The six million global deaths caused annually by combustive tobacco smoking is projected to increase to eight million within 10 years – forcing cardiologists, pulmonologists and oncologists to embrace tobacco harm reduction alternatives – according to representatives of these disciplines speaking at a global scientific summit on tobacco harm reduction.
Consensus on the importance of harm reduction emerged during a panel discussion at the 3rd Global Scientific Summit on Tobacco Harm Reduction: Novel products, research & policy, held via an Athens-based webinar on 25 September 2020, writes Chris Bateman for MedicalBrief. The summit, aimed at the scientific community, health professionals, regulatory authorities and policy-makers internationally, was organised by the University of Thessaly and the University of Patras with the University of West Attica in Athens and the National and Kapodistrian University of Athens.
There was agreement that the proven harm reduction of heat-not-burn products, e-cigarettes and other tested alternatives to combustion smoking, had persuaded them that the first line of attack — trying to persuade smokers to quit smoking completely — had mostly failed, experts told the summit.
Lighting up 100 disease-causing toxins
Dr Peter Harper, consultant medical oncologist for Guy’s and St Thomas Hospital in London and a founder partner of the London Oncology Clinic, said there were still an estimated one billion cigarette smokers in the world despite exhaustive efforts to get people to quit combustion smoking.
“We know that at combustive temperatures, around 6,000 chemicals are released, of which 100 or so cause disease. Combustive smoking is highly toxic,” Harper revealed.
“Far less toxic, smoke-free products have a relatively low uptake globally at some 70 million people, with 55 million estimated to be smoking e-cigarettes and 15 million using heated tobacco products.”
While there was no long term evidence that reducing toxicant exposure would lead to reduced disease, there were plenty of examples indicating that this would probably happen.
“There’s a lot of policy that interferes with the science, where we need to control both and make sure the science is crystal clear,” Harper added.
To illustrate, he said 33 countries had banned e-cigarettes while many others had banned heated tobacco products, many without differentiating between the two. A similar discordant pattern emerged with potentially reduced-toxicity products and combustible cigarettes.
In Sweden where chewable (pasteurised) snus tobacco pouch use had increased from 24% to 64%, combustible smoking had dropped from 50% to between 5% and 10%, with the tobacco-related mortality rate at 152 per 100,000 population compared to the European Union average of 373 per 100,000.
The notoriously strict, evidence-based US Food and Drug Administration (FDA) in 2019 backed snus as an alternative harm reduction device, but the EU continued to ban it.
“So, policy-makers across the world are interpreting the science in different ways. I think the Swedish data is real science,” Harper said.
Professor Efraín Cambronero, Chief of Surgical Oncology; Head and Neck Surgery at Centro Oncologico Costarricense in San Jose in Costa Rica, agreed. He added that 85% of his cancer diagnoses were related to combustible tobacco products.
“Over the years I’ve realised that quitting is easier said than done, in spite of my first option being to get them to go cold turkey. A study in Kentucky, United States, showed that about 30% of lung cancer patients continued smoking in spite of their diagnosis,” he added.
Harm reduction in step with Hippocratic Oath
If his patients displayed any desire to stop smoking, Cambronero recommended non-combustible alternatives, which was fully in line with his Hippocratic Oath*. He said that about 8% to 9% of Costa Ricans were smokers with just 1.6% using e-cigarettes.
Ear, Nose and Throat specialist Professor Manuel Pais, Vice-President of the European Medical Association and recently retired from Portugal’s Porto University School of Medicine, said he had dismal results following national and international guidelines.
“I’ve switched to harm reduction. Worldwide, clinicians like myself believe in harm reduction as complementary to prevention and cessation policies. Don’t come to me with that classic argument that you need more time for longitudinal studies. Nowadays toxicological studies give the perfectly right information, on time,” he added.
Pais commended the FDA’s 2020 approval of modified risk tobacco products, and their ‘acknowledging’ heat-not-burn nicotine delivery systems.
“There will always be people engaged in risk behaviours, no matter what you do to get them to help themselves,” he observed.
Pais proposed the creation of a new global medical organisation promoting education, research and care around tobacco harm reduction – something the webinar later set in motion.
Poland’s Professor Piotr Kuna, Chair of Internal Medicine, Asthma and Allergy at the Medical University of Łódź, seconded Pais’ motion. “Unfortunately, one third of our population has a psychological risk profile that cannot stop risk taking behaviour,” he added.
He cited a British Medical Journal article on chronic obstructive pulmonary disease (COPD) showing the best results with “sustained quitters”. There was a decreased incidence in COPD, coronary artery disease and lung cancer-related deaths among those who quit while suffering from these diseases.
Alternative nicotine products save lives
Cypriot pulmonologist Professor Michael G Toumbis, President of the Cyprus Institute of Respiratory Diseases in Nicosia and a member of the Cyprus National Addictions Authority, said the goal should always be complete smoking cessation.
“Even one single cigarette less per day decreases vascular risk. If my patient chose non-combustible products or e-cigarettes, I say I’ll help.”
Harm-reducing non-combustible nicotine products can dramatically reduce risk compared to combustible ones and the world needs to adjust to this reality if it wants to reduce ever-increasing associated death and disease rates, Toumbis told the Summit.
While little was known about the long-term consequences of harm reduction products, in general they are far safer than smoking cigarettes. However the World Health Organisation had adopted a ‘wait and see’ attitude to alternative harm reducing nicotine delivery systems.
Health authorities in the United Kingdom adopted the harm reduction principle in tobacco policy, but the United States remained sceptical.
Quoting the ‘father’ of harm reduction, British psychiatrist Michael Russel, who said people “smoke for nicotine but die from the tar”, Toumbis said smokers need not risk their lives to get their nicotine dose if the method of taking the drug could be changed – which it had.
“Nicotine itself carries minimal harm and is relatively safe when obtained from approved nicotine replacement therapies (NRTs). There is some risk for vulnerable groups but overall, approved NRT trumps the harm caused by continuing to smoke cigarettes,” he said.
Studies have shown that nicotine replacement therapy increases the chance of quitting by about 55%, but it is best used along with other behavioural techniques and is distinct from non-combustible nicotine products, whose considered use Toumbis promotes.
The pulmonologist emphasised that nicotine was not benign and that not all nicotine-containing alternative products were equally harmful.
“For example, the low nitrosamine Swedish-type Snus is less harmful than unrefined tobacco, being in the smokeless tobacco category,” he said, adding that harm levels among e-cigarette products differed markedly, with some having more toxic constituents than others.
An appropriate balance needed to be found between product safety, consumer appeal and regulations targeted specifically at the use of conventional combustible tobacco products. A harm reduction, evidence-based approach to tobacco control would save lives more quickly than would otherwise be possible.
“The harm reduction approach can complement proven current tobacco control efforts of prevention and cessation – providing a great opportunity to disrupt global smoking-related morbidity and mortality,” Toumbis said.
* Hippocratic Oath, modern version: I swear to fulfil, to the best of my ability and judgement, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
[link url="https://www.nosmokesummit.org"]3rd Global Scientific Summit on Tobacco Harm Reduction: Novel products, research & policy[/link]