Prof. Ghazi Zaatari: Ban filters and flavors, control nicotine, stop social-media promotion to curb the tobacco epidemic

Sursa Foto: Prof. Ghazi Zaatari

Irina Papuc

09 decembrie, 2025, 16:21

Vizualizări: 305

Between 17 and 22 November, Geneva hosted the 11th Conference of the Parties to the WHO Framework Convention on Tobacco Control. COP11 proved to be a complex session, with Parties examining the need to regulate new nicotine-based products, adopt measures that protect public health, address the environmental burden caused by tobacco-related waste, and counter—under Articles 5.2(b) and 5.3 of the Convention—the tobacco industry’s misleading harm-reduction narrative.

During the meeting, WHO also released the tenth report of the Study Group on Tobacco Product Regulation—currently the most comprehensive assessment of evidence on the risks associated with tobacco and nicotine products, offering recommendations for their effective regulation. Among the experts who contributed to the report is Professor Ghazi Zaatari, a prominent Lebanese medical professor and pathologist, Chair of the Department of Pathology and Laboratory Medicine at the American University of Beirut. Internationally recognized for his substantial work in tobacco product regulation and research on select tobacco and nicotine products, Professor Zaatari kindly agreed to speak with us.

We asked him which measures the Republic of Moldova should prioritize in its public-health policies, how policymakers can balance different approaches to achieve meaningful results, as well as about the latest evidence on smoking and cancer, the risks posed by nicotine pouches, and why the harm-reduction narrative promoted by the industry is so dangerous for public health. We invite you to read the interview:

Professor Ghazi Zaatari, the new WHO TobReg report puts major focus on protecting children and young adults. In your view, what is the most urgent regulatory step countries should take right now to curb youth tobacco and nicotine use initiation?

We believe the industry has been successful in making tobacco and nicotine products attractive. And flavorings have been one of the most effective variables. These flavorings make it conducive for children to start using them. We advocate banning or restricting the flavors that can be sold in one country. There is EU Tobacco Products Directive which prohibits characterizing flavors in cigarettes and roll-your-own tobacco, meaning flavors such as fruity, herbal or candy-like additives. Ukraine has recently updated its national tobacco control laws in line with that directive and has also banned characterizing flavors in tobacco and certain nicotine products. This could be a useful measure for your legislators to consider as well.

Another important aspect is regulating product design features and the nicotine content of e-cigarettes and related products. Some of these products are highly addictive, so controlling nicotine concentration and limiting designs that allow users to add large amounts of liquid, or other substances, are also important policy options.

In general, we consider that if a product is not yet present on the market, banning it is one approach, but if it is already available, strong regulations are needed. Therefore, practical measures that parliamentarians can consider, in addition to public education, are flavoring bans, restricting design features, and controlling nicotine contents.

What nicotine limit would you consider appropriate as a regulatory threshold?

WHO TobReg has issued recommendations on nicotine levels in cigarettes. However, we have not yet proposed a specific limit for nicotine concentrations in e-liquids. We are aware that the European Union has set a maximum of 20 mg/mL, and several countries have adopted similar limits. As I mentioned yesterday, some products now use nicotine salts, which can deliver significantly higher doses of nicotine. The industry should be required to disclose the contents of their products, whether they are conventional cigarettes or e-cigarettes, as this information is very useful for regulators in order to avoid excessively high toxic levels.

And are nicotine salts and nicotine analogues currently not being disclosed in these products?

The industry manipulates this, because when you work with salts, the composition can be quite different from what it appears to be. So they may state something on the label, but we also need to know how much actually comes out of the product when it is used. This is what we call the emission.

It is one thing to know the content, but what comes out during use is also important. It is important to know not only the content, but also how much nicotine is actually delivered, because this is crucial for anyone trying to protect the health of children. In addition, some of these e-liquid solutions are not well protected. They are not child-proof, and if children, for example, if a parent is a user , gain access to them and ingest them, this could be toxic.

So, getting back to examples of immediate regulatory measures that can be considered are banning filters, banning flavours, and restricting the amount of nicotine contents. For children, measures should also include banning social media advertising and banning sales through social media, as well as any other promotion through these platforms. These are simple steps parliamentarians from your country can take that would help control this epidemic.

Photo: WHO. Eleventh session of the Conference of the Parties to the WHO FCTC (COP11), Geneva, Switzerland, 17-22 November 2025

We developed strong regulations for radio and television, but regulating social media and the broader internet remains challenging. Today, people can buy almost anything they want online.

This is where the government must set a policy and establish penalties for both violators and offenders. If penalties are enforced, the industry will at least stop using social media for promotion. Having a strong policy is important; otherwise, the industry perceives this as a free way to promote their products.

Yes, that is exactly what they are doing. We have heard so much recently about harm reduction, which the tobacco industry uses to promote its new products. Regarding the European directive on taxes for tobacco and nicotine products, there was a public consultation until the end of October. We saw thousands of comments on the European Commission platform, presumably from the tobacco industry, using two narratives: harm reduction and the promotion of differentiated taxation.

Right, that is how they promote their products. If I tell you that this cup contains half the amount of poison as another cup, would you drink it? Of course not, and that illustrates the point. The industry is trying to create a false perception. Fewer toxins or carcinogens does not mean no harm. The narrative of harm reduction is simply a way to promote their products.

We need to shift the thinking paradigm. The core issue in tobacco use is addiction to nicotine and nothing else. When the industry began to see a drop in the use of smoked products, due to community restrictions and litigation, they shifted towards nicotine-only products, trying to evade regulations and reverse the decline in consumption. They market these products under the claim of harm reduction, but they are not harm-free. From a public health perspective, protecting citizens means avoiding harm, not simply accepting less harm.

And if the industry were genuinely interested in reducing harm, why would they continue producing products clearly aimed at children? Why introduce flavors that obviously appeal to children if the goal were truly social responsibility?

Well, they claim they produce e-cigarettes and heated tobacco products just to help adult smokers quit.

Which is not true. We have studies upon studies, referred to in our report, including meta-analyses and systemic analyses. These indicate there is no clear-cut proof. These products could be useful if used under controlled conditions with a low amount of nicotine. But how can somebody quit smoking or using nicotine when the product contains 30 milligrams of nicotine? We have to bring the burden of proof back onto the industry, not on public health.

The available evidence suggests that initiation with e-cigarettes or heated tobacco products may lead to dual or poly-product use. Could you elaborate further on this?

That is very true. There is more than one data set showing that. Many users sometimes shift to using e-cigarettes to evade indoor regulations, thinking this would be permissible indoors, which is still not acceptable. If you observe a dual user, they exhibit a striking habit: they start, put it back, and then keep getting the nicotine they are craving. This is very dangerous. The data we refer to in our papers shows that many dual users continue using both products, and the health effects are even worse, indicating an exaggerated effect.

What data do we currently have regarding nicotine pouches? I think they are something of a game-changer, because they evade many of the restrictive measures now in place for regular tobacco and nicotine products. They are very small and hardly noticeable, so children can use them without parents or teachers even realizing it.

That is the problem. In Scandinavian countries, they have smokeless tobacco which has a low amount of nicotine compared to others. It is a similar thing: a small sachet with contents, tobacco, and nicotine in a small amount. In contrast, nicotine pouches do not have tobacco but contain pure nicotine. If a product is meant to help people quit, like nicotine replacement therapy (which includes patches or lozenges), these therapies have a controlled amount and controlled delivery of nicotine. However, some nicotine pouches average 10 to 20 milligrams, and some go up to 50 milligrams. Obviously, the intention is not to help you quit. It is only a gateway to use other tobacco products. We have data showing that people who use these products ultimately transition into using smoked products. The notion that these products only expose users to nicotine without the harm of smoking is misleading. We also have data showing that they contain other unhealthy, harmful chemicals.

Are there any data regarding e-cigarettes and specific types of cancer?

It’s too premature. There is early data, but we don't have conclusive evidence to suggest it. Cancer is a disease that develops over a long period of time, not overnight, and there are many variables. As of today, we cannot say that it causes cancer. It can be facilitating the formation of cancer. We must wait until we have all the epidemiological data to see if there is indeed an association.

However, there is a precautionary principle: if I know something has carcinogens or toxins, why would I expose people just to find out later that they develop cancer? The effect may not be obvious until you are in your 40s or 50s, especially if initiation starts in the teenage years, but by then, it is too late.

The industry always asks, "Where's the evidence?". The burden of proof should not be on public health. This is an intriguing reverse of the way things should be. We have to be cautious and bring public awareness, not rushing to embrace these products before realizing the damage has already been done when it is already too late.

Photo: WHO. Eleventh session of the Conference of the Parties to the WHO FCTC (COP11), Geneva, Switzerland, 17-22 November 2025

Cigarette filters create major environmental damage and contribute to false perceptions of reduced harm. This was one of the much-discussed issues during this COP. Should Parties consider banning filters altogether, and what evidence supports or challenges this option?

Cigarette filters were introduced with the notion that they would help. When people started smoking in the 1950s, they talked about ‘dirt’ and ‘tar’, and the filter was supposed to remove this tar and reduce harm. So you see, the same notion of harm reduction. The filter created the perception of reduced harm. Then came light, ultra-light, and slim cigarettes, all of which are only a misleading façade. This has been proven. What manufacturers do is place ventilation holes around the filter so that air dilutes the concentration of chemicals when they are measured.

Historical data show that the prevalence of cancer, cardiovascular and pulmonary complications among people using filters has not become less with using them The problem today is psychological and the filter idea has become set in people’s minds that it is offering protection to their health.

So first we should change the perception?

Exactly. Filters do not protect you. People think, ‘I’m smoking with a filter, and the filter is going to take away the toxins.’ They even add chemicals to the filter that make it turn brown, leading users to believe it is removing the tar. It is deceptive. Our approach when regulating tobacco involves several strategies: 1. reducing the attractiveness; 2. reducing the addictiveness; 3. limiting and preventing design features that enhance use, and 4. lowering the level of toxicants, but without suggesting that the products are harm-free.

So, we should be cautious when considering a ban. There needs to be a cascade of related decisions for other products as well, so that we do not unintentionally encourage the consumption of other categories of products, especially the novel ones.

This is where you need a champion to set a strategy. Trying to put everything on the table at once may not be successful. Your policymakers and champion should approach this in a staged way. Asking for too many things simultaneously may not be wise. However, conventional cigarettes continue to be the most widely used tobacco products today.

We believe measures like filter bans and flavoring bans are crucial because flavoring can apply across all tobacco products. Flavoring bans will target e-cigarettes and nicotine pouches too. Today, there are up to 20,000 flavors in the market. You cannot regulate al of them, but we know some of these flavorings also have their own damaging effect independently. Restricting or banning these flavors would be a wise first step. Restricting the use of filters could be another measure. Then, you can address the levels and type of nicotine.

Always put the burden of proof on the industry: require disclosure. The government has the authority to mandate disclosure. If the industry is unable to conduct testing in their home country, samples can be sent to regional labs, and the industry should pay those charges, not the government. The government should spend money on public health to improve the quality of life for citizens, not subsidizing the industry's pockets.

We almost succeeded in banning flavors for e-cigarettes, but the legislation was amended and the ban will now only be enforced in 2029.

You need a champion in Parliament that puts public health first. You need that person, media support, and the civil society to gear up.

Looking ahead, in which areas do we most urgently need research to prepare for what is coming?

You first need to understand how these products are being used in your country and establish proper monitoring systems. This will help you prioritize decisions. It is important to conduct appropriate local studies and tests. You need basic information, and you need to determine how this new knowledge can guide policies and regulations that will ultimately assist policymakers and regulators.

Your legislation also has to be very comprehensive. Many laws only talk about banning flavors in tobacco products, but the wording should be “banning flavors in tobacco and nicotine products,” and also specify “anything that can be used to perpetuate addiction.” By stating “anything that would perpetuate addiction and normalize the use of tobacco,” you provide better coverage. If the language remains too general, the industry will invariably find a loophole.

I hope we still have some time to address the issue of survivor bias. We often hear that narrative, and it is just as misleading as it sounds.

Not all smokers get cancer. Among all smokers, maybe 15% come down with cancer. But if you look at those who have cancer, 85% of them are smokers. If you look at 100 patients with lung cancer, 85% of them are smokers. So when you reverse it, you see the picture very differently. Also, about 10 to 15% of cases are due to secondhand smoke.

Still, we should not only focus on cancer, which is always tragic and dramatic. Other diseases are precipitated by these products, including cardiovascular disease heart attacks and strokes), oral disease, maternal disease for pregnant women, asthma, and pulmonary disorders. While cancer attracts greatest attention, we should not ignore other diseases caused by the use of these deadly products.

Professor Ghazi Zaatari, thank you very much for taking the time to speak with us!

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