Health - Tobacco Harm Reduction

[Lunar Loops]

The following comes from the International Harm Reduction Agency (IHRA) website (a good source of information) http://www.ihra.net/:

Introduction

Approaches that aim to reduce the harm for those who continue to use tobacco / nicotine have received little attention to date. This set of documents is intended for people who are interested in how harm reduction can be applied to tobacco use. These documents may be used to improve advocacy for tobacco harm reduction, carry out research or develop new policy. They may also be used to plan new services or improve or evaluate existing services. This collection is intended to benefit policy makers, practitioners, communities and tobacco users around the world. These harm reduction approaches should be seen as an additional and complementary strategy to the other key tobacco control strategies.

Tobacco harm reduction is a policy or strategy for tobacco users who cannot or will not stop, which explicitly includes the continued use of tobacco or nicotine and is designed to reduce the health effects of tobacco use. Examples of harm reduction interventions could include using potentially reduced-exposure products (PREPs), reducing consumption, switching to long-term nicotine replacement therapy (NRT), switching to smokeless tobacco products, and using replacement products for temporary abstinence.

The premise behind these strategies is that dependence on nicotine is the critical factor underpinning most tobacco use. However, it is not the nicotine that causes most of the harm but rather some of the other 4000 constituents of cigarette smoke, of which 60 are known carcinogens. Drawing an analogy with illicit drug use, the cigarette is the equivalent of the ‘dirty syringe’. Consideration therefore needs to be given to separating the drug from the delivery system. The strategies considered here examine the potential for switching some or all cigarette use to other, less harmful nicotine delivery systems.

This collection contains over 80 major documents covering a range of 10 topics related to tobacco harm reduction. Until now, there has been no single, readily accessible source of up-to-date key documents about tobacco and harm reduction. This collection of tobacco and harm reduction documents is periodically reviewed, and we would welcome any feedback or suggestions contact IHRA.
Selection Process

Papers were preferred if they were recent, brief, readable, accredited by an international or national organisation, published as a paper in a high impact factor journal, and/or scientifically rigorous.

During the search process, preference was also given to documents that were of practical use to advocates, policy makers, programme managers and harm reduction practitioners. This was not an attempt to compile a scientific evidence base (although, as harm reduction is not currently being practiced widely in tobacco control, the majority of the papers are academic). In addition, consideration was given to avoid long and complex documents, because the collection may at a later date be translated.

An International Reference Panel of experts was set up to ensure that the selected documents were of a high standard and reflected global perspectives. Unfortunately, the majority of the papers and documents are from the developed world, as little work on tobacco harm reduction has been done in developing or transitional countries to date.
If You Only Read One Paper...

This paper reviews the evidence and expert opinion on tobacco harm reduction strategies such as smokeless tobacco. It advises on how to advocate for these interventions with both policy makers and, essentially, smokers themselves.Kozlowski LT, O’Connor RJ & Edwards BQ (2003) Some practical points on harm reduction: What to tell your lawmaker and what to tell your brother about Swedish snus. Tobacco Control, 12, 372-373
Acknowledgements

This collection was the result of funding from the Open Society Institute (OSI), and was put together on behalf of IHRA by Ann McNeill (Professor in Health Policy and Promotion at the University of Nottingham). Ann was supported in this work by Gerry Stimson (IHRA Executive Director), Jamie Bridge (IHRA Communications and Project Development Officer), and Erdem Pulcu (Freelance Research Consultant).

Particular thanks must also go to the International Reference Panel:

• Karl Fagerstrom
• Jonathan Foulds
• Nigel Gray
• Martin Jarvis
• Lynn Kozlowski
• David Sweano

We would also like to acknowledge the following:

• Action on Smoking and Health (ASH) (http://www.ash.org.uk/)

• Addiction (http://www.addictionjournal.org/)

• Addictive Behaviors (http://www.sciencedirect.com/science/journal/03064603)

• BMC Public Health (www.biomedcentral.com)

• Elsevier (www.elsevier.com)

• European Respiratory Society (http://www.ersnet.org/ers/default.aspx)

• Food and Drug Law Journal (http://fdli.org/pubs/Journal%20Online)

• Framework Convention Alliance for Tobacco Control (http://fctc.org)

• Harm Reduction Journal (BioMed Central) (http://www.harmreductionjournal.com)

• John Wiley & Sons, Inc (www.wiley.com)

• New England Journal of Medicine (http://content.nejm.org)

• New Zealand Medical Journal (http://www.nzma.org.nz/journal/index.shtml)

• Nicotine & Tobacco Research (http://www.tandf.co.uk/journals/titles/14622203.html)

• Royal College of Physicians (www.rcplondon.ac.uk)

Sub-Categories

To make these documents easier to navigate and locate, this collection has been divided into various sub-categories which each define a certain area of research or interest.

In total there are over 80 papers in this collection, and these have been divided into ten sections. Each of the sections contains papers advocating for harm reduction, as well as papers that provide the evidence base for harm reduction. For many of the sections, there are also articles for “further reading”. To view the documents in each section, as well as a description of the section itself, please click on the links below.

1. Overviews of harm reduction
The rationale behind tobacco harm reduction approaches is that, while dependence on nicotine (the addictive substance in tobacco) underpins most tobacco use, it is not what causes most of the harm. Cigarettes are the dominant global nicotine delivery devices and are highly engineered and sophisticated, yet extremely harmful and largely unregulated. Harm reduction approaches to tobacco use are aimed at reducing the adverse effects of tobacco use for continuing users. This can be achieved through education, promoting reduced consumption as a viable alternative to abstinence, and promoting alternative forms of nicotine delivery which, relatively at least, carry less risks of harm. This section includes papers, book chapters and reports that examine the need for a harm reduction strategy alongside other tobacco control strategies, and what the scope of such a strategy might be.Click here to view the papers in this section
2. Nicotine policy
This section examines the policies that are needed in order to improve the regulation of all nicotine products. These papers discuss how cleaner nicotine products can replace cigarettes as the dominant form of nicotine delivery. In particular, they detail the need for a single coordinated regulatory framework for all nicotine products together.Click here to view the papers in this section
3. Regulation of nicotine replacement therapies
Nicotine replacement products (NRT) are products that are manufactured by the pharmaceutical industry to be used as aids to smoking cessation and are ‘clean’ nicotine delivery devices. They have proven efficacy and currently there are six different types of NRT available in the UK, one of which (the gum) was launched in the UK in 1981. Lengthy experience with these products has demonstrated that they are much less harmful than smoking, although caution is needed with some populations such as pregnant women. However, NRT products are much more tightly regulated than tobacco and their use, until very recently, is mostly restricted to short-term use during a quit attempt.Click here to view the papers in this section
4. The health risks of smokeless tobacco and its role in a harm reduction strategy
Smokeless tobacco products are less harmful than cigarette smoking because they are non-combustible. Nevertheless, there is a wide variety of different smokeless tobacco products on the market around the world and they differ enormously in terms of their use across different populations and contexts, and their harmfulness. Some papers in this section focus on the Swedish case study and “snus” (a smokeless tobacco product manufactured to contain very low levels of many carcinogens). Snus has a long history of widespread use in Sweden, which has a low smoking prevalence and low tobacco related morbidity. Other papers focus on the types of smokeless tobacco that are used in other countries. The potential role of regulated smokeless tobacco products within a harm reduction strategy is also explored. Click here to view the papers in this section
5. Regulation of cigarettes
There will never be a truly “safe” cigarette because the process of combustion, by its very nature, releases a host of toxic smoke components. However, it may be possible to make changes to cigarettes to minimise these harmful components, and regulators and manufacturers would be negligent if they did not utilise all knowledge at their disposal to reduce the harmfulness of cigarettes to the extent that this is feasible. The cigarette is a highly engineered and sophisticated nicotine delivery device and an assessment of the harm and addictiveness of cigarettes will need to be made across a number of dimensions. The articles in this section focus on how the cigarette has changed over the years, and the various attempts that have been made to monitor and regulate them. Click here to view the papers in this section
6. The failure of light cigarettes
Thus far, the most significant attempt to reduce the harmfulness of cigarettes was the “tar reduction” strategy. It is now widely agreed that this strategy has achieved little (if any) public health benefit. Crucially, it failed to take account of the fact that smoking is a predominantly nicotine-seeking behaviour. Additionally, the tobacco industry designed cigarettes to subvert the strategy in a number of ways, including the misleading labelling of lower tar cigarettes as “light” or “mild”. This section includes papers that explain why the tar reduction strategy failed as well as those that make recommendations for future regulation. Click here to view the papers in this section
7. Cigarette reduction
Cigarette reduction has been widely proscribed as a harm reduction measure as, when reducing the number of cigarettes smoked each day, many smokers tended to smoke each individual cigarette more intensively. However, recent evidence has emerged to show that cutting down with the use of nicotine replacement therapy to top up nicotine levels may reduce compensatory smoking and result in increased quitting behaviour.Click here to view the papers in this section
8. PREPs and other tobacco use
In addition to conventional cigarettes, and smokeless tobacco (covered in Section 4), there are other forms of tobacco available. For example, traditional alternatives to cigarettes are pipes and cigars and several tobacco companies have designed (and in some cases marketed) new forms of nicotine delivery – sometimes referred to as Potential Reduced Exposure Products (PREPs). These include, for example, “Eclipse” - a product that heats the tobacco rather than burning it. In the USA, this is being marketed as a safer alternative to conventional cigarettes. The health risks of these alternative tobacco products compared to the conventional cigarette are explored in this section. Click here to view the papers in this section
9. The role of the tobacco industry and funding
This section includes articles which examine the tobacco industry’s knowledge of smoking and toxicity as well as the potential role that the industry can play in tobacco harm reduction in the future. (In addition, the role that the tobacco industry played in subverting lower tar cigarettes is covered in Section 6.)Click here to view the papers in this section
10. Communication and perceptions of relative risks
The attitudes of smokers towards harm reduction products are critically important to their success. This section includes papers which outline and investigate how much smokers understand about the role of nicotine in their tobacco use and the relative risks of smoking cigarettes compared to other forms of tobacco. Click here to view the papers in this section