Tobacco harm reduction
Tobacco harm reduction describes actions taken to lower the health risks associated with using nicotine, especially as delivered through combustible tobacco, including but not necessitating complete abstention. These measures have been argued to include:
- Cutting down before quitting smoking
- Smoking Less
- Temporary Abstinence
- Switching to non-tobacco nicotine containing products, such as medically licensed nicotine replacement therapies or currently unlicensed products such as electronic cigarettes
- Switching to Swedish or American smokeless tobacco products
- Switching to organic or additive-free tobacco products.
It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence. Harm reduction may be of substantial benefit to these individuals.
Given the varying legal, moral and historical status of tobacco, and the different types of tobacco and tobacco use in different cultures around the world, debates on tobacco harm reduction tend to be geographically defined arguments. For instance, inhalant cigarette smoking is the dominant form in the United States, with a smaller number of users availing themselves of non-inhalant cigars, pipes, and smokeless tobacco. The political climate over the last few decades has led to both restrictions in the sale and use of tobacco and widespread information (and misinformation) about the negative health effects of tobacco use. Despite this, tobacco in all its forms has remained a legal product in most societies. A notable exception is the European Union, where the most dangerous products (cigarettes) are available but smokeless tobacco products, which are far less hazardous, are banned. The exception is Sweden, where there is a long tradition of smokeless tobacco use among men.
Harm reduction, a modality of dealing with other drug use, is beginning to be applied to tobacco use. In October 2008 the American Association of Public Health Physicians (AAPHP) became the first medical organization in the U.S. to officially endorse tobacco harm reduction as a viable strategy to reduce the death toll related to cigarette smoking. Joel Nitzkin, MD, of the AAPHP wrote: "So if we can figure that the nicotine in the e-cigarettes is basically a generic version of the same nicotine that is in prescription products, we have every reason to believe that the hazard posed by e-cigarettes would be much lower than one percent, probably lower than one tenth of one percent of the hazard posed by regular cigarettes."
Cigarette manufacturers have attempted to design safer cigarettes for almost 50 years, but results have been marginal at best. Filters were introduced in the early 1950s, and manufacturers were selling low-yield cigarettes by the late 1960s. Initially it was thought that these innovations were harm reducing. For example, in 1976 investigators at the American Cancer Society published research concluding that light cigarettes were safer. The study authors wrote that "total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked 'low' tar-nicotine cigarettes than for those who smoked 'high' tar-nicotine cigarettes."
It has been established that use of Swedish and American smokeless tobacco confers only 0.1% to 10% of the risks of smoking, though smokeless products in India and Asia contain higher levels of contaminants and thus confer greater risks. Two respected medical groups believe that ST may play a role in reducing smoking-attributable deaths. In 2007, Britain's Royal College of Physicians concluded "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved."
Electronic cigarettes are battery-powered devices that deliver vaporized propylene glycol or vegetable glycerin (or a mixture of both) and nicotine when users inhale while using them. Manufacturers of electronic cigarettes often market them as a "cessation aid," claiming that they lack deadly chemicals while also satisfying both smokers' psychological and physiological needs. The regulatory status of e-cigarettes in many countries is uncertain, while in others the use or sale of electronic cigarettes with the nicotine is officially illegal (e.g. Hong Kong). There is a growing census of opinion that when seen as an alternative to smoking rather than a cessation route, the electronic cigarette does indeed have a valid place within tobacco harm reduction strategy. This new ideology has given rise to a relatively new way of regarding the electronic cigarette as a form of Recreational Nicotine Product.
Propellant-based nicotine delivery
An alternative nicotine delivery platform based on existing asthma inhaler technology is under development by a UK-based healthcare company, Kind Consumer Limited. The technology is currently under development and the company has submitted a Marketing Authorisation Application to the UK MHRA for licensing of the technology as an approved nicotine containing product. The technology is under licence to Nicoventures Limited a subsidiary of British American Tobacco who are responsible for the launch and commercialisation of the technology as an approved nicotine replacement therapy product.
Nicotine Pyruvate Technology
Philip Morris International bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University. The technology is based around the chemical reaction between nicotine acid and a base which produces a nicotine pyruvate vapour for inhalation. It has undergone preliminary clinical evaluation which has shown delivery of nicotine to the lungs.
Proponents of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths. Opponents argue that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation. Additionally, smokers remain confused about tobacco harm reduction. In a 2004 survey, about 80-100% of participants incorrectly perceived low-yield cigarettes as harm-reducing, while 75-80% mistakenly believed that switching to smokeless tobacco conferred no risk reduction.
- Cancer Research UK Report on Tobacco Harm Reduction and Nicotine Containing Products (May 2013)
- History of commercial tobacco in the United States
- List of additives in cigarettes
- List of cigarette smoke carcinogens
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