Tobacco, Harm Reduction And Ending Combustible Smoking

Today the idea of ending combustible smoking is being discussed as a reality that we may see in the next decade. Some countries have already deadlined for wiping out cigarettes. As a step towards a smoke-free future, the world is discussing the concept of tobacco harm reduction or THR.

In the 1970s, health researchers demonstrated that the primary motivation for smoking was nicotine, as it was not the cause of the most severe smoking-related harms. Health researchers such as Michael Russell and Martin Jarvis in the UK and clinician Brad Rodu in the US argued for encouraging smokers to switch to less harmful forms of nicotine delivery. These less harmful nicotine delivery systems included snuff, snus, and smokeless tobacco. In his writing in the British Medical Journal in 1976, Michael Russell said that people smoke for nicotine but die from the tar.

THR works because almost all of the disease risk attributable to smoking arises from the smoke: the particles of the tar and the toxic gases inhaled from burning tobacco. Nicotine creates dependence, which keeps people smoking. The smoke contains thousands of toxic agents because many are found in reactions during combustion. If smokers find satisfactory alternatives to cigarettes that do not involve combustion but provide nicotine, they will avoid almost all the disease risks.

The term ‘harm reduction’ was coined in the 1980s and referred to pragmatic interventions “that reduced health risks associated with substance use and sexual activity at the height of the HIV/AIDS crisis.”

However, the WHO and tobacco control activists worldwide mistrust the term “tobacco harm reduction” and claim it is another ploy by the tobacco industry.

Inhaling a burning cigarette remains the riskiest use of nicotine, as it releases tar and gases containing thousands of toxins. These are potentially dangerous for health and fatal.

It is not surprising that most smokers globally know that tobacco is harmful to their health, but still, the use of nicotine is through the burning of tobacco. As stated, nicotine does not cause severe illnesses associated with high-risk tobacco products like cigarettes. A comparatively low-risk drug, nicotine encourages repeated use. Repeated use is one of the reasons smokers find it hard to stop smoking, even when they know it is harmful to their health.

At the start of the 21st century, the world witnessed the introduction of safer nicotine products. These stood for being non-combustible as none of them burnt tobacco, even did not contain any tobacco at all. We today know them as electronic cigarettes or nicotine vapes, nicotine pouches, Swedish snus, US smokeless chewing tobacco, and heated tobacco products.

It is also important to highlight that nicotine is on the WHO’s list of essential medicines because doctors have been prescribing nicotine patches and gums to people trying to quit smoking for decades. Further, WHO recognizes and endorses the principle that people be empowered to have control over their health to live healthier lives. The Framework Convention on Tobacco Control (FCTC) defines tobacco control as “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke”.

For a country like Pakistan, with a heavy disease burden because of combustible smoking, tobacco harm reduction offers a possibility to considerably reduce tobacco use. The number of tobacco users has reached 29 million, with most of the users being youth. In 2019, the economic cost of smoking in Pakistan was Rs 615.07 billion (US$3.85 billion), equal to 1.6% of the country’s GDP. Smoking cessation services are conspicuous by their absence in Pakistan, which is one of the 15 top countries with the highest burden of tobacco use morbidities and mortality. The primary tobacco law in Pakistan – the Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002 – does not discuss smoking cessation.

As the world is looking at the role of THR in reducing cigarette consumption, Pakistan should research, review and decide how it can make THR part of its tobacco control efforts.

Today THR is offering millions of smokers help to switch out of combustible smoking, especially for smokers unable to quit nicotine. The availability of safer nicotine products brings significant benefits.

It is high time governments around the globe adopt and implement tobacco harm reduction policies and products. For using safer nicotine products, governments should implement effective and appropriate regulation that protects consumers and avoids youth uptake. They should also encourage switching among adult smokers and avoid policies and laws that intentionally or unintentionally favor risky products.