Adapting global practices: lessons with contextual relevance
LMICs can learn from high-income countries (HICs) that have implemented THR, but policies cannot be transferred wholesale. THR effectiveness depends on national context, including regulatory capacity, political feasibility, and social norms. For LMICs, the goal is to adapt core principles such as risk-based regulation and integration into existing health systems, rather than copying laws or product frameworks developed elsewhere.
Examples from the United Kingdom, Sweden, and New Zealand show that THR works when regulation differentiates clearly between combustible tobacco and lower-risk alternatives. The UK integrates e-cigarettes into smoking cessation services, Sweden’s widespread use of low-nitrosamine snus has coincided with very low smoking-related mortality, and New Zealand combines strong tobacco control with access to safer nicotine products. The transferable lesson is the use of proportionate regulation to prioritise smoking reduction, not the specific products or legal instruments.
Most LMICs operate under different constraints. Regulatory enforcement is often weaker, laboratory capacity for product testing may be limited, and public health systems face multiple competing priorities. Social context also matters: tobacco use in many LMICs is shaped by gender roles, occupation, or cultural practice, which affects how harm reduction is perceived. These factors mean that complex regulatory models used in HICs are often impractical in low-resource settings.
Effective adaptation therefore starts with feasibility, not ambition. Policymakers should assess who smokes, where people who smoke already engage with health services, and what level of regulation can realistically be enforced. Pilot programmes or phased implementation allow governments to test THR approaches, generate local evidence, and adjust policy before scaling up. Engagement with local clinicians, researchers, and communities is essential to ensure acceptability and credibility.
Economic and political constraints must also be addressed directly. Advanced taxation systems, detailed product standards, or comprehensive surveillance may not be immediately achievable. Incremental regulation, regional cooperation, and South–South knowledge sharing can help build capacity over time. External technical support can be useful, but only when it aligns with national priorities and preserves local decision-making authority.