Harm Reduction – an alternative to quitting smoking?!

It is undisputed that a complete stop to smoking is the best option for health. But not every smoker succeeds in giving up the cigarette. In recent years, therefore, the buzzword “harm reduction” has increasingly been used in connection with tobacco consumption. What is meant by this and can switching to potentially less harmful products such as e-cigarettes or tobacco heaters be an alternative to quitting smoking? An approach.

Smoking harms health – so far, so undisputed. Tobacco use is the most important preventable risk factor for chronic noncommunicable diseases such as COPD, cancer, and cardiovascular disease [1,2]. Moreover, it is considered the single most important cause of loss of quality of life and years of life [3]. Among the most consequences in terms of smoker-related deaths are cancers – 90% of all lung cancer cases alone can be attributed to the regular use of cigarettes [4]. In Switzerland, about 9500 people die each year as a result of smoking, which corresponds to 15% of all deaths [3].

Even one cigarette can affect health

It is not widely known that the amount of tobacco consumption is not so decisive in terms of health impairment. Just one cigarette a day can significantly increase the risk of coronary heart disease and stroke by a factor of 1.48 and 1.25, respectively. Thus, the risk is only about 50% lower than for people who consume 20 cigarettes per day [5]. In Switzerland, around two million people take up smoking [3]. In the process, prevention programs are in full swing. The overall goal is to further reduce tobacco-related deaths and illnesses in Switzerland. However, success is a long time coming. In 2018, the proportion of students who reported having smoked conventional cigarettes at least once in their lifetime increased sharply across age groups: among 11-year-olds, it was 5.7% among boys and about 2% among girls; among 15-year-olds, the proportion was already 35.4% among boys and 29.8% among girls [6]. Of the 15-year-olds who smoked daily (5.6% and 3.5%, respectively), just over half smoked no more than five conventional cigarettes per day, about one-third smoked 6-10 conventional cigarettes per day, and one in six consumed more than 10 conventional cigarettes per day. The frightening thing: On average, smokers lose 14 years of their lives – half do not even reach the age of 70 [7].

Smoking cessation programs rather deficient

Doctors and the federal government have been sounding the alarm for a long time. As a result, greater emphasis has been placed on smoking cessation and programs have been established with nicotine replacement products, medications and other supportive measures. However, due to psychological and physical dependence, numerous daily rituals, and social influences, tobacco abstinence is a long and difficult process for most smokers [8]. Tobacco cessation is based on the individual needs of the person concerned, but promises more chance of success if different strategies are combined. Nicotine substitution facilitates withdrawal and reduces withdrawal symptoms (overview 1). Similar success rates are reported with varenciline or bupropion. Also, although studies report abstinence rates over 12 months of between 22% (varencilin) and 15% (bupropion), these are not always achieved in everyday practice [8].

Success Concept Harm Reduction?

A buzzword that has been mentioned for quite some time in the context of smoking cessation is Harm Reduction. This refers to methods, programs, and practices aimed at reducing the individual and societal harms of the use of legal and illegal drugs by people who are unable or unwilling to stop using them. The main features of the harm reduction approach are directed at the prevention of harm to health from ingestion – as opposed to prevention of consumption per se [11].  The principle of harm reduction is based on the fact that while complete abstinence is seen as the ideal ultimate goal, it is also recognized that not all users will succeed in quitting. Harm reduction is a pragmatic approach that is now widely accepted.

In terms of tobacco use, harm reduction means switching from cigarettes to potentially less harmful products. These include, for example, e-cigarettes and tobacco heaters. While both are battery-powered, generate an aerosol and produce no ash, there are differences between the products, whose names are often used interchangeably. The main difference is that e-cigarettes vaporize so-called liquids, which are flavored and contain only nicotine extracted from the tobacco plant. Tobacco heaters (HTP), also known as “heat-not-burn” products, on the other hand, use specially prepared tobacco that is heated directly rather than burned to generate an aerosol. A patented heating system heats the tobacco to a precisely controlled temperature range of up to 350°C maximum. This temperature is well below the range of combustion. In the high temperatures of the glow zone of 600 to 900°C, both the tobacco and the additives of the normal cigarette burn. This creates the composition of water, nicotine and potentially harmful components typical of tobacco smoke. These include carbon monoxide, formaldehyde, acetaldehyde, acrolein, benzenes, benzopyrenes and butanones [12].

Potentially reduce health risk

A recent review of studies regarding the health outcomes of electronic nicotine delivery systems (ENDS) failed to demonstrate that ENDS cause adverse cardiovascular disease cardiovascular disease (CVD) [13]. The aim of the review was to identify and critically appraise the strength and quality of evidence of studies that reported on disease endpoints associated with the use of ENDS. Database searches identified 755 studies and other sources identified 265 studies; 37 studies met the final eligibility criteria. The analysis did not show ENDS to be a cause of adverse CVD outcomes; furthermore, switching from cigarettes to e-cigarettes was associated with improved control of hypertension and a reduction in exacerbations of COPD.

Similar conclusions were reached in a Japanese study that performed a time-trend analysis of data from the Japanese Medical Data Center (JMDC) database [14]. Specifically, the number of hospitalizations for chronic obstructive pulmonary disease (COPD), exacerbations, and acute ischemic heart disease (IHD) were evaluated before and after the introduction of HTPs into the Japanese market. This demonstrated a significant reduction in the number of hospitalizations for COPD. Also, a nonsignificant reduction in hospitalizations for COPD combined with lower respiratory tract infections and for IHD was observed after the introduction of HTP.

A start seems to have been made

Japan is the frontrunner in the HTP market. Cigarette sales already declined slowly but steadily between 2011 and 2015. However, this accelerated from 2016. The accelerated decline in cigarette-only sales in Japan since 2016 has corresponded with the introduction and growth in sales of HTPs (Fig. 1) [15]. This is all the more remarkable given that health authorities have largely opposed the marketing of HTPs. In addition, Japan does not have stringent measures to curb smoking and or a marketing ban on ENDS, which have been associated with a decline in cigarette sales in the United States and England.

A solution for health?

Smoking-related diseases are among the biggest health problems of the 21st century. It is estimated that about one billion people will die from tobacco-related causes by 2099 [16]. Ultimately, every smoker is aware of what they are doing to their body. But often the addiction is stronger. One harm reduction strategy would be to switch to an alternative nicotine delivery service. These include products such as smokeless tobacco, e-cigarettes or heated tobacco products. For smokers of traditional cigarettes, this means replacing a very harmful product with one that is significantly less harmful.

Literature:

1. www.dkfz.de/de/tabakkontrolle/Gesundheitliche_Folgen_des_Rauchens.html (last accessed 29.09.2022)
2. Steinberg MB, et al: Nicotine Risk Misperception Among US Physicians. J Gen Intern Med 2020. DOI: 10.1007/s11606-020-06172-8.
3. www.bag.admin.ch/bag/de/home/zahlen-und-statistiken/zahlen-fakten-zu-sucht/zahlen-fakten-zu-tabak.html (last accessed 29.09.2022)
4. Mattli R, et al: The burden of disease of tobacco use in Switzerland: estimate for 2015 and projection to 2050; final report; ZHAW. Available at: https://zahlen-fakten.suchtschweiz.ch/docs/library/mattli_ort8gw7xd8ig.pdf
5. Hackshaw A, Morris JK, Boniface S, et al: Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports. BMJ 2018; 360:j5855
6. www.suchtschweiz.ch/fileadmin/user_upload/DocUpload/HBSC-2018-rr-100.pdf (last accessed 29.09.2022)
7. www.bag.admin.ch/bag/de/home/gesund-leben/sucht-und-gesundheit/tabak.html (last accessed 29.09.2022)
8. Cornuz J, Jacot Sadowski I, Humair JP: Physician smoking cessation counseling, 3rd edition FREE FROM TOBACCO 2015.
9. Humair JP: Effective methods and place of electronic cigarette. Tobacco cessation. Primary and Hospital Care – General Internal Medicine 2018; 18(19): 339-342.
10. Kuendig H, et al.: Désaccoutumance tabagique en Suisse en 2015. Analyse des données du Monitorage suisse des addictions. Addiction Switzerland, Lausanne. 2016.
11. International Harm Reduction Association. What is Harm Reduction? A position statement from the International Harm Reduction Association, London, United Kingdom, German, April 2010.
12. Margham J, McAdam K, Forster M, et al: Chemical Composition of Aerosol from an E-Cigarette: A Quantitative Comparison with Cigarette Smoke. Chem Res Toxicol 2016; 29(10): 1662-1678.
13. Hajat C, Stein E, Shantikumar S, et al: A scoping review of studies on the health impact of electronic nicotine delivery systems. Internal and Emergency Medicine 2022; 17: 241-268.
14. van der Plas A, Antunes A, Romero-Kauss A, et al: Ischemic Heart Disease and Chronic Obstructive Pulmonary Disease Hospitalizations in Japan Before and After the Introduction of a Heated Tobacco Product. Front. Public Health 2022; 10: 909459.
15. Cummings M, Nahhas GJ, Sweanor DT: What Is Accounting for the Rapid Decline in Cigarette Sales in Japan? Int J Environ Res Public Health 2020; 17: 3570.
16. A Report of the Surgeon General: How Tobacco Smoke Causes Disease 2010. The Biology and Behavioral Basis for Smoking-Attributable Disease. In: Helath USDo, Human S, eds. Office of The Surgeon General, Rockville MD: Public Health Service 2010.

HAUSARZT PRAXIS 2022; 17(10): 58-59