Journal of the Japan Society for Tobacco Control

Vol. 17, No. 3, 2022 (Reiwa 4) MM/DDIntroduction
Some issues surrounding smoking cessation
Chairperson of Japan Society for Tobacco Control
Manabu Sakuta
1. The novel coronavirus and smoking
The novel coronavirus, which has afflicted the world during three long years, is finally becoming manageable.
During this time, the following three points have become clear.
In brief, I state that
① With smoking, serious illness or death are more likely to occur.
② Even if you get a vaccine, its efficacy is weakened for smokers relative to that of non-smokers.
③ With smoking, sequelae (associated pathological conditions) are likely to persist.
① was analyzed by Guan et al. in an essay dated 28 February 2020.1) The director of this society, Michiyuki
Matsuzaki, was the first to identify this relationship, and the Framework Convention Alliance for Tobacco Control(FCA) also acknowledged it after I reported it. After this, the WHO also acknowledged the relationship in opening
remarks of the WHO director general on 20 March referencing the papers of Liu et al.2), thereby publicizing therelationship worldwide.
Regarding ②, papers have been published in Europe, the US, and Japan about this effect, and smokers canproduce only about half of the amount of antibodies as non-smokers. Similar results have been published withheated tobacco.
As for ③, sequelae of coronavirus that have been identified since May 2020 include fatigue, shortness of breath,
impaired taste and smell, negative effects on thinking ability and memory, hair loss, joint pain and otherconditions. For smokers, the risk of developing these conditions is 4.1 times higher according to an Italian study3)
and 8.4 times higher according to British study4). The risk of developing depression is 5.5 times higher for smokers
according to a Chinese published essay5).
2. Problems from heated tobacco
Japan is the country most afflicted by heated tobacco, and the harm of active smoking and passive smoking fromthese devices is concealed by the tobacco industry. Heated tobacco should be treated equally to combustible
tobacco in the revision of the Health Promotion Act.
In July 2020, WHO cautioned against heated tobacco by publishing the following statement. “Depending on thetype of harmful substance, aerosols from heated tobacco have many higher concentration levels than in traditional
cigarette tobacco smoke. Furthermore, it has been shown that there are varieties of harmful chemicals present inthese aerosols that are not contained in traditional cigarette smoke."
In July 2021, the Japan Society for Tobacco Control issued an [urgent warning] by stating not to be deceived by thesophistry and lies about heated tobacco.
・ Even without combustion, numerous carcinogens and harmful substances are emitted. Some substances are
emitted only through the heating or aerosolizing process.
・ Even if the levels of harmful substances besides nicotine are decreased to 1/10 of the levels founded in
combusted tobacco, the physiological damage from these substances is not guaranteed to decrease
proportionally.
・ Nicotine, which is also contained in heated cigarettes, is associated with diseases like cancer, heart ailments,
respiratory diseases, and weakened immunity.
・ Please do not be misled by the sophistry and lies of the tobacco industry.

Even though smoke or vapors are difficult to see, they can passively damage the health of bystanders like thesmoke from combusted tobacco cigarettes.
In November 2021, WHO FCTC COP9 issued a report on heated tobacco. It concluded with regulations that
correspond to each article of the FCTC regulating combusted tobacco:
Article 6 The tax rate should be the same as for combustible tobacco cigarettes.
Article 8 When smoking is prohibited, using heated tobacco and vaping should be prohibited as well.
Articles 9 and 10. Harmful substances from the devices should be monitored and flavors should be prohibited.
Article 11 Plain packaging with large pictures of health warnings should be posted.
Article 12 The risks of using heated tobacco, like the dual use with combusted tobacco, should be made known.
Article 13 All forms of advertising and sponsorship should be prohibited.
Article 14 Nicotine dependence should be treated in the same way as with combustible tobacco.
Article 16 Sales and marketing by or to minors should be prohibited.
Article 20 The public should be made aware of the use and sales strategies through social media that the tobacco
industry is considering for heated tobacco.
And I would like to summarize the health impacts of heated tobacco for the revision of the Health Promotion Act.
3. The display of tobacco health impacts and the prohibition of menthol and other flavors
Tobacco (nicotine) creates a higher level of dependence than cannabis or stimulants, and many people start using
it without knowing its risks. People can continue to smoke and can eventually die without knowing the healtheffects. Large health warnings on packages, along with raising tobacco taxes, are good policies to remedy this.
The FCTC promotes pictorial labeling that shows the health effects from tobacco. This policy has been adopted bymore than 120 countries so far and has increased the effectiveness of smoking cessation (Fig. 1).
Guideline 15 of FCTC Article 11 states that, compared to traditional text warnings, pictorial warnings of the healtheffects from tobacco are said to:・ draw more attention.
・ have a greater influence on smokers.
・ create a longer lasting influence on smokers.
・ communicate more clearly the health risks from tobacco use.
・ deepen awareness about the health risks of tobacco and strengthen the motivation to quit smoking.
・increase the intention and initiative to quit smoking.
・increase the number of attempts to quit smoking.
The number of countries that are adopting plain packaging (where brand names must be shown in plain fonts andcolors) is also increasing (Fig. 2). Japan would like to promote this along with other countries.
The FDA reported on April 28 of this year that the US will ban menthol flavored cigarettes, and the Biden
administration is taking steps to ban it in manufacturing and distribution processes. The soothing effect of menthol
makes it easier for beginners to smoke, and the FCTC has already requested that menthol and other flavors bebanned. Hitherto, menthol has been banned in Brazil, EU members, the UK, Canada, and other countries. If theUnited States bans it, I want to push Japan to join these countries.
4. Concerning the shortage of Champix (varenicline), the drug was found to contain impurities of nitrosamines
similar to levels found in ham and sausages, so sales have been discontinued. The Pfizer company says it will not
be able to resume sales until next year. To avoid confusion, shipments of nicotine patches were also limited,resulting in the closure of many smoking cessation outpatient clinics. In the meantime, it is important for
outpatient smoking cessation to acknowledge psychotherapy like cognitive behavioral therapy, which one canlearn about in the general meetings of the Japan Society for Tobacco Control, smoking cessation treatment

seminars, and smoking cessation studies at Nanzando, a Japanese academic society. Learning this therapy is a
useful asset not only for smoking cessation treatment, but also for medical practice in general.
On the other hand, as of June of this year, there were no limits on the shipments of nicotine patches. Their supply
is therefore sufficient and can be fully utilized in outpatient smoking cessation.
If shortages of medical smoking cessation aids occur, the Japan Society for Tobacco Control issued the September
2022 version of the outpatient smoking cessation treatment guidelines. You are invited to read this and to use it asa reference for outpatient smoking cessation.

Figure 1 (from Russia in 2018; from Hong Kong in 2018)

Figure 2 (from Australia in 2017)

5.About SDGs
The Sustainable Development Goals (SDGs) were enacted in September 2015 and established 17 development
goals that all countries and regional bodies should attain by 2030. One of the SDGs includes smoking cessation.
SDG paragraph 3a states, "In all countries, strengthen the enforcement of the World Health Organization (WHO)
Framework Convention on Tobacco Control (FCTC) as appropriate."
In April of this year, the Japan Society for Tobacco Control established four action goals. They are
1. Publicize the fact that promotion of tobacco control is explicitly stated in SDG 3a.
2. Include SDGs in smoking cessation/anti-smoking education, training, and qualification exams.
3. Display the SDGs logo or wheel in publicity activities.
4. Publicize the deception behind the tobacco industry's SDGs promotion enterprise.
4 points. The Japan Society for Tobacco Control has created an SDGs pocketbook and posters for these objectives,
so please use them.

6. Passive smoking at restaurants
Passive smoking at restaurants seems to have decreased considerably since the introduction of the Health
Promotion Act and the Tokyo Ordinance on Passive Smoking Prevention. However, some stores still allow smoking
illegally. One of the purposes for both this law and this ordinance is to eliminate passive smoking at theseestablishments, but it is unfortunate that some people are enthralled by money and are unnecessarily endangering
themselves.
The Japan Society for Tobacco Control provides information on violations of the Health Promotion Act and theTokyo Ordinance on Prevention of Passive Smoking, and it publishes forms for requesting guidance and directives
for such cases on its website. Please actively utilize these, and I would like you to submit them to the relevant
department of the public health center in your municipality or prefecture.
7. About the Smoking Research Foundation
Its predecessor was started in 1957 as a research institution commissioned by the Japan Monopoly Corporation,
led by the Research Management Council on Smoking and Health. The Smoking Research Foundation, which wasestablished in 1986 as a front company for the tobacco industry, took over this council and currently receives
approximately 500 million yen from Japan Tobacco (JT) each year, and grants approximately 6 million yen for eachprincipal researcher over three years.
According to internal tobacco industry documents, the Foundation "uses third parties to convey the industry'smessage” and has been widely referenced for trials and consultative councils. For example, its officers wereappointed to serve on the Public Health Council to draft the 1987 White Paper on Tobacco. Tobacco industry
internal documents show that it was expected "to influence the decisions of the council through its members" andthat it did cause an actual impact.
Article 5.3 of the FCTC also stipulates that such monetary exchanges from tobacco organizations should beprohibited. According to the COI, the World Medical Association, the Japan Medical Association, the Japan Society
for Tobacco Control, and many other medical societies, such exchanges are strictly regulated.
(The literature can be reviewed from each item of Latest News on the homepage of the Japan Society for TobaccoControl.)Reference literature
1) Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med , April 30, 2020; 382:1708-1720 doi:
10.1056/NEJMoa2002032. /Viewed 1st Oct. 2022
2) Liu W, Tao ZW, Wang L, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin
Med J (Engl) 2020 May 5; 133(9): 1032-1038. doi: 10.1097/CM9.0000000000000775. /Viewed 1st Oct, 2022
3) Buonsenso D, Gualano MR, Rossi MF, et al. Post- Acute COVID-19 Sequelae in a Working Population at One Year Follow-Up: A Wide Range of Impacts
from an Italian Sample. Int J Environ Res Public Health. 2022; 19(17): 11093. Published 2022 Sep 5. doi:10.3390/ijerph191711093

4) Paul E, Fancourt D. Health behaviours the month prior to COVID-19 infection and the development of self-reported long COVID and specific long
COVID symptoms: a longitudinal analysis of 1581 UK adults. BMC Public Health: 22: 1176 https://doi.org/10.1186/s12889-022-14123-7 /Viewed 1st Oct,20225) Li Z, He J, Wang Y, et al. A cross-sectional study on the mental health of patients with COVID-19 1 year after discharge in Huanggang, China [publishedonline ahead of print, 2022 Oct 3]. Eur Arch Psychiatry Clin Neurosci. 2022; 10.1007/s00406-022-01484-8. doi: 10.1007/s00406-022-01484-8