Tobacco Harm Reduction
According to the World Health Organization, tobacco use is the leading preventable cause of death in the world today. Tobacco harm reduction is the effort to minimize the myriad risks associated with tobacco use as much as possible. The basic premise is that although smokers continue to consume tobacco for the nicotine, the other components of combusted tobacco are responsible for the vast majority of health impacts from smoking, not the nicotine. Tobacco harm reduction approaches can then be defined as any effort to reduce the harm from smoking, usually involving the continued use of tobacco or nicotine in some form. Abstinence from all nicotine and tobacco is preferable in terms of health benefits, but tobacco harm reduction is primarily geared towards those who either can’t or won’t become wholly abstinent.
History of Tobacco Harm Reduction
In many ways, tobacco harm reduction begun with the use of snuff, a powdered form of tobacco inhaled through the nose. It was used by the native Indians, but its popularity is ordinarily attributed to Jean Nicot, who introduced it to the queen of France in the mid 16th century due to his belief in its medicinal properties. Its popularity continued until technology made cigarettes easier to produce and use in the 19th century, at which point it began to fall from favor. Despite the fact that snuff wasn’t intended to reduce harm as such, the lack of combustion meant that there were no harmful components such as the tar associated with smoking.
Tobacco harm reduction didn’t purposefully surface as an idea until the 1960s and 70s, when the National Cancer Institute’s Smoking and Health program pursued a method of producing “less hazardous” cigarettes. They produced “low tar” cigarettes, which although initially appealing turned out to be a poor approach to harm reduction, due to an extremely limited reduction of risk, numerous other issues with the type of research conducted and the poor dissemination of information to the public.
This wasn’t the end of the line for tobacco harm reduction, however, and numerous other approaches have since been developed with the aim of minimizing the risks associated with nicotine and tobacco consumption.
Different Approaches to Tobacco Harm Reduction
- Snuff – Snuff is still used today, even though it is still fairly rare in “dry” form. Because it is inhaled through the nose without combustion, it enables a hit of nicotine without the harmful components associated with combusted tobacco.
- Snus – Snus is a Swedish form of snuff, composed of finely ground moist tobacco which is usually contained within a small pouch. This is held beneath the upper lip – without being chewed or sucked – and releases nicotine for around an hour before the pouch is discarded.
- Chewing tobacco – Closely related to snus, chewing tobacco is a loose form of smokeless tobacco which is held in the mouth and occasionally chewed. It works in much the same way as snus, but unlike with snus, users hold the wad of tobacco in their cheek and periodically spit out accumulated brown saliva.
- Nicotine replacement therapy – Although nicotine replacement therapy products like gums, patches and inhalators are technically intended for those trying to quit smoking, they also offer a much safer form of nicotine consumption and therefore could be considered an approach to tobacco harm reduction. Patches depend on nicotine’s ability to be absorbed transdermally (through the skin), whereas gums and inhalators use more familiar methods of absorption.
- E-cigarettes – Electronic cigarettes (e-cigarettes) are a new technology which reduces harm by delivering nicotine through a vaporized liquid instead of combusted tobacco. The nicotine-containing liquid (primarily composed of propylene glycol, vegetable glycerin and flavorings) is vaporized by a heating coil and directly inhaled by the user in a manner similar to cigarette smoke, but without the associated by-products of tobacco consumption.
- Dissolvable tobacco – Dissolvable tobacco products such as strips, lozenges (or “orbs”) and sticks are effectively similar to chewing tobacco and snus, except they dissolve in the mouth and don’t require spitting. It’s assumed that they have the potential to reduce risk much like chewing and other smokeless tobacco products.
- Cutting down – The simplest approach to tobacco harm reduction is to simply consume less tobacco. This may be attempted in combination with any of the above approaches, but there is some uncertainty regarding the benefits of simply cutting down.
Research on Tobacco Harm Reduction
There have been many pieces of research investigating the potential risks and benefits on tobacco harm reduction approaches. Generally speaking, the vast majority of approaches are believed to decrease the risks of various cancers or other ill effects of smoking, and this is largely due to the inherent reduction of exposure to harmful chemicals. However, harmful chemicals are always still present, so there is no reduced harm product that can be considered absolutely safe.
- Smokeless tobacco and cancer – Smokeless tobacco is a broad group of products including chewing tobacco, snuff, snus and even dissolvable tobacco products. The biggest concern with smokeless tobacco is the risk of oral cancers, and this has been the subject of much research. Systematic reviews of the impact of chewing tobacco and moist snuff (snus) on cancer risk consistently report only a minor increase in the risk of oral cancer, due to the presence of tobacco-specific nitrosamines (a group of carcinogens). These were historically found to be present in higher quantities in American moist snuff than in Swedish versions, but modern products all have much lower levels. The risk may be related to methods of production, as studies from Sweden (where a method is used to minimize the quantities of these chemicals) show no increase in oral cancer risk. Dry snuff carries a greater risk (an increase of around eight times) for oral cancers, but it is still considered much safer than smoking. There is also evidence of some increase in pancreatic cancer risk in smokeless tobacco users, but the research is very limited and the risk is assumed to be much lower than that from continued smoking.
- Smokeless tobacco and other conditions – A more detailed review looking at other conditions potentially related to smokeless tobacco (in snus form) – such as inflammatory bowel disease and diabetes – found that for most conditions there is no evidence of increased risk, but research has shown reduced infant birth weights when used by pregnant women. Additionally, although most studies found no increase in prevalence, one piece of research from the 1970s found an increase in cardiovascular disease risk in snus-using construction workers. However, this effect was greater in middle-aged users and may not be relevant to modern smokeless products. Overall, smokeless tobacco appears to be an effective method for smokers to substantially reduce the risk they’re exposing themselves to.
- E-cigarettes – The research conducted on the safety of e-cigarettes to date is primarily in the form of chemical analyses of the contents of the vapor, although there is also toxicological evidence available. Long-term consequences are unknown given the recent emergence of the product. Carcinogens such as tobacco-specific nitrosamines are present, but in lower quantities than in snus and much lower quantities than in combusted tobacco cigarettes. Generally speaking, harmful components detected in e-cigarette vapor are in much smaller quantities than in tobacco cigarettes, being broadly comparable to levels found in nicotine patches, inhalers and gums. There also is evidence that the majority of e-cigarette “liquids” are not toxic to cells.
- Nicotine replacement therapy – Nicotine replacement therapy is considered safe for short-term use, but the long-term use of things like nicotine gums and patches opens up a very small risk for cancer similar to those expected for other tobacco harm reduction products. This is due to the presence of tobacco-specific nitrosamines. Other research also indicates a potential risk of cardiovascular disease from long-term use, but this risk is also assumed to be small, especially in comparison to continued cigarette smoking.
- Cutting down – There is limited evidence available on the benefits of reducing cigarette consumption, and the findings aren’t always consistent. One large study found a slightly decreased risk for tobacco-related cancers, but little difference for other health impacts and overall mortality. Other studies have also found a modest decrease in cancer risk, but the biggest potential benefit of cutting down appears to be the increased likelihood of complete smoking cessation after reducing consumption.
Legality of Approaches
The vast majority of reduced harm products are currently legal in most places in the world. Snus are currently banned in all EU member states apart from Sweden, but are also allowed in Norway. Upcoming regulations may impact on the availability of e-cigarettes, both in the EU and the US, but an outright ban is unlikely. As a new product, e-cigarette laws are evolving around the world, so are likely to change in the near future.
Resources for Tobacco Harm Reduction
- Harm Reduction International – Tobacco Harm Reduction – Introduction
- Tobacco Harm Reduction – Harm Reduction: Concepts and Practices
- Parascandola, M; (2005); Lessons from the history of tobacco harm reduction: The National Cancer Institute's Smoking and Health Program and the “less hazardous cigarette”
- CASAA – Smoke-Free Tobacco Product Types
- Sapundzhiev, N and Werner, J; (2003); Nasal Snuff: Historical Review and Health Related Aspects
- Tobacco Harm Reduction – Smokeless Tobacco
- British American Tobacco – Smokeless Snus
- CASAA – Electronic Cigarette FAQs
- Broadstock, M; (2007); Systematic review of the health effects of modified smokeless tobacco products
- Rodu, B and Jansson, C; (2004); Smokeless tobacco and oral cancer: a review of the risks and determinants.
- Weitkunat, R, Sanders, E and Lee, P; (2007); Meta-analysis of the relation between European and American smokeless tobacco and oral cancer
- Sponsiello-Wang, Z, Weitkunat, R, Lee, P; (2008) Systematic review of the relation between smokeless tobacco and cancer of the pancreas in Europe and North America.
Nicotine Replacement Therapy
- Shields, P; (2011) Long-term Nicotine Replacement Therapy: Cancer Risk in Context
- Benowitz, N and Gourlay, S; (1997); Cardiovascular Toxicity of Nicotine: Implications for Nicotine Replacement Therapy
- Godtfredsen, N et. al.; (2002); Smoking Reduction, Smoking Cessation, and Mortality: A 16-year Follow-up of 19,732 Men and Women from the Copenhagen Centre for Prospective Population Studies
- Song, YM, Sung, J and Cho, HJ; (2008); Reduction and cessation of cigarette smoking and risk of cancer: a cohort study of Korean men.
- Polosa, R et. al.; (2013); A fresh look at tobacco harm reduction: the case for the electronic cigarette
- Goniewicz, M. et. al.; (2013); Levels of selected carcinogens and toxicants in vapour from electronic cigarettes
- Burstyn, I.; (2013); Peering through the mist: What does the chemistry of contaminants in electronic cigarettes tell us about health risks?
- Farsalinos, K. et. al.; (2013); Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells
Research Lists and Summaries
- CASAA – Smokefree Health Effects
- Tobacco Harm Reduction – Reading Lists
- Tobacco Harm Reduction – Smokeless Tobacco and Your Health
- Harm Reduction International – Cigarette Reduction
- American Cancer Society – Smokeless Tobacco