Tobacco and harm reduction

• History and challenges of risk reduction

• Resumption of the risk reduction discourse by the tobacco industry

• 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

Risk reduction in addiction has its origins in Great Britain where, from 1926, the treatment of heroin users recognized that reducing the risks linked to consumption could constitute another option than abstinence alone.[1]. This approach gained new momentum in the mid-1980s, when the AIDS epidemic hit injecting drug users hard. In France, it resulted in the sale of syringes over the counter 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 of methadone, already used in the United States since the 1960s, then with that of buprenorphine in 1996. These stages led to a modification of the discourse and the therapeutic paradigm: we are not looking for more to convince the user to adhere to a unique therapeutic solution, and we remain more attentive to what they are ready to accept and observe.

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

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

Two sides of risk reduction can be identified:

• One acts on the mode of consumption, which must be made as secure as possible to limit complications. The distribution of equipment (single-use syringes, “dosers” suitable for crack consumption) and the provision of advice (for example on “clean snorting” or avoiding infections) are part of this package. 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 treatments (TNS) in the form of chewing gum, at the end of the 1970s, does not exactly relate to risk reduction since these products are designed to be integrated into a weaning process, the unwanted effects of which are reduced. Steps to reduce consumption are sometimes integrated into therapeutic support protocols but, unlike alcohol or other substances, are in themselves insufficient: low consumption of tobacco is 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 cessation.[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 will quickly change the situation. Initially causing concern among tobacco manufacturers and a certain suspicion on the part of caregivers, the sudden enthusiasm of certain smokers for these electronic devices will attract attention. In France, the public authorities have also taken into account the widespread distribution of these products and have applied to electronic cigarettes, through the order of May 2016, some of the conditions of use already in force for tobacco, particularly in public places. and in the workplace. The successive recommendations of the High Authority of Health have remained cautious on the subject, considering that in the absence of conclusive data and marketing authorization (AMM), as is the case for medicines, the The use of an e-cigarette cannot be medically recommended as part of smoking cessation[5]. The public authorities, for their part, seem to pay 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.

Resumption of the risk reduction discourse by the tobacco industry

Aware of the harmful consequences of tobacco consumption for health, the tobacco industry very early on gave a reassuring speech by presenting some of its products as less harmful. This was the case from 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 does not was objectively not the case; on the contrary, these innovations have significantly contributed to increasing female smoking and increasing the pathologies already observed in tobacco use, particularly among women. Before today recognizing the extreme harmfulness of tobacco and its smoke, manufacturers have, for several decades, fiercely defended the relative safety of their products and tobacco smoke, while denying knowledge of the addictive potential of nicotine. – which they had nevertheless actively reinforced and optimized.

The fall in cigarette consumption, which began in the 1980s and intensified during the 2000s and 2010s, seems to be the main reason which led the tobacco industry to seize the discourse of reducing tobacco consumption. risks 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 just tobacco products. to smoke. The takeover of electronic 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 managing director 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 Most of PMI's revenues worldwide come from cigarette sales. PMI also invested nearly a billion US dollars to establish the Foundation for a Smokefree World (FSW), responsible for spreading the word about harm reduction and promoting new tobacco products and nicotine.

The strategy of tobacco companies regarding risk reduction can be explained in several ways.[6]. Its first aim is to stem the loss of customers from smokers who stop smoking; consequently, stopping smoking is only ever considered if consumers shift to another form of nicotine consumption, for example electronic cigarettes or heated tobacco. This strategy also makes it possible to offer new income to manufacturers using highly profitable products, particularly as long as they escape taxation on tobacco products. It seeks to win over new customers, particularly among young people, to replace smokers who have died or are in the process of quitting. It is supposed to restore the image of the tobacco industry, damaged by multiple revelations about its products and its influence practices. It aims in particular to appease the public authorities and to once again become an official interlocutor in public health debates, the objective being above all to limit or prevent regulations unfavorable to tobacco. Finally, it aims to divide the scientific and medical community, in order to call into question the Framework Convention on Tobacco Control and to weaken the World Health Organization (WHO) which supports it. This strategy was designed in 2000, as evidenced by an internal document from British American Tobacco (BAT), which already mentions the policy linked to risk reduction[7].

Manufacturers have deployed different tactics to achieve these ends. These consist of producing scientific-type 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 conflation is systematically made between heated tobacco products and electronic cigarettes, even though 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 conceal the fact that many smokers quit smoking quite easily and that the mass markets of new products reach much wider audiences. Finally, the emphasis is on the “alternatives” to smoked tobacco that would be the new tobacco and nicotine products, to the extent that 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 are currently predominant. This segment is also the one which, for several years, has generated the most research and controversy.

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

• A position favorable to the use of electronic cigarettes in reducing risks, supported exclusively by the United Kingdom and shared by certain addiction health professionals and by certain tobacco specialists. The focus is placed on the most dependent smokers and those having difficulty quitting smoking. The action of nicotine alone is designed to have no health consequences, beyond the addiction it causes. The e-cigarette is perceived as the tool of choice for smoking cessation, with a certain impatience manifesting among these actors waiting for new aid to maintain smoking cessation.
• A position, adopted by many public health and tobacco players, rather unfavorable, pending formal proof, to the discourse of risk reduction as it is commercially misused by the tobacco industry. The focus is on the absence of formal objective evidence of risk reduction among electronic cigarette users with the aim of stopping smoking tobacco. The addictive potential of nicotine and its effects on mental health and the cardiovascular system are highlighted, 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 thorny points regarding electronic cigarettes is the lack of scientific consensus on their role in smoking cessation and on the risks they pose to users. The great variety of electronic cigarette materials depending on the models and eras makes any serious assessment extremely difficult. The lack of hindsight and data currently does not allow us to estimate the consequences of vaping on long-term health. Furthermore, the fact that a large majority of vapers are former smokers or maintain dual tobacco/e-cigarette uses does not facilitate the study protocols or the interpretation of the results. Dual uses should in particular be the subject of dissuasive advice during cessation support, and be more frequently excluded from research programs.

A study[11] carried out in February 2020 for the National Health Safety Agency (ANSES) thus indicates that in France, 63% vapers maintain dual use, combining smoking and vaping, and that 64% do not intend to give up cigarettes electronic in the next twelve months, thus putting into perspective the use of e-cigarettes as a method of withdrawal. It also specifies that only 3% of vapers were not previously smokers, which would minimize the fear of seeing the use of electronic 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 grow rapidly in recent years.

The role of electronic cigarettes in smoking cessation is not sufficiently clear. According to certain studies, e-cigarettes provide better cessation results than validated nicotine substitutes (19% vs. 10%)[13] ; according to other studies, the relationship 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 small.[15], while a Public Health France study mentions that 76% of ex-smokers who are vapers or ex-vapers declare having stopped their smoking using electronic cigarettes, including 9% with other complementary help, ex-smokers who are ex-vapers having used these other aids much more often Another study by Santé Publique France based on the same data specifies, however, 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 in favor of risk reduction. Taking up, updating them, the recommendations issued in 2014 by the High Authority of Health (HAS), a recent opinion from the High Council of Public Health (HSCP) considers that electronic cigarettes cannot, in 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, described as “vaping”. Finally, he expresses reservations about the potential of electronic cigarettes to defer or prevent entry into smoking, noting that current studies lean more in the direction of an incentive effect on entry into smoking. The HSCP opinion does not include heated tobacco devices which, due to insufficient evidence, cannot be considered as harm reduction or smoking cessation products (see Heated tobacco).

Several other subjects fuel the debate on electronic cigarettes. The question of derivative uses, combining electronic cigarettes with other substances such as cannabis or CBD, currently remains very insufficiently documented, although 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 question is also raised, 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 popularity of disposable e-cigarettes, currently booming, raises the issue of waste with greater urgency.

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 smoked tobacco. However, the proportion according to which e-cigarettes are less harmful than traditional cigarettes (95% less according to defenders[20], noticeably less according to detractors) is also open to question. Studies on the harmfulness of electronic cigarettes unfortunately often forget to include non-smokers who do not vape 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, a few elements could be highlighted.

• Heated tobacco: these electronic devices heat short cigarettes fitted with a filter by pyrolysis and are presented by their manufacturers as products that are significantly less harmful than smoked cigarettes, in a proportion which would be similar to those of electronic cigarettes. The presence of very numerous toxic particles, partly similar to those of smoked tobacco and partly different, however, tends to place these products at a level of toxicity close to that of smoked cigarettes.[21], in particular due to the partial combustion of tobacco by this process. The relevance of the classification of 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 slip between the lip and the gum, originating from Sweden and only authorized in this country in the European Union, have experienced 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 cancer, and would have an impact on type II diabetes, heart attacks, premature births and in utero deaths[23].

• Pouches (= pouches): these pouches look like snus and are used in the same way, but contain synthetic nicotine and help 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 they were placed on the market.

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

• Chewing/chewing tobacco : more concentrated in nicotine, chewing tobacco contains the carcinogenic substances of tobacco and can lead to an increased risk of cancers (mouth, tongue, gum, stomach, throat, bladder), cardiovascular pathologies, 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 an avenue for reducing 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 smoking cessation plan and the United States is considering adopting them as well.[26].

Other nicotine products – for example “triangles” – are already available or in preparation by tobacco manufacturers. The takeover of several pharmaceutical companies by tobacco majors, such as that of Fertin Pharma by PMI in July 2021[27], portends the expansion of the range of smoke-free 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 capture the entire nicotine market, medicinal substitutes for heated tobacco, without abandoning the smoked tobacco market.

Most smoke-free products come in many flavors, which are known to be major attractive factors among young people. Public health stakeholders, having obtained a ban on flavorings in smoked cigarettes in different countries, are now calling for the same ban on these flavorings for all other tobacco and nicotine products.

The question of synthetic nicotine, present in pouches and disposable electronic cigarettes, is also raised. Manufacturers argue here that, as they do not contain tobacco, synthetic nicotine products should escape the legislation applicable to tobacco products; Public health stakeholders, for their part, believe that the same legislation must be applied to all tobacco and nicotine products. A group of associations of American cardiologists consider that all new products introduced onto the market should be subject to strict prior evaluation in the name of the precautionary principle, rather than being directly tested in a real situation.[28].

Oral or nasal tobacco products are consumed in 127 countries by 300 million people worldwide, located mainly in the countries of South and Southeast Asia 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 as well as 2.5 million shortened lives could be attributed to oral cancers (pharynx, esophagus) linked to these products. , while 258,006 deaths and 6 million shortened lives are due to cardiovascular pathologies[29]. These results are certainly lower than those of smoked tobacco, but which are nevertheless far from negligible and remind us that these tobacco and nicotine products contain their own risks.

Current situation

From one country to another, regulations regarding tobacco and nicotine products presented by manufacturers as “reduced risk” can vary greatly, in the absence of truly conclusive data to inform decision-makers. Focused on smoked tobacco products, the FCTC recognizes “that there is a lag between exposure to cigarettes and the use of other tobacco products and the onset of tobacco-related diseases”, the indications on the new nicotine products being detailed in accompanying documents. The FCTC, however, leaves each state free to adopt the measures it considers relevant. Many countries have banned electronic cigarettes, heated tobacco devices or pouches, often before they were placed on the market. In some cases, such as in Australia, they are banned from retail sale but can be prescribed by prescription as part of smoking cessation. In contrast, 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 the electronic cigarette in withdrawal. One hypothesis would be that countries having already significantly reduced their smoking prevalence would be more inclined to turn to electronic cigarettes to help the most die-hard smokers to stop smoking, which however seems to contradict the examples of Finland and New Zealand. -Zealand.

One of the stumbling blocks between supporters and detractors of harm reduction is the “bridge” 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 young people's smoking, but forget to remember that young people are today the vast majority of 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 the next generations of smokers or dependent customers for these new products, and more generally of relegitimize the presence of tobacco products in society. The current data does not yet make it possible to make a precise decision, but tends to validate the idea of a bridging effect between electronic cigarettes and smoking. This debate regularly refers to the question of aromas and that of their prohibition, the sensitivity to aromas of young people and adolescents and their targeting in this way 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 safe for people. patients. Whether coercive (ban on certain products, restrictions on consumption) or incentive (increase in taxes, reimbursement of TNS), collective tobacco control measures appear to be significantly more effective than individual measures in obtaining significant reductions and sustainable use of tobacco. The increase in taxes with a view to raising the price of tobacco products has notably been demonstrated as one of the most effective measures in terms of reducing smoking, particularly among young people and vulnerable people. Since non-smoked tobacco and nicotine products are currently those which 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, aims to limit pollution caused by cigarette butts but also to make cigarettes less attractive in terms of taste and in the environment. appearance of the product, while removing the illusion of false health protection. Added to this is a whole ongoing reflection 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 package.

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

Keywords: harm reduction, tobacco, snus, pouches, nicotine, health, electronic cigarettes, heated tobacco, FCTC

©Tobacco Free Generation

M.F.

[1] Couteron JP, Risk reduction in France: a little history, Actal, n°13 December 2013.

[2] Benech G, Reducing risks and harms linked to alcohol consumption (RdRDA). History, practices, analysis and proposal, Actions Addictions, January 2021.

[3] Berlin I, Is risk and harm reduction effective and what are its limits when it comes to tobacco?, Alcoholology and addiction, 2017, 39(2), 128-137.

[4] Loss C, Risk reduction in the fight against smoking, SWAPS, n°23, October-November-December 2001.

[5] Stopping tobacco consumption: from individual screening to maintaining abstinence as a first resort. Method, Recommendations for clinical practice, High Authority of Health, October 2014.

[6] Martinet Y, Béguinot E, Diethelm P, Wirth N, Nicotine industry: risk reduction, an exclusively financial objective, The Practitioner's Review, vol.71, January 2021.

[7] British-American Tobacco Company Limited, The CORA Roadmap; CORA Regional Meetings, British American Tobacco Records, June 2000.

[8] Horel S, Vaping: the real millions of fake consumer organizations, Le Monde, updated November 5, 2021, accessed March 11, 2022.

[9] Aiduce is a member of INCCO, an international network of vaping organizations driven by the FSW, itself financed by PMI. International Network of Nicotine Consumer Organizations (INNCO), Tobacco Tactics, published December 1, 2021, accessed March 11, 2022.

[10] Founded by BAT. Several members of the office are linked to the tobacco industry. https://www.francevapotage.fr/la-federation

[11] Declaration of tobacco and related products in France. Vaping products – 2016-2020 report. Appendices, ANSES, October 2020.

[12] Chyderiotis S, Spilka S, Beck F, Use of electronic cigarettes in France at age 17: results of the ESCAPAD 2017 national survey, Cancer Bulletin, T.6, n°12, December 2019.

[13] Hajek P, Phillips-Waller A, Przulj D, et al., A randomized trial of e-cigarettes versus nicotine replacement therapy. N Engl J Med. 2019;380(7): 629–637.

[14] Chen R, Pierce JP, Leas EC, et al., Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017–2019, Tobacco Control, Epub ahead of print: 02/11/2022.

[15] Scientific Committee on Health, Environmental and Emerging Risks (SCHEER), Opinion on electronic cigarettes. Published on April 16, 2021, accessed on February 11, 2021.

[16] Pasquereau A, Quatremère G, Guignard R, Andler R, Verrier F, Pourchez J, Richard JB, Nguyen‐Thanh V and the Baromètre de Santé publique France 2017 group. Public Health Barometer France 2017. Use of electronic cigarettes, smoking and opinions of 18‐75 years old. Saint‐Maurice: Public Health France, 2019. 17 p.

[17] Guignard R, Verrier F, Quatremère G, Andler R, El Khoury F, El Aarbaoui T, et al. Attempts to quit smoking, aids used and maintenance of smoking abstinence: a retrospective analysis of data from the 2017 France Public Health Barometer. Bull Epidemiol Weekly. 2021;(1):2-11.

[18] Opinion relating to the benefits-risks of electronic cigarettes, High Council for Public Health, published on November 26, 2021, accessed on February 14, 2022.

[19] Balfour D, Benowitz N, Colby S, et al., Balancing Consideration of the Risks and Benefits of E-Cigarettes, Am J Public Health. Published online September 22, 2021:e1–e12.

[20] Nicotine without smoke. Tobacco harm reduction. Royal College of Physicians, published April 28, 2016, accessed February 9, 2022.

[21] Dusautoir R, Zarcone G, Verriele M, Garçon G, Fronval I, Beauval N, Allorge D, Riffault V, Locoge N, Lo-Guidice JM, Anthérieu S. Comparison of the chemical composition of aerosols from heated tobacco products, electronic cigarettes and tobacco cigarettes and their toxic impacts on the human bronchial epithelial BEAS-2B cells. J Hazard Mater. 2021 Jan 5;401:123417.

[22] Tattan-Birch H, Hartmann-Boyce J, Kock L, Simonavicius E, Brose L, Jackson S, Shahab L, Brown J. Heated tobacco products for smoking cessation and reducing smoking prevalence. Cochrane Database of Systematic Reviews 2022, Issue 1. Art. No.: CD013790.

[23] Snus, Tobacco Tactics, published June 15, 2021, accessed February 11, 2022.

[24] Snuff, Unisanté, published January 14, 2014, accessed February 11, 2022.

[25] Chewing tobacco is as harmful as cigarettes, Health and Social Services of the Northwest Territories (Canada), accessed February 11, 2022.

[26] Reduced nicotine cigarettes soon on the American market, Generation Without Tobacco, published January 19, 2022, consulted February 9, 2022.

[27] Philip Morris buys Fertin Pharma, a specialist in nicotine substitutes, Generation Without Tobacco, published on July 5, 2021, accessed on February 9, 2022.

[28] Willett J, Achenbach S, Pinto FJ, Poppas A, Elkind MS, The tobacco endgame—eradicating a worsening epidemic, Eur Heart J. 2021 Aug 21; 42(32): 3044–3048.

[29] Siddiqi, K., Husain, S., Vidyasagaran, A. et al., Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries, BMC Med 18, 222 (2020).