Vaping Towards Cessation – Can Tobacco Harm Reduction Increase Smoking Quit Ratio?

On December 5, 2021

Professor Michael Russell, often referred to as the godfather of Tobacco Harm Reduction (THR), highlighted in one of his writings that  “People smoke for nicotine but they die from the tar.”  However, the general sentiment around the world including Africa is that Nicotine accounts for all smoking related morbidities and mortality.

A study on perceptions of Nicotine in current and former users of tobacco and THR products from seven countries revealed that many consumers were of the view that Nicotine is the cause of cancer in people who smoke.  While it is the addictive substance in cigarettes, studies have since exonerated Nicotine as the cause of cancer in persons who smoke. Instead, the health complications have been linked to combustion or burning of tobacco. When tobacco burns, it produces 7, 000 toxic chemicals, including at least 70 known to cause cancer. These cancer-causing chemicals are referred to as carcinogens.

The global public health crisis caused by smoking sees eight million deaths each year, more than from HIV/AIDS, tuberculosis and malaria combined. The populations of many low- and middle-income countries (LMICs), and vulnerable and disadvantaged groups in high-income countries, are disproportionately impacted. Across the globe, more than 8.7 million people per year die from tobacco use. Most of those deaths (7.4 million) are attributed to direct tobacco use, while the remaining more than 1.3 million are attributed to exposure to second-hand tobacco smoke. Around 80% of these deaths happen in LMICs.

Research around Tobacco Harm Reduction has shown that Nicotine is not amongst these carcinogens in tobacco and switching to non-combustible nicotine products could go a long way in reducing the burden of tobacco related deaths and diseases. Studies based on biomarkers consistently reveal that e-cigarette users are exposed to fewer toxins and carcinogens than from tobacco smoke.

From a public health point of view, quitting smoking or cessation is by far the most effective way of reducing tobacco related morbidity and mortality. On average, smoking causes more than a decade of life lost, but quitting before age 40 can return almost all those years by reducing a former smoker’s chance of tobacco-related death by 90%.   Data shows that approximately 70% of smokers want to quit, but quitting smoking is incredibly challenging because nicotine is addictive. Between 2007 and 2019, the percentage of adults who smoked declined from 22.7 percent to 19.6 percent.

In some countries such as the U.S., a number of cessation strategies have been attempted over the years to assist smokers to quit. Between 2018 and 2019, almost 3% of smokers (0.41 million) attempted to quit using counselling alone, 25 % (4.03 million) tried to quit using medication alone, 6% (0.98 million) tried to quit using both medication and counselling. However, 26% (4.16 million) attempted to quit by switching to e-cigarettes. Despite no official endorsement from any U.S. government agency, e-cigarettes remain a popular cessation tool for some smokers across the country.

Renowned Oncologist and THR advocate, Professor Abdoul Aziz Kassé told the Second Edition of the Harm Reduction Exchange 2022 in Nairobi last week that, while there is no definitive evidence that Heated Tobacco Products (HTPs) help people stop smoking cigarettes, it is an undeniable fact that switching to heated tobacco products (HTPs) is less harmful than burned tobacco.

“Burned tobacco at 850°C generates 50 carcinogens in tar.  Tobacco heated at 450° C is different and does not produce tar. We all know that quitting reduces deaths, diseases and disabilities. However, every year, 20% of all those trying to quit relapse. A single year tobacco-quit ratio is 21%. The question now is, how can we help increase the quit ratio? Can Harm Reduction help?” said Prof Kassé.

He added that while tobacco companies frame HTPs as less harmful alternatives to cigarettes, the World Health Organisation (WHO) continues to urge caution, stating that independent scientific evidence does not bear out these claims.

“Research on heated tobacco products (HTPs) is less developed than that relating to cigarettes. However, the general independent scientific consensus is that when smokers switch fully from conventional cigarettes to HTPs, they are exposed to reduced levels of some harmful substances.”

A 2022 Report on the Global State of Tobacco Harm Reduction reveals that harm reduction can end smoking and effective harm reduction interventions (at minimal cost to governments and health agencies) can end smoking within a generation.

Harm Reduction Expert, Jonathan Fell said that in Sweden, amongst other countries such as Japan, South Korea, Norway and others where THR products have been adopted, a decline in the smoking of combustible cigarettes has been recorded.

“In Sweden, Snus use has grown consistently, replacing cigarettes over the years since the 70s. In 1970, 44% of rich adults smoked according to statistics in Sweden. By 2021 smoking was at 20% amongst that population group and 14% of the adult population now uses Snus,” said Fell.

In 2019, Japan recorded a 75% exclusive use of HTPs. In Norway, while daily sales of cigarettes is currently at 1.9 percent, daily and occasional smoking is on a downward trajectory. Findings from a 2022 Nicotine vaping study in England revealed that there is high-certainty evidence that electronic cigarettes with Nicotine increase quit rates as compared with nicotine replacement therapy.

Bernice Opondi, a Drug Policy, Harm Reduction and Research consultant in Kenya said adopting punitive measures against smoking was not the solution to the multiple health challenges brought about by smoking.

“Punitive laws lead to abuse and violation. Instead of punitive laws, rather adopt effective harm reduction programs that promote safe use and result in positive health outcomes,” she said.

Meanwhile, the Global State for the THR report further revealed that the Tobacco Harm Reduction approach is under siege due to mistrust and suspicions about the tobacco industry involvement in the manufacture of some safer nicotine products. This mistrust has spread further through the proliferation of misinformation and disinformation from well-funded tobacco control institutions that are increasingly shifting their focus onto nicotine use as well as smoking.

Integra Africa Chief Executive Officer who is also a Harm Reduction advocate and Disinformation expert, Dr Tendai Mhizha said the disinformation around Nicotine and harm reduction was well coordinated and there was need for the media and scientists to collaborate to end the dis-misinformation pandemic around many issues on the continent including nicotine.

“In ending mis and disinformation, there is a role for another player, not just the media but science. In addition to efforts by journalists, the scientific community need to set a standard for producing reputable evidence-based information and then to communicate it effectively to the public.

“For example, members of the scientific community have an opportunity to increase communication around the process through producing peer reviewed papers, research and the like. It is so important that scientists are able to put out information in digestible and accessible formats that all societies can actually engage with and use to empower themselves,” said Dr Mhizha.

While THR opposition sees switching to nicotine alternatives as a undesirable way towards reducing morbidity and mortality caused by smoking, evidence has proven that Tobacco Harm Reduction, if treated as an ally, could help the World Health Organisation (WHO) set a voluntary global target of a 30% reduction in tobacco use between 2010 and 2025. Continued prohibition of safer nicotine products, while deadly combustibles remain on sale could result in negative public health outcomes.