Tobacco and harm reduction

• History and challenges of risk reduction

• Tobacco industry's takeover of harm reduction rhetoric

• The different products and their evaluation

- The case of the electronic cigarette

- Other products available on the market

• Current situation

History and challenges of risk reduction

Harm reduction in addiction has its origins in Great Britain, where, as early as 1926, the treatment of heroin users acknowledged that reducing the risks associated with consumption could constitute an option other than abstinence alone.[1]. This approach took off again in the mid-1980s, when the AIDS epidemic hit injecting drug users hard. In France, it resulted in the over-the-counter sale of syringes in 1987, a practice that had already been in place for several years in other countries. It continued in 1995 with the authorization of the first prescriptions for methadone, already used in the United States since the 1960s, and then with that of buprenorphine in 1996. These steps led to a change in the discourse and the therapeutic paradigm: we no longer sought to convince the user to adhere to a single therapeutic solution, and we remained more attentive to what they were prepared to accept and observe.

The spectacular declines in overdoses and HIV infections, as well as the better adherence of patients to therapeutic protocols, will strongly lend credibility to the harm reduction approach and contribute to its extension to other areas of addiction. In the early 2000s, the notion of harm complemented that of the risks incurred, the project becoming that of the reduction of risks and harm (RdRD), although this last point is often ignored. The 2004 law establishing the Reception and Support Centers for the Reduction of Risks for Drug Users (CARRUD) will institutionalize the notion of harm reduction.

From the 2000s onwards, the principles of risk and harm reduction were extended to other substances, in particular cannabis, synthetic drugs and cocaine, and then crack in recent years. Behavioral addictions, in particular gambling and video games, also benefited from the development of this approach. Alcohol consumption, which had already seen the development of brief interventions and early screening in the 1980s, was in turn treated from the perspective of risk reduction during the 2000s, an approach made official in France in 2016.[2].

Two aspects of risk reduction can be identified:

• One acts on the mode of consumption, which must be made as safe as possible to limit complications. The distribution of equipment (single-use syringes, "dosers" adapted to crack consumption) and the provision of advice (for example on "snorting cleanly" or avoiding infections) are part of this set. This aspect does not apply to tobacco.
• The other intervenes on the level of consumption, which must be reduced to limit somatic damage. This approach is valid for most substance or behavioral addictions, but is not valid for tobacco. For some substances, particularly opioids, a substitution product (methadone, buprenorphine, morphine) can be given to users to reduce or stop the consumption of more dangerous substances.

In terms of smoking, the appearance of the first nicotine replacement therapies (NRT) in the form of chewing gum, at the end of the 1970s, does not exactly fall under the heading of risk reduction since these products are designed to be integrated into a weaning process, of which they attenuate the undesirable effects. Stages of reduction in consumption are sometimes integrated into therapeutic support protocols but, unlike alcohol or other substances, are insufficient in themselves: low levels of tobacco consumption are enough to cause pathologies and mortality, and complete smoking cessation remains the primary therapeutic objective.[3]. Prescriptions for nicotine substitutes can nevertheless be made with a view to reducing tobacco consumption, but are therefore usually part of the perspective of more or less long-term withdrawal.[4]Many other supports will be marketed and will complete the range of therapeutic tools, first patches in 1991, followed by inhalers (1996), sublingual tablets (1999), tablets ("lozanges", 2002) and nasal (2010) and oral (2013) sprays.

From 2008, the development of electronic cigarettes would quickly change the situation. Initially arousing concern among tobacco manufacturers and a certain suspicion on the part of caregivers, the sudden craze among some smokers for these electronic devices would attract attention. In France, the public authorities also took into account the widespread use of these products and applied to electronic cigarettes, by the order of May 2016, some of the conditions of use already in force for tobacco, particularly in public places and workplaces. The successive recommendations of the High Authority of Health have remained cautious on the subject, considering that in the absence of evidence and marketing authorization (MA), as is the case for medicines, the use of an e-cigarette cannot be medically recommended as part of smoking cessation[5]The public authorities, for their part, seem to be paying little attention to respecting the ban on the sale of these products to minors.

Other tobacco and nicotine products do not involve combustion and are regularly presented by manufacturers as risk reduction tools. An overview of these products is provided below.

Tobacco industry's takeover of harm reduction rhetoric

Aware of the harmful consequences of tobacco consumption on health, the tobacco industry very early on gave a reassuring message by presenting some of its products as less harmful. This was the case in the 1930s with cigarettes presented as "milder" and less irritating. The addition of a filter to cigarettes in the 1960s, then the appearance of cigarettes presented as "light" in the early 1970s, were also accompanied by claims ensuring less harmful products, which was objectively not the case; on the contrary, these innovations significantly contributed to increasing female smoking and to worsening the pathologies already observed for tobacco use, particularly among women. Before recognizing today the extreme harmfulness of tobacco and its smoke, manufacturers have, for several decades, fiercely defended the relative harmlessness of their products and of tobacco smoke, while denying knowing the addictive potential of nicotine – which they had nevertheless actively reinforced and optimized.

The decline in cigarette consumption, which began in the 1980s and intensified during the 2000s and 2010s, appears to be the main reason that led the tobacco industry to seize the harm reduction discourse in the 2010s. The adoption and dissemination of the Framework Convention on Tobacco Control (FCTC) also encouraged manufacturers, who had been excluded from the negotiations, to expand their activities beyond smoking tobacco products alone. The acquisition of e-cigarette manufacturers by the various tobacco majors between 2012 and 2015 and the launch of heated tobacco products clearly accompanied this trend.

Arguing that their new tobacco and nicotine products would be less harmful than smoked tobacco, manufacturers have literally adopted the terms and logic of the addictological discourse of harm reduction. This attitude is taken to the extreme by the CEO of Philip Morris International (PMI) who, in July 2021, even proposed banning the sale of cigarettes – although limiting this intention to Great Britain – while the majority of PMI's revenue worldwide comes from cigarette sales. PMI has also invested nearly a billion US dollars to establish the Foundation for a Smokefree World (FSW), responsible for promoting the harm reduction discourse and promoting new tobacco and nicotine products.

The tobacco companies' strategy towards harm reduction can be explained in several ways.[6]. Its primary aim is to stem the loss of customers among smokers who quit smoking; consequently, quitting smoking is never considered except on the condition that consumers shift to another form of nicotine consumption, such as electronic cigarettes or heated tobacco. This strategy also makes it possible to offer new revenues to manufacturers using highly profitable products, particularly as long as they escape taxation on tobacco products. It seeks to win new customers, particularly among young people, to replace smokers who have died or are about to quit smoking. It is supposed to restore the image of the tobacco industry, tarnished by multiple revelations about its products and its influence practices. It aims in particular to appease the public authorities and to become an official interlocutor again in public health debates, the objective being above all to limit or prevent regulations that are unfavourable to tobacco. Finally, it aims to divide the scientific and medical community, in order to challenge the Framework Convention on Tobacco Control and to weaken the World Health Organization (WHO) which supports it. This strategy was designed as early as 2000, as evidenced by an internal document from British American Tobacco (BAT), which already mentions the policy linked to harm reduction.[7].

The industrialists have deployed different tactics to achieve these ends. These consist of producing scientific studies demonstrating the interest of new products, with the aim of serving as scientific proof. Networks of scientists and personalities (Derek Yach, David Khayat, Michael Møller), but also various front groups (World's Vapor Alliance[8], FSW and, in France, Aiduce[9], Francid Vaping[10]), take up and disseminate the arguments of the tobacco industry to legitimize them. A systematic amalgamation is made between heated tobacco products and electronic cigarettes, while the former are notably more harmful than the latter. The focus of the debate on the most dependent smokers and on the difficulties of quitting smoking makes it possible to hide the fact that many smokers quit smoking quite easily and that the mass markets for new products reach much wider audiences. Finally, the emphasis is placed on the "alternatives" to smoked tobacco that are the new tobacco and nicotine products, insofar as they "renormalize" the presence of tobacco in society in various forms.

The different products and their evaluation

The case of electronic cigarettes

Among the many non-smoked products on the market today, electronic cigarettes currently occupy a predominant position. This segment is also the one that has, for several years, generated the most research and controversy.

Two attitudes can be observed towards electronic cigarettes and more generally towards risk reduction:

• A position in favour of the use of electronic cigarettes in risk reduction, supported exclusively by the United Kingdom and shared by some health professionals in addiction and by some tobacco specialists. The focus is on the most dependent smokers who are struggling with smoking cessation. The action of nicotine alone is seen as having no consequences for health, beyond the addiction it causes. The e-cigarette is seen as the preferred tool for smoking cessation, with a certain impatience manifesting itself among these professionals waiting for new aids to maintain smoking cessation.
• A position, adopted by many public health and tobaccology stakeholders, rather unfavorable, pending formal proof, to the discourse of risk reduction as it is commercially diverted by the tobacco industry. The focus is on the absence of formal objective proof of risk reduction among e-cigarette users with the aim of quitting smoking tobacco. The addictive potential of nicotine and its effects on mental health and the cardiovascular system are emphasized, as are the consequences of vaping on overall health. The e-cigarette is designed as a process intended to perpetuate the nicotine addiction market.

One of the most difficult issues regarding e-cigarettes is the lack of scientific consensus on their role in smoking cessation and the risks they pose to users. The wide variety of e-cigarette equipment depending on the model and era makes any serious assessment extremely difficult. The lack of perspective and data currently does not allow us to estimate the long-term health consequences of vaping. Furthermore, the fact that a large majority of vapers are former smokers or maintain dual tobacco/e-cigarette uses does not facilitate study protocols or the interpretation of results. Dual uses should particularly be the subject of dissuasive advice during cessation support, and should be more frequently excluded from research programs.

A study[11] conducted in February 2020 for the French National Agency for Food Safety (ANSES) indicates that in France, 63% of vapers maintain dual use, combining smoking and vaping, and that 64% do not intend to give up e-cigarettes in the next twelve months, thus putting the use of e-cigarettes as a method of quitting into perspective. It also specifies that only 3% of vapers were not previously smokers, which would minimize the fear of seeing the use of e-cigarettes develop among non-smokers (other studies place this threshold around 1%). Observations carried out in France in 2017 among 17-year-olds reveal that 62.5% of them are dual users and that 7.6% have never smoked tobacco before, a rate significantly higher than that of adult vapers and which tends to develop rapidly in recent years.

The role of electronic cigarettes in smoking cessation is not sufficiently clear. According to some studies, e-cigarettes may provide better cessation results than validated nicotine replacement products (19% vs. 10%)[13] ; according to other studies, the ratio is clearly reversed and gives the advantage to nicotine substitutes (15% vs. 10% for e-cigarettes)[14]The SCHEER report, commissioned by the European Union, estimates that the role played by electronic cigarettes in smoking cessation is weak.[15], while a study by Santé Publique France mentions that 76% of ex-smokers who are vapers or ex-vapers declare having stopped smoking with the help of electronic cigarettes, including 9% with another complementary aid, ex-smokers who are ex-vapers having much more often had recourse to these other aids Another study by Santé Publique France based on the same data, however, specifies that 69% of smokers who stopped smoking did not use electronic cigarettes, nicotine substitutes or smoking cessation medication.[17].

The position of the French health authorities remains cautious and rational on the subject to date, but is described as cautious by those who advocate risk reduction. Taking up and updating the recommendations issued in 2014 by the High Authority for Health (HAS), a recent opinion from the High Council for Public Health (HSCP) considers that electronic cigarettes cannot, given the current state of knowledge, be considered as therapeutic withdrawal tools.[18]. It also formally advises against the dual use of e-cigarettes/smoked tobacco, known as "vapofumage". Finally, it expresses reservations about the potential of electronic cigarettes to delay or prevent the start of smoking, noting that current studies tend to suggest an incentive effect on starting to smoke. The HSCP's opinion does not include heated tobacco devices which, due to a lack of sufficient evidence, cannot be considered as risk reduction or smoking cessation products (see Heated Tobacco).

Several other topics fuel the debate on electronic cigarettes. The question of derivative uses, associating electronic cigarettes with other substances such as cannabis or CBD, currently remains very insufficiently documented, while it was the subject of a health scandal in the United States in 2019 after the death of 68 people, following the use of cannabis e-liquid.[19]The environmental issue is also raised, with the batteries and plastic elements of e-cigarettes generating a gigantic surplus of persistent waste, to which is added the release into the atmosphere of numerous heavy or poorly identified particles; the vogue for disposable e-cigarettes, currently in full swing, raises the issue of waste with greater acuity.

The use of electronic cigarettes ultimately raises more questions than it seems to provide answers, even though it is recognized that this type of device is probably significantly less harmful than smoking tobacco. However, the proportion according to which e-cigarettes would be less harmful than traditional cigarettes (95% less according to advocates[20], significantly less according to critics) is also questionable. Studies on the harmfulness of electronic cigarettes unfortunately often forget to include non-smoking non-vapers in their comparison work.

Other products available on the market

The lack of evidence on the risks associated with new tobacco and nicotine products makes their assessment difficult. However, some elements have been highlighted.

• Heated tobacco: these electronic devices heat short cigarettes equipped with a filter by pyrolysis and are presented by their manufacturers as products that are significantly less harmful than smoked cigarettes, in a proportion that would be similar to that of electronic cigarettes. The presence of a large number of toxic particles, partly similar to those of smoked tobacco and partly different, tends however to place these products at a level of toxicity close to that of smoked cigarettes.[21], particularly due to the partial combustion of tobacco by this process. The relevance of classifying these products among risk reduction options is thus clearly called into question. On the other hand, the use of heated tobacco is most often accompanied by the dual consumption of at least a few cigarettes and, to date, no independent study has demonstrated that the use of heated tobacco can serve as a method of smoking cessation[22]Heated tobacco products are nevertheless the subject of intense promotion by tobacco manufacturers, who derive substantial profit margins from them.

• Snus: these tobacco pouches to be slipped between the lip and the gum, originating from Sweden and only authorized in this country in the European Union, have been experiencing a new boom in the United States since the end of the 2000s. The presence of tobacco in these products would however be a source of pancreatic cancers, and would have an impact on type II diabetes, heart attacks, premature births and deaths in utero[23].

• Pouches (= pouches): these pouches look like snus and are used in the same way, but contain synthetic nicotine and avoid the carcinogenic elements contained in tobacco. Strongly promoted by the tobacco industry, particularly in countries that have banned snus, they are currently mainly sold in the United States, in certain European states and in emerging countries. These products were banned in Germany, Norway, Canada and Australia before being put on the market.

• Snuff: more concentrated in nicotine and presented in the form of a dry powder, this snuff contains the carcinogenic substances in tobacco and can cause inflammation of the nasal mucosa, obstruction of the nasal passages and a reduction in the sense of smell.[24].

• Chewing tobacco : more concentrated in nicotine, chewing tobacco contains the carcinogenic substances in tobacco and can lead to an increased risk of cancers (mouth, tongue, gum, stomach, throat, bladder), cardiovascular diseases, blood pressure and cholesterol, as well as dental health problems.[25].

• Very low nicotine cigarettes : not yet available on the market, these products contain very little nicotine, which seems to be a way to reduce addiction to this substance. Their use ultimately aims to completely stop their consumption, the health risks being equivalent to those of smoked tobacco. New Zealand has included them in its plan to quit smoking and the United States is considering adopting them as well.[26].

Other nicotine products – such as “triangles” – are already available or in preparation by tobacco manufacturers. The acquisition of several pharmaceutical companies by tobacco majors, such as that of Fertin Pharma by PMI in July 2021[27], suggests the expansion of the range of smokeless products and, depending on the evolution of legislation, the integration of new molecules (CBD, cannabis). We can therefore assume that tobacco manufacturers are seeking to take over the entire nicotine market, from medicinal substitutes to heated tobacco, without abandoning the smoked tobacco market.

Most smokeless products come in a variety of flavors, which are known to be major attractors among young people. Public health stakeholders, having successfully banned flavors in smoked cigarettes in various countries, are now calling for a similar ban on flavors for all other tobacco and nicotine products.

The issue of synthetic nicotine, present in pouches and disposable electronic cigarettes, is also raised. Manufacturers argue here that, since they do not contain tobacco, products based on synthetic nicotine should be exempt from the legislation applicable to tobacco products; public health stakeholders believe that the same legislation should be applied to all tobacco and nicotine products. A group of American cardiologists' associations considers that all new products introduced onto the market should be subject to a strict prior assessment in the name of the precautionary principle, rather than being directly tested in a real-life situation.[28].

Oral or nasal tobacco products are consumed in 127 countries by 300 million people worldwide, located mainly in South and Southeast Asian countries and particularly in India. A study on these smokeless tobacco products updated its previous report from 2017 in 2020 and established that 90,791 deaths and 2.5 million reduced lives could be attributed to oral cancers (pharynx, esophagus) linked to these products, while 258,006 deaths and 6 million reduced lives are due to cardiovascular diseases.[29]. These figures are certainly lower than those of smoked tobacco, but they are nevertheless far from negligible and remind us that these tobacco and nicotine products contain their own risks.

Current situation

Regulations on tobacco and nicotine products presented by manufacturers as “reduced risk” can vary widely from country to country, in the absence of truly compelling data to inform decision-makers. Focusing on smoked tobacco products, the FCTC recognizes "that there is a time lag between exposure to cigarettes and the use of other tobacco products and the onset of tobacco-related diseases", the information on new nicotine products being detailed in annexed documents. However, the FCTC leaves each state free to adopt the measures it deems relevant. Many countries have thus banned electronic cigarettes, heated tobacco devices or pouches, often before they are placed on the market. In some cases, such as in Australia, they are banned from retail sale but can be prescribed on prescription as part of smoking cessation. On the other hand, the United Kingdom has integrated electronic cigarettes into its therapeutic protocol, but remains very isolated in this regard; it should offer reimbursement, subject to the submission of an AMM-type file demonstrating the effectiveness of electronic cigarettes in smoking cessation. One hypothesis would be that countries that have already significantly reduced their smoking prevalence would be more inclined to turn to electronic cigarettes to help the most die-hard smokers to turn away from tobacco, which the examples of Finland and New Zealand seem to contradict.

One of the stumbling blocks between supporters and detractors of risk reduction is the "gateway effect", which would lead young vapers who have never smoked to then become smokers. The former argue that the availability of new tobacco and nicotine products would constitute a form of protection against smoking among young people, but forget to point out that young people are now largely non-smokers. The latter consider on the contrary that it is an attempt to capture young people through nicotine addiction, with the aim of preparing future generations of smokers or dependent customers for these new products, and more generally to re-legitimize the presence of tobacco products in society. Current data do not yet allow us to decide precisely, but tend to validate the idea of a gateway effect between electronic cigarettes and smoking. This debate regularly refers to the question of flavourings and their ban, the sensitivity of young people and adolescents to flavourings and their targeting through this means having been abundantly demonstrated, both for smoked tobacco and for electronic devices.

Rather than offering consumers products with supposedly reduced but unproven risks, public health stakeholders prefer to rely on tobacco control measures to reduce smoking prevalence and also promote validated smoking cessation treatments that are risk-free for patients. Whether coercive (ban on certain products, consumption restrictions) or incentive-based (tax increases, reimbursement of TNS), collective tobacco control measures appear to be significantly more effective than individual measures in achieving significant and lasting reductions in tobacco consumption. Increasing taxes to raise the price of tobacco products has been shown to be one of the most effective measures in reducing smoking, particularly among young people and people in precarious situations. Since smokeless tobacco and nicotine products currently offer manufacturers the highest profit margins, aligning the taxation of these products with that of smoked tobacco products would make them less profitable for manufacturers and could limit their development.

Other measures relating to product regulation are also being studied to reduce smoking prevalence. The ban on cigarette filters, envisaged in New Zealand and studied in the United Kingdom and the United States, is intended to limit pollution due to cigarette butts but also to make cigarettes less attractive in terms of taste and appearance of the product, while removing the illusion of false health protection. Added to this is a whole reflection in progress on the use of the product as an information medium on which health warnings would be affixed, the product being standardized according to the principle of the neutral packet.

These provisions are part of an overall strategy aimed at removing tobacco from society, in particular through the concept of a tobacco-free generation, which could translate into a ban on sales to anyone born after a specific date.

Keywords: harm reduction, tobacco, snus, pouches, nicotine, health, e-cigarettes, heated tobacco, CCLAT

©Generation Without Tobacco

MF

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