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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 |journal=[[Harm Reduction Journal]] |publisher=[[BioMed Central]] |volume=18 |issue=7 |page=7 |doi=10.1186/s12954-020-00446-4 |doi-access=free |issn=1477-7517 |lccn=2004243422 |pmc=7789747 |pmid=33413424 |s2cid=230800394
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.
▲'''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 |journal=[[Harm Reduction Journal]] |publisher=[[BioMed Central]] |volume=18 |issue=7 |page=7 |doi=10.1186/s12954-020-00446-4 |doi-access=free |lccn=2004243422 |pmc=7789747 |pmid=33413424 |s2cid=230800394 }}</ref><ref name="BMC Publ. Health">{{cite journal |last1=Chang |first1=Cindy M |last2=Corey |first2=Catherine G |last3=Rostron |first3=Brian L |last4=Apelberg |first4=Benjamin J |title=Systematic review of cigar smoking and all cause and smoking related mortality |journal=BMC Public Health |date=December 2015 |volume=15 |issue=1 |pages=390 |doi=10.1186/s12889-015-1617-5 |pmid=25907101 |pmc=4408600 |s2cid=16482278 }}</ref><ref name="IJERPH 2009">{{cite journal |last=Laniado-Laborín |first=Rafael |date=January 2009 |title=Smoking and Chronic Obstructive Pulmonary Disease (COPD). Parallel Epidemics of the 21st Century |journal=[[International Journal of Environmental Research and Public Health]] |publisher=[[MDPI]] |volume=6 |issue=1: ''Smoking and Tobacco Control'' |doi=10.3390/ijerph6010209 |pages=209–224 |doi-access=free |pmc=2672326 |pmid=19440278 |s2cid=19615031 }}</ref><ref name="who.int">{{cite web |url=https://www.who.int/health-topics/tobacco#tab=tab_1 |url-status=live |title=Health topics: Tobacco |date=2021 |website=www.who.int |publisher=[[World Health Organization]] |archive-url=https://web.archive.org/web/20210813230009if_/https://www.who.int/health-topics/tobacco#tab=tab_1 |archive-date=13 August 2021 |access-date=18 August 2021}}</ref><ref name="J. Periodontol.">{{cite journal |last1=Albandar |first1=Jasim M. |last2=Adensaya |first2=Margo R. |last3=Streckfus |first3=Charles F. |last4=Winn |first4=Deborah M. |date=December 2000 |title=Cigar, Pipe, and Cigarette Smoking as Risk Factors for Periodontal Disease and Tooth Loss |journal=[[Journal of Periodontology]] |publisher=[[American Academy of Periodontology]] |volume=71 |issue=12 |pages=1874–1881 |doi=10.1902/jop.2000.71.12.1874 |pmid=11156044 |s2cid=11598500}}</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 |pmid=34213549 |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, [[periodontal disease]]s, [[Tooth decay|teeth decay]] and [[Tooth loss|loss]], 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 name="J. Periodontol."/><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 |pmc=4151956 |pmid=25033140 |s2cid=207276270}}</ref><ref>{{cite journal |last1=Shapiro |first1=Jean A. |last2=Jacobs |first2=Eric J. |last3=Thun |first3=Michael J. |title=Cigar Smoking in Men and Risk of Death From Tobacco-Related Cancers |journal=Journal of the National Cancer Institute |date=16 February 2000 |volume=92 |issue=4 |pages=333–337 |doi=10.1093/jnci/92.4.333 |pmid=10675383 |s2cid=7772405 |url=http://jnci.oxfordjournals.org/content/92/4/333.full.pdf }}</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 book |title=Tobacco Smoke and Involuntary Smoking |date=2004 |publisher=IARC |isbn=978-92-832-1283-6 |id={{NCBIBook2|NBK316407}} |pmid=15285078 |pmc=4781536 |series=IARC Monographs on the Evaluation of Carcinogenic Risks to Humans |volume=83 |author1=IARC Working Group on the Evaluation of Carcinogenic Risks to Humans |pages=1–1438 }}</ref><ref>{{cite journal |last1=Jha |first1=Prabhat |last2=Peto |first2=Richard |title=Global Effects of Smoking, of Quitting, and of Taxing Tobacco |journal=New England Journal of Medicine |date=2 January 2014 |volume=370 |issue=1 |pages=60–68 |doi=10.1056/NEJMra1308383 |pmid=24382066 |s2cid=4299113 |doi-access=free }}</ref>
[[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 |
#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">{{cite journal |last1=Rodu |first1=Brad |last2=Godshall |first2=William T |title=Tobacco harm reduction: an alternative cessation strategy for inveterate smokers |journal=Harm Reduction Journal |date=2006 |volume=3 |issue=1 |
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 |last1=Sumner |first1=Walton |title=Permissive nicotine regulation as a complement to traditional tobacco control |journal=BMC Public Health |date=December 2005 |volume=5 |issue=1 |
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==
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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 |last1=Bates |first1=C. |last2=Fagerström |first2=K. |last3=Jarvis |first3=M. J. |last4=Kunze |first4=M. |last5=McNeill |first5=A. |last6=Ramström |first6=L. |title=European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health |journal=Tobacco Control |date=1 December 2003 |volume=12 |issue=4 |pages=360–367 |doi=10.1136/tc.12.4.360 |pmid=14660767 |pmc=1747769 }}</ref> The exception is [[Sweden]], where there is a long tradition of [[smokeless tobacco]] (snus) use among men.
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>{{cite
=="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 |last1=Rigotti |first1=Nancy A |last2=Tindle |first2=Hilary A |title=The fallacy of "light" cigarettes |journal=BMJ |date=13 March 2004 |volume=328 |issue=7440 |pages=E278–E279 |doi=10.1136/bmj.328.7440.E278 |pmid=15016715 |pmc=2901853 }}</ref> Filters were introduced in the early 1950s, and manufacturers were selling low-yield cigarettes by the late 1960s.<ref name="Rigotti"/> Initially it was thought that these innovations were harm reducing.<ref>{{cite journal | last1 = Russell | first1 = MAH | year = 1974 | title = Realistic goals for smoking and health: a case for safer smoking | doi = 10.1016/s0140-6736(74)92558-6 | pmid = 4130257 | journal = Lancet | volume = 1 | issue = 7851| pages = 254–258 }}</ref> For example, in 1976 investigators at the American Cancer Society published research concluding that light cigarettes were safer.<ref>{{cite journal |last1=Hammond |first1=E.Cuyler |last2=Garfinkel |first2=Lawrence |last3=Seidman |first3=Herbert |last4=Lew |first4=Edward A. |title='Tar' and nicotine content of cigarette smoke in relation to death rates |journal=Environmental Research |date=December 1976 |volume=12 |issue=3 |pages=263–274 |doi=10.1016/0013-9351(76)90036-0 |pmid=1001298 |bibcode=1976ER.....12..263H }}</ref> The study authors wrote that "total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked 'low' tar-nicotine cigarettes than for those who smoked 'high' tar-nicotine cigarettes." However, scientific evidence suggests that switching from regular to light or low-tar cigarettes does not reduce the health risks of smoking or lower the smoker's exposure to the nicotine, tar, and carcinogens present in cigarette smoke.<ref>{{cite journal |last1=Benowitz |first1=Neal L. |last2=Jacob |first2=Peyton |last3=Bernert |first3=John T. |last4=Wilson |first4=Margaret |last5=Wang |first5=Langing |last6=Allen |first6=Faith |last7=Dempsey |first7=Delia |title=Carcinogen Exposure during Short-term Switching from Regular to 'Light' Cigarettes |journal=Cancer Epidemiology, Biomarkers & Prevention |date=1 June 2005 |volume=14 |issue=6 |pages=1376–1383 |doi=10.1158/1055-9965.EPI-04-0667 |pmid=15941944 |doi-access=free }}</ref> Indeed, the WHO recommends that misleading terms, including
==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 |journal=Harm Reduction Journal |date=2008 |volume=5 |issue=1 |
===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>{{
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">{{
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 ===
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)"
=== Types ===
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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.
E-cigarettes are seen as an attractive alternative by many smokers to cigarettes.<ref name="Fagerstrom2014" /> 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 |
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>
==Heat-not-burn products==
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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|page=79|access-date=20 August 2015|location=UK|date=2015}}</ref> The report blamed "misinterpreted research findings", attracting negative media coverage, for the growth in the "inaccurate" belief that e-cigarettes were less harmful than smoking, and concluded that "There is a need to publicise the current best estimate that using EC is around 95% safer than smoking".<ref name=McNeill201580>{{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|access-date=20 August 2015|location=UK|date=2015}}, pages 6, 11, 78-80</ref>
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 book |title=WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package |date=2008 |publisher=World Health Organization |hdl=10665/43818 |isbn=9789241596282 |hdl-access=free }}{{page needed|date=October 2021}}</ref> a billion deaths will be attributable to smoking during the 21st century. Electronic cigarettes have an unparalleled potential to reduce the public-health impact of smoking, by allowing smokers to replace the habit and nicotine of smoking without the toxic effects of combustion."<ref name=Rose2016>{{cite news|title=Are E-Cigarettes a Healthy Way to Quit Smoking?|url=https://www.wsj.com/articles/are-e-cigarettes-a-healthy-way-to-quit-smoking-1460340169|newspaper=Wall Street Journal|date=11 April 2016|access-date=21 April 2016|location=US}}</ref>
==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=Amy L. |last2=Bayer |first2=Ronald |last3=Colgrove |first3=James |title=The Renormalization of Smoking? E-Cigarettes and the Tobacco 'Endgame' |journal=New England Journal of Medicine |date=23 January 2014 |volume=370 |issue=4 |pages=293–295 |doi=10.1056/NEJMp1313940 |pmid=24350902 |doi-access=free }}</ref><ref>{{cite journal |last1=Voigt |first1=Kristin |title=Smoking Norms and the Regulation of E-Cigarettes |journal=American Journal of Public Health |date=October 2015 |volume=105 |issue=10 |pages=1967–1972 |doi=10.2105/AJPH.2015.302764 |pmid=26270285 |pmc=4566542 }}</ref>
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=https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/853861/Nicotine_replacement_therapy_harm_reduction_in_smokers.pdf |publisher=MHRA |date=February 2010 }}</ref> The Royal College of Physicians reviewed evidence around dual use and smoking cessation and reported that findings were suggestive that e-cigarettes had the potential to offer the same cessation gains,<ref name="Royal College of Physicians"/> although further research would be helpful to more clearly delineate such an effect.
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== Further reading ==
* {{cite web |title=Nicotine without smoke: Tobacco harm reduction |url=https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction |website=RCP London |date=28 April 2016 }}
* {{cite
== External links ==
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