Tobacco Harm Reduction: Evidence Update

It has been conclusively shown that the profile of dangerous constituents, including particulate matter, lack of carbon monoxide and HPHCs is much more favorable in e-cigarettes, heat-not-burn and snus products than cigarettes. Not surprisingly, the decrease in exposure to these constituents leads to positive health outcomes for smokers who switch.

While concerns about poor cessation outcomes for those who switch from combustibles to ANDS and e-cigarettes acting as a gateway to combustible use for those who otherwise would not smoke are valid, they are unfounded. The most recent and robust trials indicate that ANDS users are twice as successful in achieving abstinence and that e-cigarettes have not renormalized combustible cigarettes.

Placed in a broader context of comparative risk, e-cigarettes and other reduced-risk products are likely to gain much more support—to the benefit of those trying to quit combustible cigarettes, and perhaps even to those who might have otherwise gone on to smoke.

Harm reduction policies can work alongside prevention and cessation programs to reduce the health and economic burden associated with combustible tobacco products. A harm reduction approach to smoking is not meant to supersede prevention and cessation measures, but it does recognize that there is no one-size-fits-all, abstinence-only solution that works for everyone. Harm reduction approaches are meant to help mitigate the most severe risks of smoking in the populations that either currently smoke or are most likely to smoke.

While the overall smoking rate in the United States hovers around 15 percent, smoking rates vary widely by education, income and mental health status. Those with a GED, those living at or below the poverty level or people with mental illness are over twice as likely to smoke than the national average, and they tend to smoke more heavily and have a more difficult time quitting. Harm reduction approaches can reduce smoking-related illnesses and death in these populations with disproportionate smoking rates who are either less interested in quitting or find quitting to be more difficult.

As a newer technology, the long-term health effects of e-cigarettes will not be known for several decades. Nevertheless, there is already substantial evidence that they are much less harmful than combustible cigarettes and that switching to e-cigarettes can significantly increase positive health outcomes in those who smoke. For example, in its comprehensive 2016 report, the Royal College of Physicians (RCP) in London concluded that e-cigarettes are unlikely to exceed 5 percent of the risk associated with combustible cigarettes. It also indicated that vaping remains low in adolescent never-smokers (approximately 0.2 percent of younger never-smokers use e-cigarettes) in the United Kingdom and thus recommended an approach based on risk-proportionate regulation that enables smokers to switch to reduced-risk products.

Like the RCP report, the 2018 National Academies of Sciences, Engineering and Medicine (NASEM) report on e-cigarettes found that e-cigarettes are less harmful than combustible ones and concluded that “completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens” and further that, “there is substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.” However, despite the NASEM report’s acknowledgment of decreased relative risk of e-cigarettes compared to combustible ones, it also expresses concerns about the limited data on e-cigarettes’ potential to act as a cessation aid compared to nicotine replacement therapies and about the prospect of youth uptake. As a result, it recommends a cautious approach to regulation of Alternative Nicotine Delivery Systems (ANDS).

However, the primary driver for such differing views is very likely simply the context in which ANDS are examined. For example, when the question is how to protect non-smokers from the risks of ANDS, agencies are biased toward applying a strict definition of the precautionary principle: namely, when conclusive evidence is not available on risks such as toxicity, long-term health consequences or gateway to combustible use, the best practice is to delay action. However, when the focus is shifted to improving the health of smokers (and the immediate versus long-term harms of any nicotine delivery system), employing a harm reduction approach alongside prevention strategies is the obvious course of action.

Put simply, at the present time, while sometimes valid, concerns that aim to protect non-users are often more influential in driving policy changes than evidence that points to a benefit for smokers. And, this will only result in policies that aim to restrict the availability of e-cigarettes, even as it places many current smokers at the considerable risk of continued smoking. It is therefore of the utmost importance that the most recent and robust research and evidence is considered when proposing actions that may have potential to act as a harm reduction tool for both current and future smokers. The fact is that e-cigarettes, heat not burn devices and snus are reduced-risk alternatives that may help smokers quit combustible cigarettes and the associated technology is quickly evolving. In light of this, the present review seeks to provide an updated summary of current evidence that demonstrates the relative toxicity and risks associated with Alternative Nicotine Delivery Systems (ANDS) compared to combustible cigarettes and their potential utility as a cessation device. It then provides a similar update on evidence with respect to youth use and the potential gateway effect.