Correspondence
Foundation for a Smoke-Free World, a non-profit
entity funded by Philip Morris International, with a
mandate to support scientific research and
development in the battle against smoking.
Darek Yach
derek@globalhealthconsults.net
Global Health Strategies, Southport, CT
06890-3033, USA
1 The Lancet. Tobacco control: far from the
finish line Lancet 2021; 398: 1939.
2 Hajek P, Phillips-Waller A, Przulj D, et
al. A randomized trial of e-cigarettes versus
nicotine-replacement therapy. N Engl J Med
2019; 380: 629–37.
3 Public Health England. Vaping in England. 2021
evidence update summary. 2021. https://www.
gov.uk/government/publications/vaping-in-
england-evidence-update-february-2021/
vaping-in-england-2021-evidence-update-
summary (accessed Dec 19, 2021).
4 Action on Smoking and Health. MHRA
enhanced guidance on medical licensing for
e-cigs welcomed by health leaders, clinicians
and tobacco experts. 2021. https://ash.org.uk/
media-and-news/press-releases-media-and-
news/mhra-enhanced-guidance-on-medical-
licensing-for-e-cigs-welcomed-by-health-
leaders-clinicians-and-tobacco-experts
(accessed Dec 19, 2021).
5 Royal College of Physicians. Smoking and
health 2021: a coming of age for tobacco
control? May, 2021. https://www.rcplondon.
ac.uk/projects/outputs/smoking-and-health-
2021-coming-age-tobacco-control (accessed
Dec 19, 2021).
6 National Health Service. Using e-cigarettes to
stop smoking. https://www.nhs.uk/live-well/
quit-smoking/using-e-cigarettes-to-stop-
smoking/ (accessed Dec 19, 2021).
7 Gregory A. Regulator paves way for NHS
e-cigarette prescriptions in England. Oct 29,
2021. https://www.theguardian.com/
society/2021/oct/29/regulator-paves-way-for-
nhs-e-cigarette-prescriptions-in-england
(accessed Dec 19, 2021).
Tobacco control:
getting to the finish line
Tobacco control is not working
for most of the world.1 Four out of
five of the world’s smokers are in
low-income and middle-income
countries. In these countries where
most of the eight million deaths
caused by tobacco occur each year,
rates of tobacco use are falling only
slowly. Globally, the overall number
of tobacco users has barely changed.
Only 30% of countries are on track
to achieve the WHO adult tobacco
use target of a 30% reduction in
prevalence by 2030 2 and most
countries are not on track to achieve
www.thelancet.com Vol 399 May 14, 2022
the Sustainable Development Goal 3.4
for non-communicable diseases; its
achievement will require a much more
ambitious tobacco target.3
The Lancet stresses the need for
greater compliance with the WHO
Framework Convention on Tobacco
Control (FCTC). The FCTC is no longer
fit for purpose, especially for low-
income countries. Neither WHO nor
the FCTC are grounded in the latest
evidence on the role of innovative
nicotine delivery devices in assisting
the transition from cigarettes to much
less harmful products.4 Equally, the
focus on youth vaping, most of which
is experimental, detracts from the
crucial public health goal of reducing
cigarette-caused deaths in adults.5
The missing strategy in WHO and
FCTC policies is harm reduction.
Most people smoke because they are
dependent on nicotine. Tobacco harm
reduction reduces the harm caused by
burnt tobacco by replacing cigarettes
with much less harmful ways of
delivering nicotine; these alternatives
have great potential to disrupt the
cigarette industry.
Unfortunately, WHO and the FCTC
Conference of Parties reject harm
reduction.6 This opposition is not
grounded in 21st century technological
advances, and is unduly influenced by
vested interests who promote nicotine
abstinence. This opposition privileges
the most harmful products—cigarettes.
We urge The Lancet to actively
endorse harm reduction as a crucial
strategy for reducing the health
burden caused by tobacco. The Lancet
should also add its voice to calls for an
independent review of WHO’s tobacco
control policies; millions of lives are at
stake.1
We declare no competing interests.
*Robert Beaglehole, Ruth Bonita
r.beaglehole@auckland.ac.nz
Auckland 0624, New Zealand (RBe); University of
Auckland, Auckland, New Zealand (RBo)
1 The Lancet. Tobacco control: far from the
finish line Lancet 2021; 398: 1939.
2 WHO. WHO global report on trends in
prevalence of tobacco use 2000-2025, 4th edn.
Geneva: World Health Organization, 2021.
3 Countdown NCD. NCD Countdown 2030:
pathways to achieving Sustainable
Development Goal target 3.4. Lancet 2020;
396: 918–34.
4 Hartmann-Boyce J, McRobbie H, Butler AR,
et al. Electronic cigarettes for smoking
cessation. Cochrane Database Syst Rev 2021;
9: CD010216.
5 Balfour DJK, Benowitz NL, Colby SM, et al.
Balancing consideration of the risks and
benefits of e-cigarettes. Am J Public Health
2021; 111: 1661–72.
6 WHO. WHO report on the global tobacco
epidemic 2021: addressing new and emerging
products. Geneva: World Health Organization,
2021
Tofacitinib for juvenile
idiopathic arthritis
We welcome the trial data for
tofacitinib 1 as a drug that might
provide benefit for children and
young people with juvenile idiopathic
arthritis. We are encouraged by the
findings, particularly the safety data,
but seek clarification on the clinical
efficacy.
Nicolino Ruperto and colleagues state
that stable doses of glucocorticoids
were permitted (0∙2 mg/kg per day or
10 mg of prednisolone equivalent per
day, whichever is lower, for at least
2 weeks before baseline).1 2 weeks
is a comparatively short lead in time
and could influence the response
rate in part one of the trial. Could
the higher rates of glucocorticoids
in the treatment group in part two
(39% vs 26%, median dose 5 mg per
day) also affect the reported flare
and response rates? This difference in
rates of glucocorticoid use is clinically
relevant and worth highlighting.
Long-term low-dose glucocorticoids
are useful for maintaining disease
control and reducing risk of flare in
similar conditions, such as rheumatoid
arthritis, lupus, and vasculitis. Were
supplementary analyses done to
address this potential confounding
factor? Could the authors also clarify
how many patients received intra-
articular steroid injections because this
is also important in considering overall
steroid exposure. The cost differential
of these medications in low-income
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