Tobacco harm reduction 101

Tobacco harm reduction and vaping – why should you care?

More than 34 million adults in the United States (U.S.) currently smoke cigarettes. Accounting for more than 480,000 deaths every year (or about 1 in 5), cigarette smoking is the leading cause of preventable disease and death in the US. In addition, more than 16 million Americans live with a smoking-related disease. For these reasons, it is a public health priority to reduce the number of smokers.

Eliminating smoking of combustible cigarettes will not only benefit sufferers of smoking-related illnesses and their families, but will also benefit taxpayers due to the reduced cost of care for these individuals. As such, smoking cessation should be a priority for anyone who cares about public health and reducing suffering and death.

In recent years, tobacco harm reduction (THR) through the use of reduced-risk products such as electronic cigarettes and “heat not burn” devices (collectively known as “Electronic Nicotine Delivery Systems or ENDS), as well as snus, and oral nicotine products such as lozanges, has been proven to help smokers quit and help save lives. Unfortunately, considerable misinformation has spread, leaving most Americans unaware of the overwhelming scientific evidence regarding these products and their incredible benefit to society.

This short Q&A is designed to help answer some of the most common questions about THR and its benefits.

What is harm reduction?

• Harm reduction, sometimes known as harm minimization, is a proactive series of public health policies to reduce the negative effects associated with human behaviors such as recreational drug use and sexual activity. Harm reduction policies include measures like sex-education programs, needle exchange programs, and opioid replacement therapies such as prescribing methadone to heroin addicts. Unlike abstinence-only approaches, harm reduction is based on a basic pragmatism recognizing that some individuals will always engage in risky or dangerous behaviors and that is smarter to seek to minimize the damage that these activities can cause rather than putting forth the futile effort to eliminate the behavior or activity.

• Harm reduction in a myriad of activities has proven highly effective in saving millions of lives around the world.

How does harm reduction apply to smoking?

• THR specifically refers to policies designed to help smokers transition to less harmful products. Traditionally, these THR methods have included nicotine replacement therapies like patches and gums, which deliver nicotine to the user without the harmful effects associated with combustible cigarettes. More recently, newer and more innovative nicotine delivery systems such as electronic nicotine delivery systems have been introduced, while other delivery systems such as snus and nicotine lozanges have seen users continue to use nicotine without the deadly chemicals caused by the process of combustion. These options pose a fraction of the risk presented by traditional tobacco products.

• SOURCE: Cdc.gov, 2014 Surgeon General’s Report: The Health Consequences of Smoking-50 Years of Progress.

• SOURCE: Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019; 68: 1013-1019 (accessed 14 Nov 2019).

Is nicotine harmful?

• Nicotine is the key reason that people become addicted to smoking even though it is not the reason that people die from smoking. Nicotine is a mild stimulant similar to coffee, and while addictive, nicotine is not carcinogenic. It is a fundamental principle of tobacco tpolicy that people “smoke for the nicotine but die from the tar.” Additionally, nicotine is not classified as a carcinogen by the International Agency for Research on Cancer and is relatively safe for human consumption in low concentrations.

• Although potentially lethal at very high doses, the blood levels typically achieved by consuming nicotine via harm reduction products “does not result in clinically significant short- or long-term harms” which is why smokers have been using nicotine replacement therapies (NRT) for decades without incident. These products replace smoking with nicotine patches and gums, which provide users with controlled doses of nicotine. These patches and gums are widely sold as consumer goods, including to people under the age of 18. NRT products have been consistently approved for smokers as young as 12 years old for 30 years, with no noted adverse effects.

• It is also worth noting that, regardless of its benign health impacts, millions of vapers go on to completely quit nicotine and thus eliminate their exposure to even nicotine itself.

• SOURCE: World Health Organization International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 83, tobacco smoke and involuntary smoking. Geneva: International Agency for Research on Cancer, 2004.

• SOURCE: Greenland S, Satterfield M, Lanes S. A meta-analysis to assess the incidence of adverse effects associated with the transdermal nicotine patch. Drug Saf. 1998; 18:297–308.

• SOURCE: Tobacco Advisory Group of the Royal College of Physicians. Nicotine without smoke – tobacco harm reduction. London: RCP, 2016.

• SOURCE: Lee PN, Fariss MW. A systematic review of possible serious adverse health effects of nicotine replacement therapy. Archives of toxicology, 2016.

What are Electronic Nicotine Delivery Systems (ENDS)?

• Electronic Nicotine Delivery Systems (ENDS), usually known as vapes or electronic cigarettes (e-cigarettes), were invented in 2003 as a way to simulate the experience of smoking without the associated health effects of inhaling smoke. Since 2012, ENDS have become particularly popular as a method for smokers to quit their deadly habit. In particular, these products benefit users who have tried and failed at other methods of quitting.

• Vaping products mimic the sensation of smoking and provide nicotine to addicted persons without the smoke from burning tobacco. Because ENDS mimic the sensation of smoking, they provide users a method of nicotine delivery similar to their habits. What is absent is the deadly cocktail of chemicals that make cigarettes dangerous to smokers themselves and those around them. As a result, public health bodies around the world have concluded that vaping is significantly safer than traditional products. Using ENDS products allows users to avoid the process of tobacco combustion entirely and thus the harmful health byproducts of smoking.

What types of vaping products are available?

• Vaping products are broadly divided into two main categories. In one product category, nicotine is mixed with water and then heated and vaporized into steam. The aerosol is then inhaled. These liquid-based products are what most people consider e-cigarettes.

• A newer technology, known as heat not burn, produces aerosol by the heating or steaming (instead of burning) of a tobacco-based mixture. Similar to other reduced-risk products, this process closely approximates a traditional smoking experience. However, as with e-cigarettes, the deadly chemicals present in traditional cigarettes are almost completely absent in these devices.

What is the difference between closed system and open system e-cigarettes?

• Liquid-based e-cigarettes are divided into two additional categories: open system and closed system. The health benefits of both compared to traditional cigarettes are nearly identical in that neither produces smoke, a byproduct of combustion. However, the design of the e-cigarette is different. Open systems are filled manually by the user with e-liquid generally obtained from a specialty vape store either in person or online. Many users prefer this as a quit-smoking aid as it allows for greater customization of the experience for the smoker’s particular needs. Closed systems use pre-filled tanks that are directly inserted into the device and then disposed of when finished. Closed system users cite the convenience of pre-filled tanks compared to open, manual systems.

Are there any other tobacco harm reduction products besides ENDS?

• Yes. Other harm reduction products include smokeless tobacco products and oral nicotine products. Smokeless tobacco, sometimes known as moist loose tobacco or snus, can be found in a teabag-like pouch and allows users to ingest nicotine without smoking it. This usually involves placing the product between the gum and the cheek. Other oral nicotine products include lozenges and similar products and do not contain any actual tobacco. In addition, nicotine replacement therapies such as patches and gums are also considered harm reduction products and have been available for decades.

Do ENDS help smokers quit and how do they compare to other nicotine replacement therapies?

• Multiple studies have shown that smokers who make the switch to vaping either substantially reduce their cigarette intake or quit completely, and that 69.4 percent of people who use e-cigarettes intended to use e-cigarettes as a complete replacement for regular cigarettes.

• Two recent studies out of the United Kingdom (U.K.) found that ENDS products are at least twice as effective as conventional smoking cessation aids, including traditional Nicotine Replacement Therapy products and “behavioral support.” ENDS relative effectiveness is likely significantly higher in the U.S. as the U.K. places nicotine caps on vaping products, making them less appealing to smokers.

• There are four main reasons why ENDS products are more effective than other nicotine replacement therapies:

• •The action of vaping is similar to that of smoking, and therefore assists with the habit-forming part of smoking.

• •Nicotine is delivered faster through the lungs than through the mouth or the skin (hence why some pharmaceutical companies market nicotine inhalers).

• •Vapes are more customizable with a variety of flavors, strengths and sensations, allowing users to adapt the product to best suit their need.

• •Appealing flavors have been instrumental in many adults successfully making the switch.

• As a result, a majority of smokers now use vaping as their preferred smoking cessation method.

• SOURCE: Berg CJ, Barr DB, Stratton E, Escoffery C, Kegler M. Attitudes toward e-cigarettes, reasons for initiating e-cigarette use, and changes in smoking behavior after initiation: a pilot longitudinal study of regular cigarette smokers. Open Journal of Preventive Medicine. 2014; 4(10):789-800.

• SOURCE: Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction. 2011; 106(11):2017-2028.

• SOURCE: Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011; 11(1):786.

• SOURCE: Jackson SE, Kotz D, West R, Brown J. Moderators of real-world effectiveness of smoking cessation aids: a population study. Addiction (Abingdon, England). 2019; 114(9):1627–38.

• SOURCE: Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, Ross L. A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine. 2019; 380(7), 629-637.

• SOURCE: Brose et al. Mental Health and Smoking Cessation – a population survey in England. BMC Medicine. 2020; 18:161.

• SOURCE: Benmarhnia T, Pierce J, Leas E, White M, Strong D, Noble M, Trinidad D. Can E-Cigarettes and Pharmaceutical Aids Increase Smoking Cessation and Reduce Cigarette Consumption? Findings From a Nationally Representative Cohort of American Smokers. American Journal of Epidemiology. 2018; 187.

• SOURCE: CASAA e-cigarette survey results.

How many American lives could vaping save?

• According to the most comprehensive peer-reviewed research on the effects of switching coordinated by the George Washington University Medical Center, if a majority of smokers in the United States quit smoking through the use of e-cigarettes over the next ten years, there would be 6.6 million fewer premature deaths with 86.7 million fewer life-years lost.

• A further study was released in August 2020 which examined the proportion of U.S. smoking-produced mortality that e-cigarettes might eliminate and produced 360 possible scenarios. Of these 357 (99%) yielded positive estimates of life-years saved (LYS) due to vaping by 2100, from 143,000 to 65 million

• SOURCE: Levy DT, Borland R, Lindblom EN, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control. 2018; 27:18-25.

• SOURCE: David Mendez, PhD, Kenneth E Warner, PhD, A magic bullet? The potential impact of e-cigarettes on the toll of cigarette smoking, Nicotine & Tobacco Research