Tobacco harm reduction – time for grassroots action
Redukcja szkód spowodowanych paleniem tytoniu – czas na działania oddolne
Niezależny dziennikarz naukowy, Poznań
Walka z paleniem tytoniu jest jednym z priorytetów współczesnej ochrony zdrowia. Dotychczasowe metody stosowane na całym świecie były efektywne tylko do pewnego czasu. Pojawienie się na rynku nowych urządzeń, takich jak papierosy elektroniczne oraz produkty typu heat-not-burn, daje szansę na rozszerzenie listy narzędzi wspomagających walkę z paleniem. Ponieważ wiedza osób zajmujących się zawodowo doradztwem w tym zakresie jest ograniczona, w artykule zebrano podstawowe informacje o papierosach elektronicznych, stosowanych płynach, jak też o możliwych działaniach niepożądanych. W Polsce nowe urządzenia spotkały się z nieufnością, a nawet niechęcią instytucji decyzyjnych, czego efektem jest brak rzetelnych informacji na ich temat skierowanych do środowiska medycznego. Dlatego też zaproponowano, aby pracownicy ochrony zdrowia mający bezpośredni kontakt z pacjentami uzyskali dostęp do wiedzy na temat papierosów elektronicznych niezbędnej w procesie doradzania osobom pragnącym porzucić nałóg. Wyposażeni w minimum informacji o tych produktach będą mogli wiedzę tę przekazać swoim pacjentom. Jednocześnie zwrócono uwagę na niebezpieczeństwa wynikające z używania tych produktów przez dzieci i młodzież.
The fight against tobacco smoking is one of the priorities of contemporary health prevention. Previous, globally used methods were effective only to some point. The introduction of new devices, such as electronic cigarettes and heat-not-burn products, provides an opportunity to extend the list of tools supporting the fight against smoking. Considering the limited knowledge of professional advisors in this regard, the paper presents basic data on electronic cigarettes, e-liquids, and the possible adverse effects. In Poland, these new devices met with distrust and even reluctance of decision-making authorities, resulting in the lack of reliable data on these products addressed to the medical community. Therefore, it was proposed that healthcare personnel being in direct contact with patients should gain access to knowledge on electronic cigarettes, which is essential for advising those who wish to quit the addiction. With minimum information about these products, they will be able to convey this knowledge to their patients. At the same time, attention was drawn to the risks associated with the use of these products by children and adolescents.
Smoking is still a major problem worldwide. Since the introduction of tobacco to Europe by Columbus, the number of smokers had been steadily increasing, and smoking was at that time recommended as a therapeutic method (1). The breakthrough came after the publication of “Smoking and Health”: Report of the Surgeon General of the United States in 1964 (2).
A World Health Organisation report, which was published in 2008 (3), mentions already in the introduction that 100 million people died due to smoking in the 20th century, and the number may reach one billion in the 21st century. It is widely known that smoking is harmful, and 75% of smokers are aware of the danger and wish to quit the addiction (4). Unfortunately, only 2-3% of them succeed owing to their strong will alone. Others need support in the form of different methods.
Poland is one of the countries where 65% of men smoked daily in the mid-1970s, with an increasing percentage of smokers among women, reaching 32% in the 1980s (5). Since the early 1980s, smoking prevalence has started to decline, reaching 27% in the second decade of the 21st century. The strong downward trend observed at the end of the 20th century slowed down and the percentage of smokers stabilised at the turn of the century.
Countries around the world are trying to combat this epidemic. Different top-down restrictions, such as smoking bans in restaurants, bars and other public places, are being introduced. Also, increasingly high taxes, representing several dozen percent of the price of tobacco products, are being imposed. However, this causes the grey and the black market to expand; therefore its effectiveness is only limited. Importantly, the introduction of both non-branded cigarette packaging and the Tobacco Products Directive had the opposite effect – there was an increase in the percentage of smokers in the UK from 16.1 to 16.8%, whereas a significant decrease from 20.4 to 16.1% was observed after the e-cigarette boom (2012-2013) (6).
It has been several decades since healthcare professionals began the battle against the tobacco epidemic. Telephone helplines and institutions providing specialist support for those who wish to discontinue smoking represent the simplest methods. However, counselling alone is usually not enough, and other methods, mainly pharmacological ones, are needed in most cases. Nicotine replacement therapy (NRT) is the most popular of these methods. A person with withdrawal syndrome receives a product containing pharmacopoeial nicotine, without being exposed to tobacco smoke. A variety of OTC products, such as chewing gums, lozenges, nicotine patches, nasal sprays or intraoral inhalations, are available on the market. Additionally, nicotine-free products that contain other active substances, such as over-the-counter cytosine (Tabex and Desmoxan), as well as prescription-only bupropion (Zyban, Wellbutrin XR) and varenicline (Champix/Chantix) are approved for use. These compounds are nicotine receptor agonists and reduce nicotine craving (7-9). Today, in addition to the methods discussed above, smokeless tobacco, whose typical representative is snus (and also Polish snuff), electronic cigarettes and the so-called innovative heat-not-burn products, are also known worldwide (10). Snus is a popular substance in Scandinavia, but it is banned in the European Union, including Poland (11, 12).
Time for a new approach
Unfortunately, unlike in the UK, where all methods for tobacco harm reduction are supported by the government, Polish institutions speak negatively about such methods as e-cigarettes or heat-not-burn products. Such an opinion was presented during the procedure of Polish implementation of the EU Tobacco Products Directive (TPD), which introduced additional tightening of regulations. The total ban on distance (including the Internet) and cross-border sale was the strictest limitation. It seems that we cannot wait any longer. Fortunately, products showing significantly lower toxicity are legally available on the market, therefore they should be included in the set of recommended products. Since NRT products have been available on the market for many years, most of health care professionals have sufficient knowledge about this type of treatment. Unfortunately, more recent methods are not yet commonly known. Most doctors and nurses, when asked about e-cigarettes or HNB products, provide information that is based on popular media sources. According to these sources, e-cigarettes are “all just chemistry”, and it is not really known what they are comprised of. This negative image created by the media reaches those who wish to abandon smoking and seek professional help. This phenomenon is not limited to Poland. A similar situation may be observed in most countries, including the USA. In 2016, a study conducted in the USA among telephone counsellors providing advice on smoking cessation showed that e-cigarettes were considered ineffective by 70% of respondents. As a result, only 4% of over 400 respondents recommended e-cigarettes as an aid in smoking cessation (13). A recent study in Southern California, which included 17 doctors with varying experience, showed that most of them paid attention to contradictory information about e-cigarettes in the media and professional sources, which is why many of them do not recommend this method of supporting smoking cessation (14). It seems that the UK is a notable exception in this context; the UK healthcare professionals have access to reasonable information about products with reduced harmfulness, including e-cigarettes. Government organisations are involved in these measures, with an example of the report of a Special Committee of the House of Commons of the British Parliament, which was published in August last year (15).
Differences between tobacco smoke and e-cigarette aerosol
As a chemist and a research journalist generally involved in everything that concerns electronic cigarettes for more than 9 years, I suggest that healthcare professionals who encounter individuals seeking advice on smoking cessation should acquire basic knowledge that will be useful in their work.
Using an e-cigarette is not smoking. Combustion is a specific chemical process associated with oxidation, which leads to the formation of thousands of chemical compounds, the least complex of which are carbon monoxide (a product of complete combustion of organic compounds) and particularly dangerous carbon monoxide (16). The latter one binds to haemoglobin to form carboxyhaemoglobin, which in turn leads to reduced oxygen-carrying capacity of the blood (17). In the case of vaping (a jargon term for using e-cigarettes), none of these compounds is formed. Tobacco smoke contains thousands of different compounds, many of which are toxic, and at least a few dozen are carcinogenic. However, e-cigarettes generate aerosol, which consists of up to several dozen compounds, with none of them reaching concentrations considered dangerous. Media reports on aerosol carcinogens virtually always lack the data on the most important aspect, i.e. their concentration. However, as we know since the times of Paracelsus, “the dose makes the poison”.
Tobacco smoke contains another important factor, which has significant effects on addictive properties of nicotine. These are monoamine oxidase (MAO) inhibitors – harman and norharman in particular. A large body of research indicates that when combined with nicotine, they promote tobacco dependence (18-20). A similar role is attributed to acetaldehyde, which is also found in tobacco smoke and is a by-product formed during the combustion of sugar added to cigarette tobacco (21). Since the aerosol normally generated by e-cigarettes contains no MAO inhibitors, their very low addictive potential is similar to that of chewing gums or nicotine patches.
An e-cigarette (electronic nicotine inhaler)
An e-cigarette is a very simple device, which transforms liquid into an aerosol form to be inhaled by the user. Each model consists of power supply (usually a small battery), electronic controls and an atomizer. The latter one is a liquid container with a replaceable heating element. A mouthpiece is attached to the atomizer. There are also disposable e-cigarettes, which are simply disposed of after use. These may help get acquainted with this technology and thus are recommended for beginners. Their low price, equivalent to about one pack of conventional cigarettes, in an additional advantage (22).
Since the introduction of the first e-cigarette models, i.e. the middle of the first decade of the 21st century, the production technology of these devices has been developing rapidly. The first designs did not allow the user to control the preheating process. Furthermore, studies have shown that the first-generation e-cigarettes delivered nicotine ineffectively. Blood nicotine levels were significantly lower compared to those reached during smoking conventional cigarettes. This forced vapers to use high nicotine strength e-liquids (often exceeding 30 mg/mL) and to puff more frequently.
Gradually, this situation has changed – models featuring replaceable heating elements with varying resistance, followed by devices allowing for voltage regulation, occurred. At present, a number of e-cigarettes may be found on the market, from the simplest devices designed for beginners to models with electronics allowing for both power regulation (VW – variable wattage systems), as well as strict temperature control of the heating element (TC – temperature control systems). Depending on the software, the user can also control the number of puffs, the amount of nicotine used and other parameters. Unlike the models available 10 years ago or more, the present devices are more durable and require only periodic replacement of heaters and cleaning.
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