate nicotine use is both wrong in principle (we should just tolerate other people’s preferences for recreational drugs - many people in public health enjoy a glass of wine!) and wrong in practice (prohibitions have a terrible record of creating more harm than they prevent).

What is driving regulation?

Moving away from tobacco-based combustibles to nicotine use through non-combustibles would be a very good public health mission, but unfortunately, that is not driving regulators, lawmakers or activists. The whole field is bedevilled by hysterical press coverage, evangelical campaigners, unaccountable foundations, grandstanding politicians, and academic activists. Regulators exist and function in this ecosystem of influences and act accordingly.

Much policy is driven by a “scream test” - if the tobacco industry screams, it must be the right thing to do. That simplistic mentality is particularly damaging when tobacco companies benefit from doing something beneficial for health, like the transition to non-combustible products. The WHO FCTC has codified the scream test into something I call the “Irreconcilable Conflict Principle” in Guidelines for the implementation of Article 5.3 of the FCTC:

Principle 1: There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests.

Adherence to that flawed principle means that any form of tobacco harm reduction is unavoidably deemed unacceptable if it is in the interests of tobacco companies, which it clearly is.

What do you think about the tobacco industry?

Firstly, the tobacco industry is not one monolithic thing we can call “Big Tobacco”. The companies vary in size, ownership (including many state-owned or parastatal companies), professionalism, and strategy. There are major differences between firms and, within firms, where there are usually competing visions of the future and intense competition for promotion and preferment. In my view, the most forward-looking companies can see where consumers are heading (toward smoke-free nicotine use) and have aligned their business models to meet that demand. That is unambiguously a good thing. If they make a profit doing that, I will be glad because that is what will move the market towards safer nicotine use and avoid millions of premature deaths.

The scientific work of international tobacco companies on tobacco harm reduction has been of very high quality, in my view. The bioscience, behavioural insights, engineering and product stewardship of the leading companies are genuinely impressive. Their science is held to a much higher standard than most work in tobacco control, as it is intended to convince sceptical regulators or reassure jittery product-liability lawyers. However, the companies drag around a vast burden of reputational baggage that they did much to earn and deserve. That lingering toxic reputation remains a barrier to having their research and analysis taken seriously on its merits or to participating in the policy discourse. It is up to the public health side to act pragmatically here - we have to look forward, informed by history but not trapped by it.

These companies have mixed interests: the cigarette business is highly lucrative, and some will lose from market disruption or greater competition. The tobacco industry should never be uncritically trusted (and I think its executives accept that it never will be). However, that is not the same as always disagreeing with it, always doing the opposite of whatever it wants, always dismissing its research, always excluding it, or believing that everything it does or wants is harmful. Everything about the industry should be judged on its merits and in the current context.

What is the right public health approach to the tobacco industry?

The easiest and laziest approach is to adopt a moralising high ground, dismiss the industry, and exclude them from everything. I do not believe that is the right approach. They are and will remain major players in the nicotine market and have the potential to transform it beyond recognition, given the right incentive framework. The right approach to dealing with these companies is to be open-minded, sceptical, and challenging, rather than denying or excluding. When we shut out someone’s opinions, we implicitly assume our own infallibility (and there is no justification for that!). See John Stuart Mill, On Liberty: “All silencing of discussion is an assumption of infallibility”.

What about youth uptake of these new products, especially among youth who have never smoked?

The youth vaping issue is partly a legitimate concern but mostly an emotive political battering ram designed to secure regulation across the market as a whole, not just focused on youth. We know this because the position of vaping in the portfolio of youth risk behaviours is nuanced (see below), but the discussion of youth and vaping by anti-vaping activists is conducted without any nuance at all - it is not a genuine attempt to understand the problem and to respond to it. I challenge anyone to find a thoughtful discussion of youth nicotine use on websites such as Campaign for Tobacco Free Kids or the Truth Initiative.

I’ll just make four points about this nuance:

1. The counterfactual: in a world without vaping (etc), then many of those taking up vaping would have smoked. For them, there is a large benefit if they initiate with vapes rather than smoking.

2. The low risk: for those who take up vaping (etc) but would never have smoked or used nicotine, the net additional risks are quite low and probably transient, given they would not have become smokers in the counterfactual world.

3. Risk behaviours are pervasive: whatever we think, some people will engage in risky behaviours, including substance use and will initiate them as adolescents. It is very unlikely to stop, but it can be made much less harmful.

4. Young people have a stake in adult wellbeing: young people are often discussed as though they are a distinct population, yet they benefit from adult harm reduction through reduced role-modelling, household expenditure, impacts of smoking on adults, and secondhand smoke exposure at home.

If we could start the discussion about youth by accepting these ideas, we could do far more for both adults and young people.

Why has the WHO taken a hard, negative stance on harm reduction?

I am filled with dismay and despair about WHO, and believe it has let down a billion people at risk from smoking-related disease in order to pursue a nicotine prohibition agenda, favouring bans on newer, far safer products than cigarettes. No organisation has done more to protect the global cigarette trade or to deter people from life-saving changes in the way they use nicotine. Its behaviour is toxic and irrational, and, at least in this field, it is doing far more harm than good. It should cease and desist.

Why is it doing this? I think it is largely because it is disconnected from the consequences and has no accountability for outcomes, so it takes the path of least resistance. This means bureaucrats take extreme positions because it sounds “tough” and ambitious, and it wins applause from NGOs and other unaccountable bureaucrats. In practice, it means getting in the way of doing practical things to improve the situation.

You are a critic of Michael Bloomberg’s role in tobacco policy, why?

The New York financial services billionaire and philanthropist, Michael Bloomberg, spends hundreds of millions of dollars in this field and serves as a WHO ambassador for non-communicable diseases. Yet his policy instincts are those of an out-of-touch elitist, beset by a range of obvious, harmful, unintended consequences. He remains totally unaccountable for the consequences of his actions and interactions with governments through his giant complex of well-funded activists, academics, PR professionals, and officials. He is surrounded by people who refuse to engage with evidence suggesting he is doing more harm than good. Nowhere is this more evident than in low- and middle-income countries, where his staff and money can make a significant impact with little resistance. Though they like to pretend to be independent academics, journalists or civil society organisations, Bloomberg’s complex of organisations serves the ambitions and policy preferences of one overconfident, unaccountable billionaire and his prohibition agenda. It is the most counterproductive use of philanthropic money in the whole of public health, and it needs to stop before even more people are killed by philanthropic negligence.

What is your take on the UK policy and its signature legislation, The Tobacco and Vapes Bill

This is dreadful legislation. I will give two reasons.

First, the headline smoke-free generation ” is a useless anti-smoking measure. This is mainly because it misses the most important population at risk: middle-aged people born well before 2009. It will have a negligible effect until about 2050, and even this relies on ridiculous assumptions about the efficacy of age restrictions (we already have smoking under age 18) and only if we assume that young people would still be smoking in 2050 without the measure. It is far more likely that they will have switched to much safer alternatives. Contrary to popular sentiment, the smokefree generation is exclusively an adult measure (it only takes effect after the current age limit of 18) and raises novel concerns about state intervention in adult free choice. In my view, it will be replaced by a T-21 limit as Parliament comes to see the folly.

Second, it bears down on the one thing likely to help adults who smoke with a range of populist measures designed to look tough on vaping (not all within the legislation), including high taxes, bans on disposables (despite millions using these as alternatives to smoking), bans on vaping ads (a gift to the incumbent), and a whole series of powers to do even more damaging crowd-pleasing things that will harm nicotine users and deter switching to safer forms of nicotine use.

You have said that the market is becoming harder to regulate and a new model of tobacco control is now needed. What do you mean?

When I started in 1997, the world was a simpler place. We could all unify around opposition to cigarettes, tobacco, nicotine, passive smoking and the loathsome tobacco industry. Now, the situation is more complex and requires greater subtlety. This is because the range of health-improving products and options is more complex, and also because I think regulators are now more constrained by the risks of unintended consequences (e.g., increased smoking, greater illicit trade, and more risky workarounds) that arise in response to regulation or taxation.

The difficulty of controlling these markets has changed radically. We have a range of technologies and business models that barely existed in 1997. These include e-commerce, cross-border sales, encrypted messaging apps, social media for promotion, courier services, international payment systems, and cryptocurrency. The supply chain has become more international and fluid, with longer supply chains and greater distance between the manufacturer and the final seller. Illicit products are concealed in misdescribed consignments buried in containerised freight reaching criminal suppliers and then entering informal markets. Illicit drug networks can adapt to lucrative tobacco and nicotine smuggling and have illegal networks for distribution and corruption of port officials and law enforcement. Law enforcement struggles to keep up (not least because, deep down, they know it isn’t that harmful).

Even in a jurisdiction such as Australia, with high-powered law enforcement and muscular regulators, over half the tobacco market is illicit, and nearly all the vape market is through sales outside the official regulatory regime. It turns out Australia was grossly underestimating the size of its illicit markets until a recent reassessment. [see Australia’s Illicit Tobacco and E-cigarette Commissioner’s report 2024-25]. And Australia is hardly the only example.

This should tell us something important: the scope for regulation that denies adults what they want has contracted, and policies that rely on restrictions and coercion are more likely to fail. This is why I see harm reduction approaches that rely on consent rather than coercion as far more promising. Yet no one is learning from this, or even showing much interest in these outcomes.

What is the way forward from a policy point of view

It’s a big question, so let me put down a few guiding ideas:

1. There should be clarity on the goal. The goal should be reducing harm to the greatest extent possible, and in practice, that means reducing smoking and the existing stock of people who smoke and the flow of people taking up smoking. It is not a nicotine-free society, the end of the tobacco industry, stopping youth vaping, or anything else. The overall aim should be to achieve a large-scale global migration of nicotine use to safer alternatives to smoking. Do that, and the job is largely done.

2. The need to keep the market mainly legal is an overarching constraint, and policies that drive illicit trade to unacceptable levels should never be adopted. Illicit markets create unregulated commerce, engage young people in supply chains, undermine law and order, and are ultimately controlled by violence and corruption.

3. Policy should rely primarily on informed consent. This means being honest and candid about risks and consequences of nicotine use, and also about the large differences in risk between products. That understanding needs to be baked into policymaking, professional practice, and public health advocacy.

4. Regulation should primarily focus on consumer protection and the consumer interest - this means that products should be what they say they are, and should meet high standards for chemical, microbiological, thermal, electrical and mechanical safety, with reasonable quality assurance in manufacturing and distribution.

5. Policymakers should be wary of regulation aimed at behaviour change or at deterring use, rather than at consumer protection; this is where unintended consequences emerge, as consumers and suppliers work around regulation. I see a place for age restrictions and marketing controls (including controls on trademarks, flavour descriptors, packaging, and display), but bans on product features (such as flavours) that work against consumers will have unintended consequences.

6. Regulation can evolve over time, and may be linked to the level of smoking in a jurisdiction. With a high level of smoking, a liberal, permissive approach to safer alternatives may be justified, but a more restrictive approach may be adopted when smoking is largely squeezed out.

Please leave any other questions in the comments, and I will try to respond.

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