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{{short description|Public health strategy to lower health risks of tobacco use}}
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'''Tobacco harm reduction''' ('''THR''') is a [[public health]] strategy to lower the [[Health effects of tobacco|health risks to individuals and wider society]] associated with using [[tobacco products]]. It is an example of the concept of [[harm reduction]], a strategy for dealing with the use of drugs. [[Tobacco smoking]] is widely acknowledged as a [[Leading cause of death|leading cause of illness and death]],<ref name="Nitzkin2014">{{cite journal |author=Nitzkin, J |date=June 2014 |title=The Case in Favor of E-Cigarettes for Tobacco Harm Reduction |journal=[[International Journal of Environmental Research and Public Health]] |publisher=[[MDPI]] |volume=11 |issue=6 |pages=6459–71 |doi=10.3390/ijerph110606459 |pmc=4078589 |pmid=25003176 |quote=A carefully structured Tobacco Harm Reduction (THR) initiative, with e-cigarettes as a prominent THR modality, added to current tobacco control programming, is the most feasible policy option likely to substantially reduce tobacco-attributable illness and death in the United States over the next 20 years. |doi-access=free |s2cid=19155518}}</ref> and reducing smoking is vital to public health.<ref name="Harm Reduct. J.">{{cite journal |last1=Rodu |first1=B. |last2=Plurphanswat |first2=N. |date=January 2021 |title=Mortality among male cigar and cigarette smokers in the USA
Tobacco use if not stopped can be the cause of death in 50% of its users according to WHO report. <ref>{{Cite web |title=Tobacco |url=https://www.who.int/news-room/fact-sheets/detail/tobacco |access-date=2024-02-24 |website=www.who.int |language=en}}</ref> The benefits of tobacco cessation starts within minutes as heart rate and blood pressure starts falling.
The consumption of tobacco products and its harmful effects affect both smokers and non-smokers,<ref name="Nicotine Tob. Res.">{{cite journal |last1=Skipina |first1=T. M. |last2=Upadhya |first2=B. |last3=Soliman |first3=E. Z. |date=July 2021 |title=Secondhand Smoke Exposure is Associated with Prevalent Heart Failure: Longitudinal Examination of the National Health and Nutrition Examination Survey |editor-last=Munafò |editor-first=Marcus |editor-link=Marcus Munafo |journal=[[Nicotine & Tobacco Research]] |publisher=[[Oxford University Press]] on behalf of the [[Society for Research on Nicotine and Tobacco]] |volume=23 |issue=9 |pages=1512–1517 |doi=10.1093/ntr/ntab047 |eissn=1469-994X |issn=1462-2203 |lccn=00244999 |s2cid=235707832}}</ref> and is a major [[risk factor]] for six of the eight leading causes of deaths in the world, including [[respiratory disease]]s, [[cardiovascular disease]]s, [[cerebrovascular disease]]s, over 20 different types or subtypes of [[cancer]]s, [[stroke]]s, several debilitating health conditions, and [[malignant disease]]s.<ref name="Harm Reduct. J."/><ref name="BMC Publ. Health"/><ref name="IJERPH 2009"/><ref name="who.int"/><ref>{{cite journal |last1=Nonnemaker |first1=James |last2=Rostron |first2=Brian |last3=Hall |first3=Patricia |last4=MacMonegle |first4=Anna |last5=Apelberg |first5=Benjamin |date=September 2014 |title=Mortality and Economic Costs From Regular Cigar Use in the United States, 2010 |editor-last=Morabia |editor-first=Alfredo |editor-link=Alfredo Morabia |journal=[[American Journal of Public Health]] |publisher=[[American Public Health Association]] |volume=104 |issue=9 |pages=e86–e91 |doi=10.2105/AJPH.2014.301991 |eissn=1541-0048 |issn=0090-0036 |pmc=4151956 |pmid=25033140 |s2cid=207276270}}</ref><ref>{{cite journal |last1=Thun |first1=Michael J. |last2=Jacobs |first2=Eric J. |last3=Shapiro |first3=Jean A. |date=February 2000 |title=Cigar Smoking in Men and Risk of Death From Tobacco-Related Cancers |url=https://academic.oup.com/jnci/article/92/4/333/2624751 |url-status=live |editor-last=Ganz |editor-first=Patricia A. |editor-link=Patricia A. Ganz |journal=[[Journal of the National Cancer Institute]] |publisher=[[Oxford University Press]] |volume=92 |issue=4 |pages=333–337 |doi=10.1093/jnci/92.4.333 |doi-access=free |eissn=1460-2105 |issn=0027-8874 |pmid=10675383 |s2cid=7772405 |archive-url=https://web.archive.org/web/20210421095250/https://academic.oup.com/jnci/article/92/4/333/2624751 |archive-date=21 April 2021 |access-date=28 August 2021}}</ref> In high income countries, smoking rates have been reduced mostly by reducing the uptake of smoking among younger people rather than improving the rates of [[Quit smoking|quitting]] among established smokers. It is, however, mostly current smokers who will face disease and death from smoking.<ref>{{cite web|title=IARC Monographs- Tobacco smoke and involuntary smoking|url=http://monographs.iarc.fr/ENG/Monographs/vol83/|website=monographs.iarc.fr|publisher=International Agency for Research on Cancer|access-date=18 April 2017}}</ref><ref>{{cite journal|last1=Jha|first1=P|last2=Peto|first2=R|title=Global effects of smoking, of quitting, and of taxing tobacco.|journal=The New England Journal of Medicine|date=2 January 2014|volume=370|issue=1|pages=60–8|pmid=24382066|doi=10.1056/nejmra1308383}}</ref>▼
▲The consumption of tobacco products and its harmful effects affect both smokers and non-smokers,<ref name="Nicotine Tob. Res.">{{cite journal |last1=Skipina |first1=T. M. |last2=Upadhya |first2=B. |last3=Soliman |first3=E. Z. |date=July 2021 |title=Secondhand Smoke Exposure is Associated with Prevalent Heart Failure: Longitudinal Examination of the National Health and Nutrition Examination Survey |editor-last=Munafò |editor-first=Marcus |editor-link=Marcus Munafo |journal=[[Nicotine & Tobacco Research]] |publisher=[[Oxford University Press]] on behalf of the [[Society for Research on Nicotine and Tobacco]] |volume=23 |issue=9 |pages=1512–1517 |doi=10.1093/ntr/ntab047 |
[[Nicotine]] itself, however, is addictive but not otherwise very harmful, as shown by the long history of people safely using nicotine replacement therapy products (e.g., [[nicotine gum]], [[nicotine patch]]).<ref name=Fagerstrom2014/> Nicotine increases heart rate and blood pressure and has a range of local irritant effects but does not cause cancer.<ref>{{cite web|title=IARC Monographs- Classifications|url=http://monographs.iarc.fr/ENG/Classification/|website=monographs.iarc.fr|publisher=International Agency for Research on Cancer|access-date=18 April 2017}}</ref> None of the three main causes of death from smoking—[[lung cancer]], [[chronic obstructive pulmonary disease]] (COPD) (including [[emphysema]] and [[Bronchitis#Chronic bronchitis|chronic bronchitis]]), and [[cardiovascular diseases]]—is caused primarily by nicotine; the main reason smoking is deadly is the toxic mix of chemicals in smoke from combustion (burning) of tobacco. Products that can effectively and acceptably deliver nicotine without smoke have the potential to be less harmful than smoked tobacco. THR measures have been focused on reducing or eliminating the use of combustible tobacco by switching to other nicotine products, including:▼
▲[[Nicotine]] itself, however, is addictive but not otherwise very harmful, as shown by the long history of people safely using nicotine replacement therapy products (e.g., [[nicotine gum]], [[nicotine patch]]).<ref name="Fagerstrom2014">{{cite journal |vauthors=Fagerström KO, Bridgman K |date=March 2014 |title=Tobacco harm reduction: The need for new products that can compete with cigarettes |journal=Addictive Behaviors |volume=39 |issue=3 |pages=507–511 |doi=10.1016/j.addbeh.2013.11.002 |pmid=24290207 |quote=The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. |doi-access=free}}</ref> Nicotine increases heart rate and blood pressure and has a range of local irritant effects but does not cause cancer.<ref>{{cite web|title=IARC Monographs- Classifications|url=http://monographs.iarc.fr/ENG/Classification/|website=monographs.iarc.fr|publisher=International Agency for Research on Cancer|access-date=18 April 2017}}</ref> None of the three main causes of death from smoking—[[lung cancer]], [[chronic obstructive pulmonary disease]] (COPD) (including [[emphysema]] and [[Bronchitis#Chronic bronchitis|chronic bronchitis]]), and [[cardiovascular diseases]]—is caused primarily by nicotine; the main reason smoking is deadly is the toxic mix of chemicals in smoke from combustion (burning) of tobacco. Products that can effectively and acceptably deliver nicotine without smoke have the potential to be less harmful than smoked tobacco. THR measures have been focused on reducing or eliminating the use of combustible tobacco by switching to other nicotine products, including:
#Cutting down (either long-term or before [[Quit smoking|quitting smoking]])
#Temporary abstinence
#Switching to non-tobacco nicotine containing products, such as pharmaceutical [[Nicotine replacement therapy|nicotine replacement therapies]] or currently (generally) unlicensed products such as [[electronic cigarettes]]
#Switching to [[smokeless tobacco]] products such as [[Sweden|Swedish]] [[snus]]
#Switching to non-combustible tobacco products
Quitting all tobacco products definitively reduces risk the most. However, quitting is difficult, and even approved [[smoking cessation]] methods have a low success rate.<ref name="Nitzkin2014" /> In addition, some smokers may be unable or unwilling to achieve abstinence.<ref name="Rodu">{{
The strategy is controversial: supporters of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths.<ref name="Rodu"/><ref name="RCP"/> Opponents have argued that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation.<ref>{{cite journal |
among adults in Great Britain [http://www.ash.org.uk/files/documents/ASH_891.pdf]</ref> and France <ref>[http://www.ofdt.fr/publications/collections/notes/resultats-de-lenquete-etincel-ofdt-sur-la-cigarette-electronique-prevalence-comportements-dachat-et-dusage-motivations-des-utili/ Résultats de l'enquête cigarette électronique ETINCEL - OFDT, 2014]</ref> suggest that on the contrary, the availability of safer alternatives to smoking is associated with decreased smoking prevalence and increased smoking cessation. In Japan the sales of cigarettes have decreased by 32% since the introduction of heated tobacco products.<ref name=":0">{{
==History==
The concept of tobacco harm reduction dates back to at least 1976 when Professor Michael Russell wrote: "People smoke for nicotine but they die from the tar"<ref name="Russell76">{{cite journal |last1=Russell |first1=M A |title=Low-tar medium-nicotine cigarettes: a new approach to safer smoking |
Debates on tobacco harm reduction tend to be geographically defined arguments, because of the varying legal, moral, and historical status of tobacco, and the different types of tobacco products and use in different cultures around the world. For instance, cigarette smoking is the dominant form in the [[United States]], while use of [[cigar]]s, pipes, and smokeless tobacco is limited to a much smaller population. Anti-smoking advocacy efforts and widespread popularization of the negative health effects of smoking over the last few decades have led to restrictions in the sale and use of tobacco products. Despite this, tobacco in all its forms has remained a legal product in most societies. A notable exception is the European Union, where the most dangerous products (cigarettes) are available but smokeless tobacco products, which are far less hazardous, are banned.<ref name=Bates2003>{{cite journal |
In October 2008 the [[American Association of Public Health Physicians]] (AAPHP) became the first medical organization in the U.S. to officially endorse tobacco harm reduction as a viable strategy to reduce the death toll related to cigarette smoking.<ref>
=="Safer cigarettes"==
{{main|Lights (cigarette type)}}
Cigarette manufacturers have attempted to design safer cigarettes for almost 50 years, but results have been marginal at best.<ref name="Rigotti">{{cite journal |
==Smokeless tobacco ==
It has been established that use of Swedish and American [[smokeless tobacco]] confers only 0.1% to 10% of the risks of smoking,<ref name="Rodu"/> though smokeless products in [[India]] and elsewhere in [[Asia]] contain higher levels of contaminants and thus confer greater risks.<ref name="RCP">{{cite web|url=http://www.tobaccoprogram.org/pdf/4fc74817-64c5-4105-951e-38239b09c5db.pdf|title=Harm reduction in nicotine addiction: Helping people who can't quit|date=October 2007|publisher=Tobacco Advisory Group of the Royal College of Physicians|access-date=21 April 2012|archive-date=14 May 2012|archive-url=https://web.archive.org/web/20120514231702/http://www.tobaccoprogram.org/pdf/4fc74817-64c5-4105-951e-38239b09c5db.pdf|url-status=dead}}</ref> Two respected medical groups believe that smokeless tobacco may play a role in reducing smoking-attributable deaths. In 2007, Britain's Royal College of Physicians concluded "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved."<ref name="Royal College of Physicians">{{cite web|title=Nicotine without smoke: Tobacco harm reduction|url=https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0|website=RCP London|publisher=Royal College of Physicians|date=28 April 2016}}</ref>
In the United States, a study based on National Health Interview Survey data found that 73% of smokers who switched to smokeless tobacco as part of their latest quit attempt were successful in quitting smoking.<ref name="RoduPhillips2008">{{cite journal |last1=Rodu |first1=Brad |last2=Phillips |first2=Carl V |title=Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey |
===Snus===
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Based on the mounting evidence that the health risks of [[Swedish snus]] are far lower than those of combustible tobacco products, in August 2014, Swedish Match (a manufacturer) filed a Modified Risk Tobacco Product (MRTP) application with the FDA Center for Tobacco Products (CTP). The MRTP application seeks to modify the warning labels on smokeless tobacco products such that they reflect the evidence of reduced-harm compared to smoking. Among the proposed labeling changes, the MRTP application requests replacing the current warning, "This product is not a safe alternative to cigarettes," with this text: "No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes."<ref name="SM MRTP">{{cite web | url=http://www.accessdata.fda.gov/Static/widgets/tobacco/SMNA_MRTPA_FDA-2014-N-1051.html | title=Swedish Match North America MRTP Applications | date=27 August 2014 | access-date=24 October 2014 | pages=100,000+}}</ref>
After five years, on October 22, 2019, the FDA granted the first-ever modified risk orders to Swedish Match USA, Inc. for eight snus smokeless tobacco products.<ref>{{cite journal|url=https://www.fda.gov/tobacco-products/advertising-and-promotion/fda-authorizes-modified-risk-tobacco-products|title=FDA Authorizes Modified Risk Tobacco Products|journal=FDA|date=17 August 2021}}</ref>
The FDA's review determined that the claim proposed by the company in its application is supported by scientific evidence, that consumers understand the claim and appropriately perceive the relative risk of these products compared to cigarettes, and that the modified risk products, as actually used by consumers, will significantly reduce harm and the risk of tobacco-related disease to individual tobacco users and benefit the health of the population as a whole.<ref name="fda.gov">{{cite web|url=https://www.fda.gov/news-events/press-announcements/fda-grants-first-ever-modified-risk-orders-eight-smokeless-tobacco-products|title = FDA grants first-ever modified risk orders to eight smokeless tobacco products| website=[[Food and Drug Administration]] |date = 24 March 2020}}</ref>
In particular, the FDA states, "the available scientific evidence, including long-term epidemiological studies, shows that relative to cigarette smoking, exclusive use of these specific smokeless tobacco products poses lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis."<ref name="fda.gov"/>
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==Electronic cigarettes==
{{Main|Electronic cigarette}}
E-cigarettes are [[battery-powered]] devices that provide nicotine for inhalation in a vapour generated by heating a solution of water, nicotine propylene glycol or vegetable glycerin and typically some flavouring. They were first developed in China in 2003, and first introduced to Europe and the US around 2006.<ref>{{cite web|last=Wlesenthal|first=Kelly|title=Electronic Cigarette History|url=http://21centurysmoke.org/electronic-cigarette-history/|access-date=25 November 2013|year=2013|archive-date=28 November 2013|archive-url=https://web.archive.org/web/20131128075505/http://21centurysmoke.org/electronic-cigarette-history/|url-status=dead}}</ref>
=== Effectiveness and safety ===
There are many brands and models of e-cigarettes available today but they can be broadly grouped into three categories. First generation e-cigarettes are similar in appearance to a conventional cigarette and are typically designed to be for single use. Second generation e-cigarettes are around the size of a large fountain pen, have a battery linked to a permanent vapouriser and a refillable tank for the nicotine solution. Third generation e-cigarettes tend to be larger, with a more powerful battery and two heating elements which allow users to carry the power.<ref name="Royal College of Physicians"/> Nicotine delivery has typically increased with successive generations of e-cigarette,<ref>{{cite journal|last1=Talih|first1=S|last2=Balhas|first2=Z|last3=Eissenberg|first3=T|last4=Salman|first4=R|last5=Karaoghlanian|first5=N|last6=El Hellani|first6=A|last7=Baalbaki|first7=R|last8=Saliba|first8=N|last9=Shihadeh|first9=A|title=Effects of user puff topography, device voltage, and liquid nicotine concentration on electronic cigarette nicotine yield: measurements and model predictions.|journal=Nicotine & Tobacco Research|date=February 2015|volume=17|issue=2|pages=150–7|pmid=25187061|doi=10.1093/ntr/ntu174|pmc=4837998}}</ref> and it has been suggested that repeated use of second and third generation devices can result in sustained venous blood levels of nicotine which are comparable with those expected in smokers.<ref>{{cite journal|last1=Ramôa|first1=CP|last2=Hiler|first2=MM|last3=Spindle|first3=TR|last4=Lopez|first4=AA|last5=Karaoghlanian|first5=N|last6=Lipato|first6=T|last7=Breland|first7=AB|last8=Shihadeh|first8=A|last9=Eissenberg|first9=T|title=Electronic cigarette nicotine delivery can exceed that of combustible cigarettes: a preliminary report.|journal=Tobacco Control|date=April 2016|volume=25|issue=e1|pages=e6–9|pmid=26324250|doi=10.1136/tobaccocontrol-2015-052447|pmc=4888876}}</ref>▼
When comparing people who use electronic cigarettes with nicotine to no treatment (or "usual treatment") for quitting smoking, a recent systematic review has found that: "there was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT)"<ref name=":1">{{cite journal |last1=Lindson |first1=Nicola |last2=Butler |first2=Ailsa R. |last3=McRobbie |first3=Hayden |last4=Bullen |first4=Chris |last5=Hajek |first5=Peter |last6=Begh |first6=Rachna |last7=Theodoulou |first7=Annika |last8=Notley |first8=Caitlin |last9=Rigotti |first9=Nancy A. |last10=Turner |first10=Tari |last11=Livingstone-Banks |first11=Jonathan |last12=Morris |first12=Tom |last13=Hartmann-Boyce |first13=Jamie |date=2024-01-08 |title=Electronic cigarettes for smoking cessation |journal=The Cochrane Database of Systematic Reviews |volume=1 |issue=1 |pages=CD010216 |doi=10.1002/14651858.CD010216.pub8 |issn=1469-493X |pmc=10772980 |pmid=38189560|pmc-embargo-date=January 8, 2025 }}</ref> When comparing electronic cigarettes with nicotine to electronic cigarettes without nicotine, those with nicotine may be more effective (moderate quality evidence).<ref name=":1" /> Research into the long term safety of e-cigarettes for smoking cessation is limited.<ref name=":1" />.However, England's Office for Health Improvement and Disparities have concluded that, in the short and medium term, vaping poses a small fraction of the risks of smoking. And that, while vaping is not risk-free, particularly for people who have never smoked there is significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions.<ref>{{cite web | url=https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-main-findings | title=Nicotine vaping in England: 2022 evidence update main findings }}</ref> And, in an effort to [[tobacco control movement|decrease tobacco related death and disease]], e-cigarettes appear to have a potential to be part of the strategy.<ref name="Cahn2011">{{cite journal |last1=M. |first1=Z. |last2=Siegel |first2=M |date=February 2011 |title=Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? |journal=Journal of Public Health Policy |volume=32 |issue=1 |pages=16–31 |doi=10.1057/jphp.2010.41 |pmid=21150942 |doi-access=free}}</ref>
=== Types ===
Electronic cigarettes are a promising harm reduction technology because they deliver nicotine without the dangerous chemicals in tobacco smoke, while remaining attractive to smokers.<ref name=Fagerstrom2014>{{cite journal | title=Tobacco harm reduction: The need for new products that can compete with cigarettes | author=Fagerström, KO, Bridgman, K | journal=Addictive Behaviors |date=March 2014 | volume=39 | issue=3 | pages=507–511 | doi=10.1016/j.addbeh.2013.11.002 | pmid=24290207 | quote=The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward.| doi-access=free }}</ref> While the eventual [[regulation of electronic cigarettes|regulatory status]] of e-cigarettes in many countries remains uncertain,<ref name=Fagerstrom2014/> public health advocates view electronic cigarette as having a valid place within tobacco harm reduction strategy.<ref name=West2014>{{cite journal | title=Electronic cigarettes: fact and faction | author=West, R, Brown J | journal=British Journal of General Practice |date=September 2014 | volume=64 | issue=626 | pages=442–3 | doi=10.3399/bjgp14X681253 | pmid=25179048 | quote=It is important that interpretation of the evidence and communication with policy makers and the public is not distorted by a priori judgements. | pmc=4141591}}</ref> In a first step towards the regulation of e-cigarettes, the MHRA granted Marketing Authorisations (licences) for the medicinal products e-Voke 10 mg and 15 mg Electronic Inhaler (PL 40317/0001-2) on 16 November 2015.<ref>{{cite web|url=http://www.mhra.gov.uk/home/groups/par/documents/websiteresources/con616843.pdf|publisher=Medicines and Healthcare Products Regulatory Association}}</ref> Public health researchers in the UK estimated that 6,000 premature smoking-related deaths per year would be prevented for every million smokers who switched to e-cigarettes.<ref name=West2014/> Since currently approved [[smoking cessation]] methods have a 90% failure rate, the use of e-cigarettes as a prominent THR modality is likely to substantially reduce tobacco-related illness in the United States, with the potential to save 4.8 million lives over the next 20 years.<ref name=Nitzkin2014>{{cite journal | title=The Case in Favor of E-Cigarettes for Tobacco Harm Reduction | author=Nitzkin, J |journal=[[International Journal of Environmental Research and Public Health]] |publisher=[[MDPI]] |date=June 2014 | volume=11 | issue=6 | pages=6459–71 | doi=10.3390/ijerph110606459 | pmid=25003176 | s2cid=19155518 | quote=A carefully structured Tobacco Harm Reduction (THR) initiative, with e-cigarettes as a prominent THR modality, added to current tobacco control programming, is the most feasible policy option likely to substantially reduce tobacco-attributable illness and death in the United States over the next 20 years. | pmc=4078589}}</ref>▼
▲There are many brands and models of e-cigarettes available today but they can be broadly grouped into three categories. First generation e-cigarettes are similar in appearance to a conventional cigarette and are typically designed to be for single use. Second generation e-cigarettes are around the size of a large fountain pen, have a battery linked to a permanent vapouriser and a refillable tank for the nicotine solution. Third generation e-cigarettes tend to be larger, with a more powerful battery and two heating elements which allow users to carry the power.<ref name="Royal College of Physicians" /> Nicotine delivery has typically increased with successive generations of e-cigarette,<ref>{{cite journal |last1=Talih |first1=
=== Regulation of electronic cigarettes and use around the world ===
A survey of UK adults found that over two thirds of ex-smokers and over one third of current smokers report that one of the main reasons they use e-cigarettes is to help them stop smoking completely.<ref name="Action on Smoking and Health">{{cite web|title=Use of electronic cigarettes (vapourisers) among adults in Great Britain {{!}} Action on Smoking and Health|url=http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/|website=ash.org.uk|publisher=Action on Smoking and Health}}</ref>▼
{{Main|Regulation of electronic cigarettes}}
Regulation of e-cigarettes varies around the world. The Institute for Global Tobacco Control (IGTC) has identified 68 countries that have laws regulating e-cigarettes, as at November 2016.<ref>{{cite web|title=Country Laws Regulating E-cigarettes {{!}} Global Tobacco Control - Learning from the Experts|url=http://globaltobaccocontrol.org/e-cigarette/country-laws-regulating-e-cigarettes|website=globaltobaccocontrol.org|publisher=Institute for Global Tobacco Control}}</ref> Types of regulation include complete prohibition on the sale and marketing of e-cigarettes, prohibition on their use in enclosed public places, minimum age for purchase, an allowance for e-cigarettes to be sold under general consumer product regulations and most recently, in the UK, e-cigarettes may be brought to market as either medicines or consumer products (with those seeking medicines approval undergoing the standard medicines licensing process). The World Health Organization acknowledge that e-cigarettes may play a role in harm reduction strategies, but should be regulated to minimize any potential risks. However, the vast differences in regulatory approaches evident around the world highlights the challenge of developing a global regulatory approach.▼
▲
▲A survey of UK adults found that over two thirds of ex-smokers and over one third of current smokers report that one of the main reasons they use e-cigarettes is to help them stop smoking completely.<ref name="Action on Smoking and Health">{{cite web |title=Use of electronic cigarettes (vapourisers) among adults in Great Britain {{!}} Action on Smoking and Health |url=http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/ |website=ash.org.uk |publisher=Action on Smoking and Health |access-date=2017-04-18 |archive-date=2017-08-02 |archive-url=https://web.archive.org/web/20170802002210/http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/ |url-status=dead }}</ref>
▲Regulation of e-cigarettes varies around the world. The Institute for Global Tobacco Control (IGTC) has identified 68 countries that have laws regulating e-cigarettes, as at November 2016.<ref>{{cite web|title=Country Laws Regulating E-cigarettes {{!}} Global Tobacco Control - Learning from the Experts|url=http://globaltobaccocontrol.org/e-cigarette/country-laws-regulating-e-cigarettes|website=globaltobaccocontrol.org|publisher=Institute for Global Tobacco Control}}</ref> Types of regulation include complete prohibition on the sale and marketing of e-cigarettes, prohibition on their use in enclosed public places, minimum age for purchase, an allowance for e-cigarettes to be sold under general consumer product regulations and most recently, in the UK, e-cigarettes may be brought to market as either medicines or consumer products (with those seeking medicines approval undergoing the standard medicines licensing process). The World Health Organization acknowledge that e-cigarettes may play a role in harm reduction strategies, but should be regulated to minimize any potential risks. However, the vast differences in regulatory approaches evident around the world highlights the challenge of developing a global regulatory approach.
==Heat-not-burn products==
{{Main|Heat-not-burn product}}
== Public perceptions==
Smokers remain confused about tobacco harm reduction. In a 2004 survey, about 80-100% of participants incorrectly perceived low-yield cigarettes as harm-reducing, while 75-80% mistakenly believed that switching to smokeless tobacco conferred no risk reduction.<ref>{{cite journal |
Similar confusion exists about electronic cigarettes. In the UK, research commissioned by the anti-smoking charity Action on Smoking and Health found that in 2016, more than three times as many people think e-cigarettes are as harmful or more harmful than smoking than in 2013 (25% vs 7%), the highest proportion since the survey began.<ref name="Action on Smoking and Health"/> They expressed concern that the proportion of adult smokers who thought that e-cigarettes were more or equally harmful than cigarettes was highest in those who had never tried e-cigarettes, and these perceived potential harms was the main reason why they had not tried them.<ref name="Action on Smoking and Health"/>
In 2015 a report commissioned by Public Health England noted, as well as the UK figures above, that in the US belief among responders to a survey that vaping was safer than smoking cigarettes fell from 82% in 2010 to 51% in 2014.<ref name=McNeill201579>{{cite web|last1=McNeill|first1=A, SC|title=E - cigarettes: an evidence update A report commissioned by Public Health England|url=https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/454516/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England.pdf|website=www.gov.uk|publisher=Public Health England|
In an article published by the Wall Street Journal in 2016 entitled "Are E-Cigarettes a Healthy Way to Quit Smoking?", [[Jed Rose (scientist)|Dr. Jed E. Rose]] co-inventor of the [[nicotine patch]] said, "Having worked my entire career to develop effective smoking-cessation treatments, I have realized that current approaches are ineffective for the vast majority of smokers. Alternative approaches are urgently needed. The World Health Organization predicts<ref name=Who2008>{{cite
==Concerns around tobacco harm reduction strategies==
Whilst tobacco harm reduction approaches have the potential to reduce risks to the current adult smoking population, there are hypothesised potential hazards to wider public health. Smoking has become less acceptable over recent years in a number of countries, a result of a number of the Framework Convention on Tobacco Control (FCTC) guidelines to reduce smoking prevalence. The renormalisation of smoking is a concern if e-cigarette use appears to become more appealing, for example through their use in locations where conventional cigarettes are prohibited, advertising and increased e-cigarette use by parents, siblings, peers, celebrities or other influential groups.<ref>{{cite journal |last1=Fairchild |first1=
Concerns have also been raised that non-tobacco nicotine use may results in uptake of tobacco smoking that would not otherwise have occurred. This
Dual use of tobacco products and non-tobacco nicotine by continuing smokers is another aspect which has raised concern. It is suggested that dual use could inadvertently sustain smoking by making it easier for smokers to temporarily abstain from tobacco use, or encourage smokers to move towards dual use rather than complete cessation in the mistaken belief that this offers significant health gains. Dual use of tobacco and NRT is licensed by the Medicines and Healthcare products Regulatory Authority (MHRA) as a tobacco harm reduction strategy which actually increases the chance of quitting.<ref>{{cite web |title=The use of nicotine replacement theory to reduce harm in smokers |url=
Much of the opposition to tobacco harm reduction has come from organisations funded by the US Bloomberg Philanthropies including Vital Strategies, the Campaign for Tobacco Free Kids and the UK University of Bath Tobacco Control Group and it is claimed that the USA is the epicentre for all anti tobacco harm reduction globally.<ref name=":0" />
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== Further reading ==
*
* {{cite journal |last1=De Andrade |first1=Marisa |last2=Hastings |first2=Gerard |title=Tobacco Harm Reduction and Nicotine Containing Products: Research Priorities and Policy Directions |date=May 2013 |url=http://hdl.handle.net/1893/13224 |hdl=1893/13224 |hdl-access=free |website=University of Stirling}}
== External links ==
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