Quit or Switch: The urgency of Tobacco Harm Reduction (THR) strategy in Ghana to reduce the harm caused by smoking

Combustible tobacco continues to be one of the leading causes of preventable diseases worldwide, with millions of people suffering from the health consequences of nicotine addiction and tar. As the global community tackles the burden of tobacco-related illnesses, a growing number of countries are exploring the potential of Tobacco Harm Reduction (THR). The THR approach is towards minimizing the health risks of smoking by providing safer alternatives.

The urgency of the THR approach is increasingly evident, especially in countries where smoking is prevalent, and Ghana dwells in a pivotal moment to embrace the science of controlled strategies (quit or switch) over the traditional strategies (Quit or Die) to reduce the combustible tobacco-related diseases to save lives.

The Dilemma of Quit or Switch

The traditional stance on tobacco control has been to encourage smokers to quit entirely. This is an ideal scenario, where individuals are free from both nicotine and the harmful chemicals found in cigarettes. However, quitting is often extremely challenging due to nicotine addiction; which is why millions of smokers around the world struggle to give up the habit.

In light of these challenges, THR advocates propose a different approach: ‘Instead of pushing smokers to quit altogether, governments can offer them safer alternatives that reduce the health risks while still satisfying their nicotine cravings’. This approach has been successfully adopted in countries like Sweden and New Zealand, where smoking rates have dropped significantly as a result of the introduction of safer alternatives such as nicotine pouches, e-cigarettes, and heated tobacco products.

For Ghana, tobacco use is on the ascendency with 6 in every 100 adults currently patronizing it, juxtaposed against 4 in every 100 adults in 2019. There is a higher prevalence in males at 7% and 0.4% among females, where combustible tobacco use causes more than 6,700 deaths, and 66% of such deaths are premature. This presents significant public health risks. Therefore, adopting a THR strategy could be a game-changer in minimizing the impact of smoking on public health without criminalizing or stigmatizing smokers. Again, the economic implications of combustible tobacco use in Ghana led to a loss of GH668 million, 0.2% of Ghana’s Gross Domestic Product (GDP) in 2029.

According to recent statistics, smoking rates in Ghana stand at around 3.5% among the youth. While this figure is alarmingly lower than in many other countries, the consequences of smoking on public health are far-reaching. Smoking as a major contributor to cardiovascular diseases, respiratory illnesses, and cancers placed a significant burden on Ghana’s already strained public health system and contributed to increased healthcare costs and the government’s budget for healthcare over the years.

Despite this, smokeless tobacco use remains largely unregulated in Ghana, with most policies focusing on traditional methods of tobacco control such as public smoking bans and advertisement restrictions. Although these policies have had some effect, they are not enough to address the risks posed by smokers who are unwilling to quit.

This is where THR could play a crucial role. By offering less harmful smokeless alternatives, Ghana can reduce the health impact of smoking without forcing smokers to quit nicotine entirely. As Mr. Mensah Thompson of the Alliance for Social Equity and Public Accountability (ASEPA) noted during a recent smoke-free society policy dialogue by the Institute for Liberty and Policy Innovation (ILPAI), smoking is a personal choice, and while it should be regulated, it should not be criminalized. Hence, the THR provides a balanced approach by protecting public health while respecting individual rights.

The Power of Substitutes: Case study of Sweden and New Zealand

One of the most compelling examples of successful THR implementation is Sweden. In the 1960s, Sweden had one of the highest smoking rates in Europe, with 36% of the population regularly smoking. By 2022, that number had dropped to just 5.6%, and Sweden is now on the verge of becoming the first country in Europe to be declared smoke-free, with a smoking prevalence of less than 7%.

The answer to this remarkable transformation lies in the adoption of Harm Reduction Strategies (HRS). Thus, instead of banning smoking outright, Sweden introduced Snus, a smokeless, moist tobacco product. Snus delivers nicotine without the harmful byproducts of combustion, which makes it a far less harmful alternative to traditional cigarettes. Over time, a lot of smokers switched to Snus, leading to a dramatic reduction in smoking rates.

It is important to acknowledge that Sweden’s success was not just due to the introduction of Snus, but also because the government used fiscal policies to encourage smokers to switch. This was done through taxing Cigarettes at a higher rate than Snus, creating a financial incentive for smokers to choose the safer alternatives. This strategic use of taxation proved to be a powerful tool in promoting harm reduction.

New Zealand also effectively used THR to reduce smoking rates. Between 2020 and 2023, New Zealand saw its smoking prevalence fall from around 15% to 6.8%, with the country on track to becoming smoke-free in the near future. Like Sweden, New Zealand did not rely solely on traditional tobacco control measures to achieve these results. Instead, the government introduced safer alternatives such as e-cigarettes and nicotine pouches while educating the public about the relative harms of different tobacco products.

The success story of New Zealand demonstrates the importance of public health campaigns in promoting harm reduction and educating smokers about the risks associated with traditional cigarettes and the benefits of switching to safer alternatives. This highlights an important lesson for Ghana to adopt harm reduction strategies to attain a smoke-free society.

The Policy Approach for Ghana

One of the key messages from Sweden and New Zealand’s experiences is the importance of fiscal policy in advancing THR. Both countries strategically used taxation to create a price differential between traditional cigarettes and safer alternatives, making harm-reduction products more affordable and accessible.

In Ghana, the adoption of similar fiscal policies could play a crucial role in promoting THR. By lowering taxes on e-cigarettes, nicotine pouches, and other harm-reduction products while maintaining higher taxes on traditional cigarettes, the government could incentivize smokers to switch. This would help reduce the financial barrier to safer products and encourage more smokers to adopt them.

As Dr Gyedu Owusu highlighted during the policy dialogue on THR, without a favourable tax structure, harm reduction products will remain inaccessible to many smokers, particularly those from lower-income backgrounds, leading to the use of sub-standard products that could exacerbate other public health challenges. If the price of safer alternatives remains higher than that of traditional cigarettes, smokers will have little incentive to make the switch. Therefore, any THR policy in Ghana must include a fiscal component that ensures these products are affordable and widely available.

Also, there should be significant changes to the country’s regulatory framework. As it stands, Ghana’s public health laws provide limited to no guidance on how to regulate alternative nicotine products such as e-cigarettes and nicotine pouches. This lack of regulation leaves both consumers and businesses in a grey area, with no clear guidelines on the safety, marketing, or taxation of these products. Hence, to effectively promote THR, Ghana must update its public health laws to include comprehensive regulations for harm-reduction products. This includes ensuring that these products meet safety standards, are marketed responsibly, and are taxed in a way that encourages their use over traditional cigarettes.

As postulated by Lawyer Richard Armah during the policy dialogue, Ghana’s current tobacco control laws are outdated and focus mainly on public smoking bans and advertisement restrictions. Moving forward, the government must prioritize updating these laws to reflect the changing landscape of tobacco use and the potential of harm-reduction products to save lives.

Based on empirical evidence of success stories demonstrated by Sweden and New Zealand, ILAPI is calling on the government for the urgency of adopting Tobacco Harm Reduction strategies in Ghana. Since smoking is still posing a significant threat to public health, and despite the country’s relatively moderate smoking rates, it is clear that traditional tobacco control measures are not enough, making people hide and smoke. Notwithstanding, offering safer alternatives and creating a supportive regulatory and fiscal environment can reduce the health risks associated with smoking and move Ghana towards a smoke-free future. In this vein, Ghana needs a THR Blueprint Document with extensive consultations to adopt the science of alternative products to save lives and reduce the burdens on our health facilities.

Furthermore, Ghana should learn to adopt the strategies of successful countries like Sweden and New Zealand, which include making smokeless tobacco products available with incentives to import for its use. This should come with unique labelling because THR products cannot be labelled the same as combustible tobacco. This will also prevent the illicit importation of the product through unapproved routes. These smokeless alternatives must be less expensive with continuous education of the public on how harmless they are to use to improve public health and consumer choice.

The time to act is now; whether smokers quit or switch, the goal is the same: a healthier, smoke-free Ghana is the focus!

About Author

Peter Bismark Kwofie is the Chief Executive Officer (CEO) and President of the Institute for Liberty & Policy Innovation (ILAPI).