Barriers in the use of nicotine as a tobacco harm reduction tool
Bariery w wykorzystaniu nikotyny jako narzędzia redukcji szkód wywołanych paleniem tytoniu
Katedra Psychologii i Socjologii Zarządzania, Wydział Zarządzania, Uniwersytet Warszawski
Postęp w nauce i technice na początku XXI wieku wymusił zmianę w sposobie myślenia o nikotynie, a także umożliwił analizę szkodliwości różnych rodzajów produktów dostarczających nikotynę – co stanowi niezbędny krok do określenia kontinuum szkodliwości produktów tytoniowych. Dostępność produktów o silnie zróżnicowanej szkodliwości umożliwia podejmowanie względem osób palących papierosy pełnego spektrum oddziaływań, zarówno zmierzających do całkowitego rzucenia palenia, ale także opartych na idei redukcji szkód, tj. ochronie osób trzecich przed szkodliwością dymu tytoniowego oraz minimalizacji ryzyka dla osób, które nie potrafią całkowicie zrezygnować z używania nikotyny. Te ostatnie oddziaływania są powstrzymywane przez szereg barier: (a) stereotypy dotyczące szkodliwości e-papierosów, (b) niedoskonałości legislacji i regulacji rynkowej, (c) brak zaufania i dialogu pomiędzy kluczowymi grupami wpływającymi na kształt rynku produktów nikotynowych oraz (d) niewykorzystany potencjał motywacji finansowej użytkowników wyrobów tytoniowych.
W XXI wieku przedwczesną śmierć z powodu chorób związanych z paleniem papierosów może ponieść miliard osób. Aby do tego nie dopuścić, niezbędne jest zniesienie wyżej wymienionych barier oraz wykorzystanie pełnego spektrum najnowszych wyników badań nad nikotyną i produktami nikotynowymi o obniżonej szkodliwości, a także wszelkich dostępnych oddziaływań, z uwzględnieniem technik redukcji szkód.
At the beginning of the 21st century the scientific and technological advancement forced a change in the way of thinking about nicotine; it also enabled the harmfulness of various types of nicotine delivery products to be analysed, which constitutes an essential step towards the determination of the continuum of risk of tobacco products. The availability of products with various levels of harmfulness enables one to take a complete set of actions towards smokers which include both those aiming at complete smoking cessation and those based on the idea of harm reduction, i.e. the protection of third parties from the harmful effects of tobacco smoke and risk minimisation for individuals who are not able to quit nicotine completely. Harm reduction actions are hampered by a number of barriers: (a) stereotypes regarding the harmfulness of e-cigarettes, (b) imperfect legislation and market regulation, (c) lack of trust and dialogue between the key groups which influence the nicotine products market and (d) unused potential of financial motivation in tobacco users.
In the 21st century one billion people can die prematurely as a result of smoking-related diseases. In order to prevent this, it is essential to remove the barriers mentioned above, take advantage of the complete spectrum of the latest research on nicotine and reduced-risk nicotine products and take all available measures, including harm reduction techniques.
At the end of the second decade of the 21st century the condition of science, technology, public awareness and public health discourse regarding nicotine and the harmfulness of smoking is entirely different from the one at the end of the 20th century. The predictions from the earlier period suggested that it would be possible to completely eradicate the ‘smoking epidemic’ by 2030 despite the fact that in the nineties only legislative (smoking ban) and propaganda measures were available and alternative tobacco products available on the market were limited to nicotine gums and patches. In 2018 there are no longer any doubts that the world will not be tobacco-free in 2030. Some Scandinavian countries hope to be tobacco-free either as a result of legislation (a total smoking ban in Finland planned for 2030) or the promotion of safe nicotine products such as snus (Norway, Sweden) (1, 2). Meanwhile, the invention and promotion of the e-cigarette by the Chinese chemist Hon Lik in 2001-2003 was the beginning of a technological revolution which dramatically increased the availability of alternative, safer nicotine products and resulted in the rapid development of a great number of solutions not by legislators or the industry, but by consumers looking for safer ways of using nicotine (3). Perhaps it was this ‘grassroots’ nature of the fast progressing changes that caused international organisations such as the World Health Organization (WHO) as well as governments and the pharmaceutical and tobacco industries to fail to keep pace with these changes, thus hampering the health promotion potential of reduced-risk nicotine products.
Continuum of risk
Under pressure from researchers and users of modern reduced-risk nicotine products (RRNP) the organisations which deal with public health and regulatory practice in this area start to admit publicly that the greatest harm associated with tobacco products is not caused by nicotine as a chemical substance, but by harmful chemical compounds generated during tobacco combustion. The modern approach based on scientific research results indicates the presence of a ‘continuum of risk’: although every product containing nicotine currently available on the market can be harmful to some extent, a precise determination of the magnitude of this risk is necessary. For example, reports of 2015 and an update of 2018 by Public Health England (PHE) indicate a 95% lower harmfulness of e-cigarettes compared to conventional cigarettes (4, 5). The U.S. National Academy of Sciences (NAS) has also accepted that e-cigarettes are less harmful and expressed it in the report ‘Public Health Consequences of E-cigarettes’ of 2018 (6). Such an approach presented by key institutions in the UK and USA contributes to the gradual change in the dynamics of debate on the negative consequences of nicotine dependency. It points to the need to clearly separate the effects of tobacco smoking (particularly toxic compounds formed in the process of tobacco combustion) from the effects of nicotine as a chemical substance, which can be delivered in various ways safer than tobacco burning.
Currently, one of the important tasks for the academic and medical communities regarding nicotine research is precise quantification of the harmfulness of different products. Only once precise quantitative indicators of the harmfulness of particular types of products become available, a better, reliable and evidence-based dialogue between scientists, consumers, decision-makers and legislators will be possible.
The progress in research on the harmfulness of e-cigarettes and heat-not-burn products seems to be detached from the social perception of the harmfulness of these products. For this reason, scientific progress has been accompanied for some time with actions by consumer organisations and science promoters aiming at the eradication of erroneous, stereotypical opinions that RRNP products such as e-cigarettes, for example, are more harmful than traditional cigarettes. Research conducted in Norway demonstrated that compared to conventional cigarettes (100% of relative harmfulness) snus is perceived as harmful in 78-88% and e-cigarettes are perceived as such in 57-75% (7, 8).
The development of the idea of tobacco harm reduction faces an additional barrier in less developed countries, which is the lack of scientific experts and authorities who could oppose the dictate of international organisations or tobacco industry lobbyists. In recent years local pseudoexperts have repeatedly presented erroneous opinions that the level of harmfulness of smoking and e-cigarette use is identical, contrary to the results of research on the matter. Therefore, it is of particular importance to reach the groups and areas at the highest risk with objective information and research results and to make them realise that nicotine as a pure chemical compound delivered in a safe form not associated with carcinogenic smoke and tarry substances should not be considered as inseparable from cigarettes and stigmatised as a highly harmful tobacco product.
Legislation and market regulation
Powered by grassroots initiatives of small, very active companies, the rapid expansion of reduced-risk nicotine products (e.g. e-cigarettes, heat-not-burn products, snus) requires quick reaction from market regulatory institutions to establish clear procedures for the marketing of user-safe products, for which there is a huge demand. In the USA alone over 20 million smokers express active interest in new reduced-risk products.
RRNP users are trying to exert a growing pressure on manufacturers pointing out that there is no one universal solution, one product that could satisfy various needs of the multimillion group of consumers. Consumer organisations and umbrella organisations which connect individual national associations into a large network with a much higher potential for action (e.g. International Network of Nicotine Consumer Organisations – INNCO) aim at receiving the right to speak at international forums, including WHO meetings where the most important decisions are taken affecting RRNP legal regulation (9).
Product quality standards are key both for manufacturers and consumers. Legislators should take care of minimum quality standards; however, at the same time, it is unjustifiable to continue the ban on the Scandinavian product snus, which, unlike e-cigarettes, for instance, is supported by a few decades of research, including clinical trials on human subjects which confirm its little negative effect relative to cigarettes (10).
Over the last few months snus, which is illegal in the European Union except for Sweden, has become the subject of debate in Europe again. Snus pouches are a popular and much less harmful tobacco product than cigarettes and an effective harm reduction measure which has helped thousands of people in Sweden and Norway to reduce their smoking-related disease risk. As a result, Sweden and Norway have the lowest lung cancer rate in Europe (11). The European Court of Justice debated the problem at the beginning of 2018 as part of a case filed in 2017 by the Swedish Match and supported by the New Nicotine Alliance UK (NNA UK) (12). NNA UK argues that the ban is harmful for health and that smokers in Great Britain and the European Union deserve better availability of safe nicotine products through snus ban removal.
Trust and dialogue
Is new thinking about nicotine possible without new thinking about the tobacco industry? A barrier against the development of a multi-party dialogue is the lack of trust since in the second half of the 20th century the tobacco industry frequently showed that it could not be trusted: the lies told by the management of tobacco companies, in 1994 before the U.S. Senate, for example, have continued to arouse emotions regarding the trust towards the studies published by the tobacco industry (13, 14). At the same time, it is worth bearing in mind that the problem of lobbying and the risk of the public being mislead is involved, not only in the context of tobacco, but also in every large industry in which billions worth of profit is at stake. For this reason, institutions have been formed whose role is to arbitrate between the industry and consumers, such as, for example, FDA in the USA (15).
It seems, therefore, that with a full support of strong control mechanisms such as those of FDA, it is worth changing the attitude of ignoring the actions and voice of the tobacco industry and e-cigarette manufacturers altogether. One should, instead, start to take into account very cautiously the recent actions of the industry, some of them as surprising as the declaration by Philip Morris of January 2018 on the intention to stop selling traditional cigarettes in Great Britain completely in favour of reduced-risk products (16). It is also difficult not to reflect on the fact that currently the majority of large tobacco companies spend billions of dollars on the development of e-cigarettes and advanced clinical studies on their harmfulness. Assuming that all of these studies are biased and worthless is tantamount to wasting the effort of not only many researchers but also the individuals taking part in carefully controlled clinical trials. So long as the authors provide access not only to the final conclusions and interpretations, but also to the full methodology and complete raw results allowing both study replication and data reanalysis, it is worth using these data as well in the development of a knowledge base on the relative harmfulness of different products and in the construction of a continuum of risk for modern nicotine products.
Currently, facts and scientific evidence do not dominate the scientific discussion on nicotine and smoking-related harm: emotions and bias are all too often the main component of such debates (17). A moralistic approach can be observed in the public discourse, which involves confidence in authorities being used by scientists, politicians and lobbyists to pursue their own agenda. In order to enable progress in such an important and novel area as tobacco harm reduction, one needs to stop using arguments based on confidence in authority (the strength of unjustified authority is demonstrated in a dramatical way by the classical Milgram experiment in which the subjects, instructed by an anonymous authority figure, administered painful electrical shocks to a different person even though this person begged them to stop) (18). Instead, the debate should only be based on data and analyses delivered by verifiable scientific studies.
All too frequently, international organisations such as WHO use a policy of bans in the fight against smoking instead of being more open to dialogue with scientists and the chance provided by harm reduction. WHO seems not to listen to the voice of scientists who deal with the issue of tobacco-related harm reduction, persistently focusing on programmes aiming at a ‘tobacco-free world’, which is as respectable a goal as it is unrealistic within the next few decades. WHO is fully aware of the potential for health and life protection associated with the advantages of immediate cigarette use cessation: in the latest report of 2017 on the tobacco epidemic WHO reports that every year over 7 million people die as a result of tobacco-related diseases; considering the growing world population one billion people can potentially die due to smoking in the 21st century (19). The example of Scandinavian countries where products such as snus have been available for many years does not leave any doubts regarding the relationship between the availability of RRNP products with the exceptionally low proportion of conventional cigarette users and a decrease in the smoking-related morbidity and mortality.
The attitude of WHO is extremely dangerous particularly in areas of the world such as Africa or Southeast Asia where WHO is a huge authority both for governments and individuals (researchers, politicians, activists) (20).
Motivation for change
It is worth choosing from a complete set of available actions towards smokers which include both those aiming at complete smoking cessation and those based on the idea of harm reduction, i.e. the protection of third parties from the harmful effects of tobacco smoke and risk minimisation for individuals who are not able to quit nicotine completely. In the latter group, one of the most commonly declared motivations for a switch to RRNP, e.g. e-cigarettes, is saving money and not, as one might expect, caring for one’s health. For this reason, the policy aiming at increasing taxation on RRNP products is counterproductive since it discourages smokers from switching to safer products if they are not significantly cheaper than cigarettes and thus more beneficial economically (21).
The most effective way of harm reduction advancement is taking a comprehensive approach to the problem, involving (a) differential taxation on nicotine products depending on their level of harmfulness, (b) simplification and more precise determination of procedures for new nicotine products marketing and (c) elimination of social ignorance and erroneous, stereotypical thinking about the harmfulness of products such as e-cigarettes or snus.
Conclusion: a change in thinking about nicotine
People have used nicotine in America for thousands of years and in Europe since the 15th century when Christopher Columbus brought it to the continent due to its exceptional neurostimulating properties. At present, at the beginning of the 21st century, there are unique possibilities of nicotine delivery to addicted individuals in a form which is radically safer than tobacco burning and this should be used to a maximum, with a benefit for public health and for all individuals who have been at risk of smoking-related diseases to date.
Nicotine is usually used for pleasure, but it can also cause dependency or lead to addiction. It is important to differentiate between these two concepts. Experts such as Konstantinos Farsalinos stress that from the point of view of public health the latter problem, which is associated with a significant risk for an individual’s health, should be reduced and eliminated (22). In the case of nicotine the aspect which determines whether dependency or a harmful addiction is present is the method of nicotine delivery (tobacco burning vs. vaping, tobacco gum chewing) as well as the additives used, nicotine dosing and the characteristics of absorption of a given form of nicotine.
Taxation on nicotine, as in the case of alcohol and fuel, represents a significant source of income for the majority of governments, which significantly hampers debate and actions to prevent a billion people from dying prematurely due to smoking in the 21st century. Considering the fact that consumers base their choice of nicotine products on their cost, legislators should aim at developing taxation depending directly on the level of harmfulness of a given product. In order to achieve this, it is necessary to reach a consensus on the continuum of risk for nicotine products which is discussed above as well as making the language used by the stakeholders: consumers, manufacturers, legislators and researchers more precise. Imprecise phrases can lead to undesirable side effects, which was pointed out by, for instance, Scott Balin during one of the ‘Morven Dialogues’ meetings (23).
Legislators and international organisations (e.g. WHO) should take into account the aspect of human rights to the most extent. The WHO Framework Convention on Tobacco Control (FCTC) requires the signatory states to implement measures for tobacco control and the reduction of its use. The implemented measures should include harm reduction and not just abstinence. This approach has been universally accepted in the area of psychoactive substance dependency for over two decades in nearly all countries of the world.
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