Andrzej Sobczak1, 2
The current potential of tobacco harm reduction
Współczesne możliwości redukcji szkód wywołanych paleniem tytoniu
1Zakład Chemii Ogólnej i Nieorganicznej, Wydział Farmaceutyczny z Oddziałem Medycyny Laboratoryjnej, Śląski Uniwersytet Medyczny w Katowicach
2Zakład Szkodliwości Chemicznych i Toksykologii Genetycznej, Instytut Medycyny Pracy i Zdrowia Środowiskowego w Sosnowcu
Streszczenie
Palenie tytoniu jest przyczyną powstawania największej liczby nowotworów i chorób chronicznych oraz największej ilości zgonów w krajach rozwiniętych. Pomimo wielu metod zwalczania nałogu palenia (terapie behawioralne, nikotynowa terapia zastępcza, farmakoterapia) liczba palaczy zmniejsza się powoli. Dla osób, które nie są w stanie zaprzestać palenia, pomoc w zakresie redukcji szkód wywoływanych przez palenie tytoniu mogą stanowić alternatywne formy dostarczania nikotyny, które pojawiły się na rynku konsumenckim w ostatnich latach. Należą do nich elektroniczne papierosy, a ostatnio również bezdymne wyroby tytoniowe. Brak spalania tytoniu w tych produktach znacznie ogranicza liczbę szkodliwych związków inhalowanych przez użytkownika w porównaniu z dymem tytoniowym. Na podstawie dotychczasowych badań szereg prestiżowych organizacji ocenia pozytywnie redukcję szkód zdrowotnych po przejściu z konwencjonalnych wyrobów tytoniowych na elektroniczne papierosy, wyrażając jednocześnie zaniepokojenie związane z dalszym uzależnieniem użytkowników tych urządzeń od nikotyny oraz niebezpieczeństwem uzależnienia młodzieży od nikotyny. Większość z nielicznych doniesień dotyczących ich szkodliwości jest autorstwa pracowników laboratoriów badawczych pracujących na rzecz koncernów tytoniowych. Wydaje się jednak, że te nowe produkty mogą rzeczywiście zredukować szkody wywołane paleniem tytoniu, ale w jakim stopniu pozostaje kwestią otwartą.
Summary
Smoking is the cause of the highest number of cancers and chronic diseases as well as the highest mortality rates in developed countries. Despite a variety of methods to combat tobacco dependence (behavioural therapies, nicotine replacement therapy, pharmacotherapy), the decrease in the number of smokers is slow. Alternative forms of nicotine delivery, which have been introduced in the consumer market in recent years, may help reduce harm caused by smoking in individuals for whom smoking cessation is not feasible. These include electronic cigarettes and more recently developed smokeless tobacco products. Due to the absence of tobacco combustion in these products, the number of harmful compounds inhaled by the user is significantly reduced compared to tobacco smoke. Based on previous studies, a number of prestigious organizations express their positive opinion on the reduced adverse effects on health following transition from conventional tobacco products to electronic cigarettes, while expressing their concern over the continued dependence of the users of these devices on nicotine as well as the risk of nicotine addiction among adolescents. Most of the few reports on their harmfulness were published by laboratory workers employed by tobacco companies. It seems, however, that these new products can actually reduce tobacco-related damage, but to what extent it remains to be seen.
Introduction
Nicotine belongs to psychoactive substances, like ethyl alcohol and opioids. The common feature of these substances is their ability to induce addiction, which should be regarded as a complex disease of the central nervous system characterised by a persistent urge to obtain and use these substances. Discontinuation of psychoactive substances leads to somatic and mental disorders referred to as a withdrawal syndrome or withdrawal symptoms.
Smoking tobacco and, in a wider sense, nicotinism is a particular type of addiction, which has spread considerably due to its widespread acceptance. Only after the extent of the harmful effects of nicotine and the large number of toxic compounds inhaled by smokers have been revealed, harm reduction strategy was incorporated in the management of nicotinism (1).
According to the International Harm Reduction Association, which is a non-governmental organisation, the term “harm reduction&rdquop; refers to strategies, programmes and practices whose primary aim is to limit the health, social and economic consequences of using both legal and illegal psychoactive substances without necessarily reducing their consumption (2). Harm reduction strategy rejects the idea that total abstinence is the only and the most appropriate way to address the issue of substance abuse. In the case of smokers, the strategy is aimed at the elimination of toxic substances, while maintaining the use of nicotine.
Tobacco smoking and associated health risks
Tobacco belongs to the most widespread group of products that contain psychoactive substances (nicotine). Nicotine inhalation during tobacco smoking was already known by Aztecs and spread in Europe in the fifteenth century after arrival of tobacco seeds with Columbus. Over the centuries, tobacco has gained popularity in most cultures in the world.
It was not until the mid-twentieth century that articles pointing to the harmful effects of tobacco smoking started to emerge, initially in scientific journals. The first observations led to the conclusion that smoking tobacco is closely related to neoplastic transformations in the lungs (3). In 1952, Roy Norr’s article entitled “Cancer by the Carton&rdquop; was published in Reader’s Digest, a magazine targeting mass audience (4). This was the first information on the correlation between smoking cigarettes and the incidence of lung cancer, which was intended for a large group of readers. The increasing number of works on the harmful effects of smoking tobacco resulted in the introduction of the first regulation on clean indoor air, banning smoking cigarettes in enclosed public places and enforcing separate areas for smokers and non-smokers in restaurants. This took place in Berkeley, California in 1977. In this respect, some of the US states are up to several dozen years ahead of European countries. Similar regulations were not introduced in Poland until the 15th November 2010 (5).
Dozens of years of research devoted to smoking addiction provided indisputable evidence that nicotine is an addictive substance and chronic tobacco smoking is one of the leading preventable causes of mortality (6).
The WHO’s 2009 report identified 19 types of global health risk associated with mortality (7). Smoking tobacco comes the second in the list covering all countries, while it is the most common cause of death in highly developed countries.
It seems that the last few decades, during which more than 143,000 works on tobacco/cigarette smoking were published (according to PubMed database, 2018 data), should explain all health aspects and consequences of tobacco dependence. However, many issues still remain unsolved. New evidence indicating multi-directional negative effects of tobacco smoke on the smoker’s health has emerged. Data included in periodic US Chief Medical Officer’s reports is a prominent example in this regard. In 2010, a total of 10 cancer locations and 10 chronic diseases, including cardiovascular diseases, were ascribed to tobacco smoking (8). Four years later, the authors of another report found that there was sufficient evidence indicating significant effects of tobacco smoking on colon cancer and six other diseases (degeneration of the macula, facial cleavage as a result of smoking during pregnancy, diabetes, ectopic pregnancy, erectile dysfunction, rheumatoid arthritis) (9).
The considerable negative impact of tobacco smoke on health may be illustrated by the number of deaths due to smoking. It is estimated that 20 million Americans died prematurely due to tobacco use between 1964 and 2014 (9). A total of 7.8 million Americans died due to cardiovascular and metabolic diseases, 6.58 million due to cancer and 3.8 million due to respiratory diseases. Furthermore, mortality was reported for 2.5 million of passive smokers and 108,000 children, with 86,000 victims of fires caused by cigarette butts. Cigarette smoking causes 480,000 deaths each year, with 300 billion dollars in lost productivity. In the European Union, tobacco consumption accounts for 700,000 of deaths annually, with an estimated loss in life expectancy of about 14 years (10).
The destructive effect of tobacco smoke on the smoker’s body is due to multiple chemical compounds, which are estimated at more than 6000, contained in tobacco smoke. Many of these exhibit significant toxicity and carcinogenicity. A total of 52 compounds with a varying carcinogenic potential have been identified in tobacco smoke. Nine of these were classified by the International Agency of Research on Cancer (IARC) as group 1 carcinogens with proven carcinogenic effects on humans (11).
Polycyclic aromatic hydrocarbons (PAHs), which are primary components of tar, belong to a group of particularly dangerous compounds contained in tobacco smoke. They are formed during combustion of tobacco. It was already in 1976 that professor Michael Russell, an eminent British specialist on addictions, wrote in one of his articles that “people smoke for the nicotine, but they die from the tar&rdquop; (12). Tobacco smoking is the cause of chronic myocardial ischemia due to the binding of carbon monoxide contained in tobacco smoke to haemoglobin, which impairs oxygen transport from the lungs to the tissues (8).
Due to the health, social and economic consequences, combating the tobacco epidemic was and still is one of the priorities of health policy of governmental and non-governmental organisations in developed countries.
The potential of tobacco harm reduction – nicotine replacement therapy
Substitution therapy is one of the basic trends in harm reduction. It involves replacing harmful substances with lower-risk compounds exhibiting similar or identical pharmacological effects. Nicotine replacement therapy (NRT) is a type of substitution therapy associated with tobacco harm reduction. Nicotine contained in chewing gums, patches, lozenges and inhalers is the same compound inhaled by smokers with tobacco smoke. According to the Anatomical Therapeutic Chemical (ATC) classification system, nicotine belongs to a group of agents used for dependence therapy under the number N 07 BA 01. After NRT initiation, smokers no longer inhale the enormous amount of harmful substances contained in tobacco smoke, limiting themselves to the substance responsible for dependence, that is nicotine. Consumption of nicotine in controlled doses allows to minimise withdrawal symptoms and may even lead to abstinence.
A comprehensive meta-analysis of works on all forms of NRT revealed that this type of treatment increases the chance of successful smoking cessation. There was a 50% up to 70% increase in the probability of smoking cessation. Furthermore, the analysis showed that different forms of NRT show similar efficacy (13).
On the other hand, some researchers believe that the long-term success of smoking discontinuation is low and NRT is not more effective than the attempts of smokers to quit without these measures. In both groups, about one-third of smokers returned to tobacco use after some time (14, 15).
Although NRT products have been available in the pharmaceutical market for several decades and bupropion, varenicline and cytisine-based pharmacotherapy was introduced in the mid ‘90s, the rate of reduction in the number of smokers has not changed significantly in most developed countries. At present, tobacco smokers account for an average of 24% of adult EU population (28% in Poland) and 15.5% of US population (10, 16).
According to the forecasts of many organisations from the late twentieth century, which were based mainly on research devoted to NRT efficacy and anti-tobacco policy, the endgame for tobacco should occur around 2030.
Meanwhile, an analysis of the trend of changes in the prevalence of tobacco smoking in developed countries between 1980 and 2012 indicates that the end of tobacco smoking should be expected after 2050 (17). Other authors also agree that the date proposed in the 90’s is unrealistic. An editorial of the prestigious Lancet magazine pointed out that the current anti-tobacco campaign has failed; therefore the journal has begun a campaign “Tobacco-free world by 2040&rdquop; (18).
The potential of tobacco harm reduction – electronic cigarettes
The prospect of dozens of years of dealing with a large population of smokers undoubtedly presents a challenge for public health, a field of science responsible for disease prevention, life prolongation, as well as health and physical fitness promotion through organised efforts for environmental hygiene.
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