If not stop, then at least minimize the damage

Worldwide, around 30-40% of cardiovascular diseases are attributable to smoking. This figure is around 80% for cancer cases and 63% for COPD cases. Around half of healthcare costs can be linked to cigarette consumption. A complete ban seems unrealistic at present, but limiting the damage by using substitutes such as e-cigarettes could make a big difference.

Quitting smoking is the best way to limit damage to your health. However, only 30-40% succeed in quitting smoking, including those who take advantage of psychological and pharmacological support. Harm reduction is an important tool for those who are unable to stop smoking.

In 2018, the costs associated with smoking cigarettes amounted to around 600 billion dollars, explained Prof. Dr. Andrzej Fal, Director of the Institute of Medical Science at the Cardinal Wyszyński University (UKSW) and Head of the Department of Allergy, Lung Diseases and Internal Diseases at the Central Clinical Hospital of the Ministry of the Interior in Warsaw and President of the Polish Public Health Society, at the 6th Polish Public Health Forum in Warsaw^th Summit Tobacco Harm Reduction in Athens [1]. 240 billion dollars are spent on healthcare, 184 billion dollars correspond to the loss of productivity due to smoking-related illnesses and health impairments. A further 180 billion dollars is accounted for by productivity losses due to premature deaths in the working population caused by smoking. And finally, there are 7 billion dollars in losses for those who die prematurely even though they are only passive smokers. “This must be emphasized: Smoking cigarettes is the only habit where the smoker does something – namely exhale – and someone else gets sick by inhaling.”

“Road Map” over 12 years

Some countries and governments have learned their lessons from this, as Prof. Fal explained, citing the example of New Zealand: The government there had spent 12 years preparing for the January 1, 2024 deadline. On the one hand there was an awareness campaign, on the other a policy of prohibition and control mechanisms for public health (Fig. 1). “There was a timetable for increasing the cigarette tax – ten times in 12 years! Every smoker knew that cigarettes would still be 10% more expensive next year than this year. So it was a kind of stress incentive and helped those who wanted to quit.”

From his own experience and work in Poland, Prof. Fal gave some recommendations on how to proceed efficiently in order to reduce the number of cigarette smokers and tobacco addicts in a structured way in the future:

1. priority prevention (social and economic policy measures that have an impact on health)
Establishment of at least one prevention clinic in each district/county:

• They should be managed by trained specialists.
• The clinics should be accessible without referral.
• They should be responsible for regional health prevention, programs (including schools) and smoking cessation, information campaigns – these campaigns should be uniform nationwide and less geared to regional needs.
• The coherence of the message should come first.

2. primary prevention

• Regulating the market by sensibly reducing availability, especially in the fast-selling areas (e.g. petrol stations). Ban the exposure of products at the point of sale.
• Radical but gradual increase in excise duties (and thus the price) for cigarettes as the most harmful products for smokers and their environment.

3. secondary prevention

Establish at least one prevention clinic in each district/county:

• For the reasons already mentioned under “1. Priority prevention”, but also, in the context of secondary prevention, to enable unrestricted access to anti-smoking therapy, nicotine replacement, pharmacotherapy and harm-reduction products.

4. tertiary prevention

Revision of the legislation:

• All products associated with smoking and nicotine should be subject to the same rules on sales and marketing restrictions.
• In the group thus defined, structure the consumption tax according to the motto “less damage, less tax”.

Do e-cigarettes suppress smoking cessation?

The extent to which e-cigarettes can help smokers who want to quit smoking normal cigarettes has often been the subject of heated debate since their market launch. A study group began systematically evaluating findings and evidence on this topic in 2023. Their initial preliminary results, presented by Dr. Renee O’Leary, Centre for the Acceleration of Harm Reduction, University of Catania, Italy, included data from five systematic reviews since 2021, which examined a total of 21 randomized controlled trials (RCTs) and 18 longitudinal cohort studies [2]. The scientists investigated two areas with regard to smoking cessation and the significance of e-cigarettes: firstly, the cessation rate and secondly, the comparative effectiveness.

With regard to people who had switched from cigarettes to e-cigarettes, 44% were still abstaining from traditional cigarettes six months after the switch. At the lower end, the rate was 14% after 12 months, but only in relation to a group that had no intention of quitting traditional smoking. The drop-out in this cohort was spontaneous. Overall, the success rate for quitting is around 10%. “That’s why we need harm reduction, because even those who try don’t succeed in quitting smoking,” Dr. O’Leary said.

On the other hand, the meta-analysis of the cohort studies revealed no significant differences in cessation rates between the groups. No improvement, but no disadvantage either. Dr. O’Leary therefore disagrees with the assertion that e-cigarettes suppress smoking cessation: “At worst, they make no difference.” She attributes the different results between the cohort studies and the RCTs to the methodology. “In the RCTs, you are in the laboratory, the subjects are aware of the situation, they think about what they are doing and consider changing something about their behavior.” In a cohort study, on the other hand, the doctors do not intervene.

Putting an end to tobacco addiction with ENDS

A large amount of positive data for the comparative effectiveness of e-cigarettes (ENDS – Electronic Nicotine Delivery System) could be read from the RCTs, the expert explained. When looking at nicotine ENDS, these were significantly more effective by a median of 161% compared to behavioral therapy or no support. Even at the lowest end of the statistical comparison, ENDS were 44% more effective (44%-374%) than no support or behavioral therapy alone.

With regard to nicotine replacement therapy (NRT), two systematic reviews have found that ENDS are 65% more effective than NRTs in smoking cessation. A third review showed no significant difference in efficacy. The range here was from 3% less effective to 109% more effective. Another study looked at ENDS compared to any type of therapy. Here, ENDS were more effective by a median of 55%.

“All this data tells us that ENDS should be promoted because they have been shown in RCTs to be more effective than other treatments,” Dr. O’Leary concluded. “Also, we’d like to think that a good part of the effect of ENDS is behavioral substitution, but that doesn’t seem to be the case. In two of the systematic reviews, nicotine-containing ENDS were 75% more effective than nicotine-free ENDS, meaning that behavioral support appears to be present to some degree, but not as strong as we would like.”

The scientist also referred to a recent study in which the test subjects had to be abstinent for six months without interruption, and abstinence also had to be proven biochemically. ENDS were 77% more effective in this study than any other treatment investigated. “That’s a big improvement. And with smoking cessation, we need every kind of improvement we can get. If ENDS offer that route, then they need to be taken seriously as an option.”

Take-Home Messages

• Prevention is the most effective way to invest in future health.
• Lifestyle changes, reduction of behavioral risk factors and harm reduction can reduce the burden of non-communicable diseases (NCDs).
• NCDs are responsible for more than 90% of premature deaths and more than 60% of curative medical costs in highly developed countries.
• In order to stop the smoking pandemic and its financial and health effects, it is necessary: 1. increase funding for primary prevention (lifelong education) and 2. introduction of the “less damage, less tax” scheme
• 44% of smokers who switched from cigarettes to e-cigarettes remained abstinent from traditional cigarettes 6 months after the switch.
• ENDS have been shown to be more effective than NRTs for smoking cessation.

Sources:

1. Fal A: On our way to a smoke free world – a common point of view of public health and economy. Keynote Speech,^6th Summit Tobacco Harm Reduction, Athens, 25.09.2023.
2. O’Leary R: At the Top of the Evidence Pyramid – Clinical Evidence on the Effectiveness of E-Cigarettes for Tobacco Cigarette Cessation,^6th Summit Tobacco Harm Reduction, Athens, 26.09.2023.
3. Farsalinos K: Tobacco Control in the^21st century from a socio-ethical perspective. Keynote Speech,^6th Summit Tobacco Harm Reduction, Athens, 26.09.2023.
4. Ministry of Health: Proposals for a Smokefree Aotearoa 2025 Action Plan: Discussion document. Wellington: Ministry of Health 2021.

Congress:^6th Summit Tobacco Harm Reduction

FAMILY PHYSICIAN PRACTICE 2023; 18(11): 42-44