Why smoke-free products are important for tobacco harm reduction

Many stakeholders, including public health organizations, healthcare professionals and regulators, now recognize that new policies are required to complement prevention and cessation strategies. Just to mention one example, here is a letter written to the World Health Organization (WHO) by 53 prominent public health advocates in 2014:

“The potential for tobacco harm reduction products to reduce the burden of smoking-related disease is very large, and these products could be among the most significant health innovations of the 21st century, perhaps saving hundreds of millions of lives.”

-- Letter to Margaret Chan from specialists in nicotine science and public health policy

The harm reduction equation

The harm reduction equation provides an intuitive way to think about how better choices, and an increased rate of adoption of those better choices, can benefit public health. 

The best way for smokers to reduce their risks associated with smoking is to quit tobacco and nicotine altogether. Still, according to WHO estimates, around 1 billion people will continue to smoke for the foreseeable future. There is a growing consensus that for adult smokers completely switching to tobacco- or nicotine-containing products that do not burn tobacco has the potential to present less risk of harm than continued smoking. 

For any smoke-free alternative to be successful in reducing harm compared with continued smoking, it has to fulfill two criteria: it must be scientifically substantiated as significantly less harmful than cigarettes; and it should be satisfying for current adult smokers so that they completely switch.

The more adult smokers who choose the lower risk options instead of continuing to smoke, the bigger the impact on reducing population harm. This is known as the harm reduction equation. The overall goal, therefore, is to develop smoke-free alternatives that present significantly less risk of harm than continued smoking, that are acceptable to current adult smokers who would otherwise continue to smoke cigarettes, and which are generally not attractive to youth, nonsmokers, or former smokers.

Heating instead of burning tobacco generates significantly lower levels of harmful chemicals  

The tip of a cigarette can rise above 800 °C, creating cigarette smoke that contains over 6000 chemicals. Around 100 of these have been classified by public health authorities as Harmful and Potentially Harmful Constituents (HPHCs). Most of these constituents are formed or released when tobacco is burned, which is why avoiding the combustion of tobacco should lead to the release of fewer and lower levels of HPHCs. Each smoke-free product should be scientifically assessed to confirm and quantify this reduction.

Most smoke-free alternatives contain nicotine, which is not risk free and addictive. Even so, nicotine is not the primary cause of smoking-related diseases but the high level of HPHCs generated by burning tobacco.  This means that scientifically validated products that contain nicotine but don’t burn tobacco can have a role to play in tobacco harm reduction.

What is the role of nicotine in tobacco harm reduction?

Nicotine, a well-known compound of tobacco, is one of the reasons that people smoke, along with taste and ritual. Nicotine is addictive and not risk free. Even so, it is not the primary cause of smoking-related diseases. For those men and women who would otherwise continue smoking, smoke-free products that contain nicotine have the potential to reduce their risk of developing smoking-related diseases. As nicotine is one of the reasons people smoke, its presence in smoke-free products can help adult smokers to switch instead of continuing to smoke cigarettes.

Our goal is to develop less harmful alternatives for adult smokers in which the levels of HPHCs are reduced or even eliminated.

Smoker acceptance: one key to tobacco harm reduction

Several leading tobacco policy experts acknowledge that successful harm reduction depends on adult smoker acceptance of alternative products. In 2007, the UK Royal College of Physicians stated that:

“The alternative sources of nicotine need to be acceptable to smokers as substitutes for cigarettes…"

As early as 1979, Dr. Ernst Wynder noted: 

“Research…should therefore be directed toward developing a [product] containing the lowest possible amount of harmful elements for all tobacco-related diseases, but one that has sufficient acceptability for the largest segment of smokers.”

We have shown, through testing our Tobacco Heating System (THS), that if tobacco is heated above 250 °C, similar amounts of nicotine as those found in cigarette smoke, can be released. At the same time, keeping the temperature low enough means the tobacco is not burned and the levels of HPHCs generated and therefore inhaled are significantly reduced. Our studies have shown an average reduction of 90-95% in the levels of HPHCs measured in the aerosol of THS compared to those found in the smoke of a standard research reference cigarette (3R4F).

Our oral nicotine pouches and e-vapor products do not contain tobacco and provide nicotine in an alternative way, for example with aerosol formers like glycerol, that are not HPHCs.

These products could, indeed, complement existing tobacco control efforts and be part of an overall harm reduction strategy to benefit public health. In recent years, an increasing number of adult smokers have switched from cigarettes to smoke-free alternatives such as e-cigarettes, heated tobacco, or oral tobacco products to reduce the risk of harm to their health compared to continued smoking. 

While smoke-free products are not risk free and in general contain nicotine which is addictive, switching completely to a scientifically substantiated smoke-free alternative can be a better choice for adults who would otherwise continue to smoke. The risk reduction potential of each product must be scientifically verified on a product by product basis.