2019 began auspiciously, with a sense that the end of smoking might finally be on the horizon. This ambience of optimism, however, was short-lived. Instead of progress, 2019 brought a series of setbacks, schisms, and squandered opportunities to improve global health. Still, I remain hopeful that 2020 can be different.

Over the past year, the source of hope and of controversy was one and the same: innovation in the field of tobacco harm reduction (THR). THR products (defined as products that separate nicotine from the products of combustion or sources of cancer) have existed for decades in the form of nicotine gums and patches. Recently, this category has expanded to include e-cigarettes, which research suggests may be far more successful than previous THR interventions. Yet, just as the public health community was beginning to recognize the promise of e-cigs, a so-called “vaping crisis” tarnished their name.

This crisis was not entirely manufactured. Real people got sick; and some of them, tragically, lost their lives. By now, the bulk of these illnesses have been traced back to vitamin E acetate in black market products containing THC (i.e., not nicotine). Yet, hyperbolic coverage by the media led to widespread conflation and demonization of all vaping devices—including THR products that could save smokers’ lives.

Questionable science, combined with worried parents and an ethic that places theoretical concerns about children’s future health above the urgent needs of adult smokers, has bolstered negative narratives about THR. Fearmongering of this nature counteracts tremendous progress in this field and has the potential to send ex-smokers back to their deadly combustibles.

Further, THR controversy has driven a wedge between parties that should be on the same side. Scientists, physicians, public health organizations, and regulators agree that smoking is a societal scourge that should be eliminated. Yet, rather than collaborating to achieve this goal, these groups have spent countless hours debating the merits or drawbacks of THR. As we greet a new decade, it is critical that we avoid this sort of infighting and instead focus on the goals that unite the anti-tobacco movement.

New Year, New Resolutions

In 2020 we celebrate the 50^th Anniversary of the first World Health Organization (WHO) resolution on “the health consequences of smoking.” Tabled at the Executive Board of the WHO in 1970, this resolution delineated the dire consequences associated with tobacco use and called for early actions, including: the formation of an expert group to develop further recommendations; and studies on crop alternatives in tobacco-producing regions. This call yielded many meetings and proposals but little tangible change.

Since 1970 we have witnessed the rise and slow decline of smoking in most of the developed world. Yet, smoking rates remain alarmingly high in the most populous countries, including China, India, and Indonesia. In 2020, we must not only acknowledge that smoking persists as a pressing global health threat, but also adapt our tactics to address the ways in which this threat has evolved.

Most of the world’s smokers now live in low- and middle-income countries. Enacting change in these countries requires knowledge of and sensitivity to their cultural, regulatory, and economic nuances. The shape of the smoking epidemic has evolved not only with respect to geography, but also gender. 50 years ago, women smoked far less than men; today, they are catching up. Whereas global smoking rates among men are declining, rates among women likely have yet to peak. Resultantly, there are now countries in which lung cancer kills more women than breast cancer.

The longevity of the smoking epidemic has, unfortunately, relegated its devastating impact to old news. It should thus be no surprise that vaping hysteria attracts more attention than the eight million people killed by smoking each year. E-cigarettes are far less harmful than combustibles; but they’re new, and therefore newly ripe for panic. Rather than add to this misguided frenzy, experts in this field must work together to tackle smoking with fresh eyes and bold ideas.

My hope is that we will revisit the passion of those who fought to get smoking onto the WHO agenda 50 years ago, keeping our focus on the prevention of tobacco-related deaths. And in 2020 we have an opportunity to do just that. This October, the ninth session of Conference of the Parties will review the goals outlined in the Framework Convention on Tobacco Control. This event, which will take place in the Netherlands, creates an opportunity to address gaps in current approaches to tobacco control, and to infuse new energy into this decades-long fight.

To this end, there are several key steps we can take to usher in real change. First, we must build a coalition of diverse players devoted to ending smoking. In the spirit of the Morven Dialogues, the only requirement for participation in this coalition would be a commitment to tangible actions that expedite a reduction in smoking-related deaths. Second, genuine progress requires that we embrace the full spectrum of tobacco harm reduction and cessation interventions, and that we enact regulations aligned with this stance.

Third, future strides must attend to the needs of groups for whom smoking rates remain disproportionately high. These include people with comorbid conditions, ranging from clinical depression to tuberculosis. Social factors can also increase the risk of tobacco use and therefore must also be addressed. For example, smoking rates remain high in marginalized groups, including indigenous people and the LGBTQ community; we must work to better understand this phenomenon and generate solutions catered to these groups.

Finally, it is vital that we develop policies and interventions that reach the poorest groups in countries where smoking rates have shifted little over the decades. These communities have for too long been neglected and warrant our urgent attention.

We have work to do.