The WHO Schism: When the World's Top Health Authority Becomes an Obstacle to Health

In November 2023, the WHO's Conference of the Parties to the FCTC convened in Panama. On the agenda: a report recommending that member states prohibit or severely restrict e-cigarettes, heated tobacco products, and nicotine pouches. The report, prepared by the WHO secretariat, characterized these products as a 'threat' to tobacco control and dismissed the evidence that they help smokers quit as 'inconclusive.' The conference adopted the recommendations with little debate. **Not a single consumer of these products was permitted to testify. Not a single representative of the estimated 100 million people worldwide who have used vaping to quit smoking was allowed in the room.** The WHO's position on harm reduction has never been based on evidence. It is based on institutional ideology—and that ideology is now being challenged by a growing movement of researchers, advocates, and even member states who have concluded that the WHO is obstructing, rather than advancing, the goal of reducing tobacco-related mortality.

**The evidence the WHO ignores is not subtle.** The United Kingdom—which has embraced vaping as a smoking cessation tool since Public Health England's landmark 2015 review—has one of the fastest-declining smoking rates in the world. Sweden—where snus has largely replaced cigarettes among men—has the lowest smoking prevalence and the lowest lung cancer mortality in Europe. New Zealand—which integrated vaping into its national smoking cessation strategy—saw smoking rates fall faster after adopting harm reduction than before. Japan—where heated tobacco products captured a quarter of the nicotine market—experienced a 40% decline in cigarette sales in five years, a rate of decline unprecedented in any major market. The pattern is consistent across countries: **embrace harm reduction, accelerate smoking cessation.** The WHO's response to this pattern has been to ignore it—or, when pressed, to argue that the declines might have happened anyway, or that the long-term effects of the alternative products are not yet known, or that the industry that produces them cannot be trusted. All three arguments have some basis—but none of them justifies the WHO's categorical rejection of a strategy that is demonstrably saving lives in the countries that have adopted it.

**The institutional dynamics driving the WHO's position are not mysterious.** The WHO's tobacco control program has been built over decades on the abstinence framework: the goal is a world without tobacco, and any product that sustains nicotine use—regardless of its risk profile—is an obstacle to that goal. The program is staffed by people who have spent their careers within this framework, funded by governments and philanthropies that support it, and advised by experts whose professional identities are invested in it. Accepting harm reduction would require the program to acknowledge that a strategy it opposed for two decades was more effective than the one it championed. **Institutions do not do this voluntarily.** They defend their founding assumptions until the evidence against them becomes undeniable—and even then, they resist. The WHO's tobacco control program is following the same trajectory as every institution that has faced a paradigm challenge: denial, dismissal, and—eventually, when the evidence becomes overwhelming—grudging, partial accommodation. We are still in the denial phase.

**The human cost of the WHO's position is measurable.** The FCTC's hostility to harm reduction has been exported to low- and middle-income countries through the treaty's implementation guidelines, which urge member states to 'prevent the initiation of e-cigarette use' and to 'apply regulatory measures...to prohibit or restrict the manufacture, importation, distribution, presentation, sale and use of electronic nicotine delivery systems.' The countries that follow this guidance—and many do, because they lack the resources to conduct independent risk assessments and defer to the WHO's authority—are denying their smokers access to the most effective smoking cessation tool ever invented. An estimated 80% of the world's smokers live in low- and middle-income countries, where cessation support is minimal and smoking-related mortality is rising. The WHO, by urging these countries to restrict the products that could most effectively reduce that mortality, is not protecting them from a new epidemic. It is condemning them to the old one.

**The schism is becoming visible.** A growing number of public health experts—including former WHO advisors, prominent tobacco control researchers, and the directors of national public health agencies—have publicly criticized the WHO's position. The criticism is not coming from the tobacco industry or its proxies. It is coming from within the public health community itself—from people who have spent their careers fighting the tobacco epidemic and who have concluded that the WHO's hostility to harm reduction is harming the people it claims to protect. The critics include Robert Beaglehole, a former WHO director; Clive Bates, a former director of the UK's Action on Smoking and Health; and numerous researchers whose work has been cited by the WHO when it supports the abstinence framework and ignored when it supports harm reduction. The critics are not fringe figures. They are the people who built the evidence base that the WHO selectively deploys.

**The resolution of the schism** will depend on whether the WHO can adapt its institutional culture to the evidence—or whether the evidence will eventually force the adaptation from outside. Institutions that resist evidence eventually lose—the history of public health is littered with the reputations of organizations that clung to discredited orthodoxies too long. But 'eventually' can be a very long time, and in the interim, the people who suffer are the smokers whose access to life-saving products is restricted by the policies the WHO's orthodoxy sustains. The WHO schism is not a theoretical dispute. It is a conflict between institutional self-preservation and the lives of the billion-plus people who smoke—and the outcome of that conflict will be measured in mortality statistics, not in academic citations.

**💬 What do you think?** Should global health authorities follow the evidence where it leads—even when that means acknowledging that a strategy they opposed was right? Or is there a legitimate case for the precautionary approach, even when the evidence suggests the precaution is causing more harm than it prevents?