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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}}</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 |page=390 |doi=10.1186/s12889-015-1617-5 |pmid=25907101 |pmc=4408600 |s2cid=16482278 |doi-access=free }}</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>▼
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 |issn=1477-7517 |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 |page=390 |doi=10.1186/s12889-015-1617-5 |pmid=25907101 |pmc=4408600 |s2cid=16482278 |doi-access=free }}</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>
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#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
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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 |page=18 |doi=10.1186/1471-2458-5-18 |pmid=15730554 |pmc=554785 |doi-access=free }}</ref><ref>{{cite journal |last1=Tomar |first1=Scott |last2=Fox |first2=Brion |last3=Severson |first3=Herbert |title=Is Smokeless Tobacco Use an Appropriate Public Health Strategy for Reducing Societal Harm from Cigarette Smoking? |journal=International Journal of Environmental Research and Public Health |date=23 December 2008 |volume=6 |issue=1 |pages=10–24 |doi=10.3390/ijerph6010010 |pmid=19440266 |pmc=2672338 |doi-access=free }}</ref> However, surveys carried from 2013 to 2015 in the UK<ref>Action on Smoking and Health, May 2016, Use of electronic cigarettes (vapourisers)
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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==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 |page=18 |doi=10.1186/1477-7517-5-18 |pmid=18500993 |pmc=2427022 |quote=Switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. |doi-access=free }}</ref> In the same study, smokers who used pharmaceutical nicotine products in their most recent quit attempt had success rates between 0 and 35%.<ref name="RoduPhillips2008"/>
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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)"<ref name=":1">{{cite journal |
=== Types ===
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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 |vauthors=West R, Brown J |date=September 2014 |title=Electronic cigarettes: fact and faction |journal=British Journal of General Practice |volume=64 |issue=626 |pages=442–3 |doi=10.3399/bjgp14X681253 |pmc=4141591 |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.}}</ref>{{Update needed|date=March 2022}} 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 |title=Find product information about medicines |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" />
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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