Tobacco harm reduction: the potential

No longer just ‘quit or die’, but ‘quit and try’

From the 1980s onwards, the main tobacco harm reduction product was nicotine replacement therapy (NRT) – products including patches, gum and inhalators. NRT is now the medically approved way to consume nicotine without t obacco and is on the WHO’s List of Essential Medicines. Given this, it is easy to refute any claims that the harmful chemical in a cigarette is the nicotine . Though still banned or tightly regulated in some countries, in others NRT is widely available, and in many places, it can be obtained without prescription, including by young people.

Since the mid-2000s, however, an entirely new harm reduction front for tobacco has opened up. There has been widespread uptake of nicotine vaping products among consumers in many countries, together with the realisation of significant public health gains from the switch from combustible tobacco to smokeless tobacco (snus) in Sweden, and a proliferation in the range of newer products, such as heated tobacco products and oral nicotine pouches (containing no tobacco).¹⁴

In comparison to conventional tobacco control initiatives, uptake of safer nicotine products has largely occurred without any overall public health input – without encouragement or investment from governments, tobacco control experts or tobacco control NGOs. However, following consumer uptake, the UK and New Zealand gave strong policy support to this development. A few other governments are beginning to be supportive, but again, this has come after initial consumer interest.

Safer nicotine products

There is substantial international, independent evidence that the new products are demonstrably and significantly safer than traditional cigarettes.

There is no more dangerous way to consume nicotine than by smoking a tobacco cigarette.

Nicotine vaping products (also known as e-cigarettes)

These products allow the user to inhale nicotine in a vapour which contains no tar or carbon monoxide. All vaping products have three basic elements: the battery, which heats up the coil or atomiser, which turns the flavoured liquid into a vapour to be inhaled.

Most e-liquids contain four ingredients: vegetable glycerine (VG) which provides the vapour, propylene glycol (PG) which carries the flavour (although PG-free liquids are available as some people are allergic to this ingredient), nicotine, and flavouring.

The first modern e-cigarette came onto the market in 2003. Since then, there have been numerous product developments. Vaping products range from very simple disposable or partially disposable devices through to more complicated devices which consumers can customise for themselves using different component parts or settings.

Using vaping products instead of combustible tobacco cigarettes reduces the users’ exposure to multiple toxicants and carcinogens present in tobacco smoke. This means that vaping products are at least 95 per cent safer than cigarettes.¹⁶ There is no evidence so far that second-hand vapour causes harm to bystanders.¹⁷

Heated tobacco products

A new generation of devices called heated tobacco products has reached the market recently in many countries. These devices heat tobacco below the level of combustion to a temperature of no more than 350°C, which is sufficient to release nicotine in a vapour containing significantly reduced levels of toxins compared to combustible cigarettes.³⁴ Tobacco for use in heated tobacco devices is powdered and mixed with glycerine, guar gum, and other ingredients.

Heated tobacco products generate significantly lower levels of harmful constituents compared to cigarettes; in terms of cancer potency, a review of extant studies of toxicological risk and likely daily exposure indicated that cancer risk from heated tobacco products is between one and 10% that of cigarettes.³⁵

Snus

In contrast to the new safer nicotine products, snus has been used for over 200 years, but only recently has its relative safety compared to cigarettes been confirmed by independent clinical and epidemiological investigation. Snus is a moist to semi-moist smokeless tobacco product, made from ground tobacco leaves and food-approved additives. The final product is placed in the mouth (not chewed).

Loose snus is pinched into shape before being inserted into the mouth, often under the upper lip. ‘Portion snus’ is sold in small teabag-like sachets.

The nicotine content of snus varies between brands, with the most common strength being 8 mg of nicotine per gram of tobacco. Stronger varieties can contain up to 22 mg of nicotine per gram of tobacco.

Tobacco-free snus is a recent addition to the range. These products use other plant fibres impregnated with nicotine instead of tobacco.

Swedish snus is the dominant form of smokeless tobacco in the Nordic countries. It is illegal to sell snus in all European Union countries except Sweden. In Canada and several regions of the USA, it is sold alongside American-produced forms of snus, and in October 2019, the US Federal Drug Administration (FDA) granted the first ever modified risk orders to eight Swedish snus products, meaning they can be advertised with specific information about the lower risks of certain health effects compared to smoking cigarettes.⁴⁰

A European Commission review concluded that complete substitution of smokeless tobacco products for tobacco smoking would ultimately prevent nearly all deaths from respiratory disease currently caused by smoking, and reduce the cardiovascular mortality that currently arises from smoking by at least 50%.⁴¹ There is no significant association between snus and premature deaths, diabetes, pancreatic and oral cancers, heart disease or strokes.

substitution of smokeless tobacco products for tobacco smoking would prevent nearly all deaths from respiratory disease caused by smoking

Substituting Swedish snus for high risk oral or chewed smokeless tobacco (SLT) products could be transformative to health in many LMIC. In India, for example, the use of high risk SLT products is common, especially among women, for whom it is less socially acceptable to smoke; around 70 million girls and women in India aged 15 or over are thought to use SLT on a regular basis. India has the highest global rate of oral cancer due to the high prevalence of SLT use, accounting for around 400,000 deaths annually.⁴²