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{{short description|Public health strategy to lower health risks of tobacco use}}
{{Expand Greek|Μείωση της βλάβης από το κάπνισμα|date=November 2016}}
'''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/> 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 |url=https://harmreductionjournal.biomedcentral.com/track/pdf/10.1186/s12954-020-00446-4.pdf |url-status=live
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 |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, [[periodontal disease]]s and [[Tooth loss|teeth 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 |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>
[[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:
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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 | volume = 3 | pages = 37 | year = 2006 | doi = 10.1186/1477-7517-3-37 | pmid = 17184539| pmc =1779270 }}</ref> Harm reduction is likely of substantial benefit to these smokers and public health.<ref name="Nitzkin2014" /><ref name="Fagerstrom2014" /> Providing reduced-harm alternatives to smokers is likely to result in lower total population risk than pursuing abstinence-only policies.<ref name="Phillips2009">{{cite journal | title=Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments | author=Phillips, CV | journal=Harm Reduct. J. |date=November 2009 | volume=6 | pages=29 | doi=10.1186/1477-7517-6-29 | quote=Hiding THR from smokers, waiting for them to decide to quit entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could. | pmc=2776004 | pmid=19887003}}</ref>
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 = W | year = 2005 | title = Permissive nicotine regulation as a complement to traditional tobacco control | journal = BMC Public Health | volume = 5 | page = 18 | doi=10.1186/1471-2458-5-18| pmid = 15730554 | pmc = 554785 }}</ref><ref>{{cite journal | last1 = Tomar | first1 = SL | last2 = Fox | first2 = BJ | last3 = Severson | first3 = HH | year = 2009 | title = Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking? | journal = Int J Environ Res Public Health | 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">{{Cite web|last=Shapiro|first=Harry|date=4 November 2020|title=Burning Issues: the Global State of Tobacco Harm Reduction 2020.|url=https://gsthr.org/resources/item/burning-issues-global-state-tobacco-harm-reduction-2020|page=5}}</ref>
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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|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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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>
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|title=Find product information about medicines}}</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| doi-access=free }}</ref>
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>
Recently a cochrane review stated that electronic cigarettes do help people stop smoking, in fact they report electronic cigarettes to be more effective than [[Nicotine replacement therapy]] with 10 or 11 out of 100 being successful at quitting, compared with 6 out of 100 with NRT <ref name="cochrane review">{{cite
Research into the safety and efficacy of e-cigarettes for smoking cessation, published up until January 2016, is limited, but suggests a potential increase in long term smoking cessation using e-cigarettes containing nicotine compared to those without, with no increased health risk compared to smokers with medium term use (two years or less).<ref>{{Cite journal|
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.
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{{Main|Heat-not-burn product}}
A 2016 [[Cochrane review]] found that it was unclear whether using heat-not-burn tobacco products instead of traditional cigarettes would "substantially alter the risk of harm".<ref name=Lindson-HawleyHartmann-Boyce2016>{{cite journal|last1=Lindson-Hawley|first1=Nicola|last2=Hartmann-Boyce|first2=Jamie|last3=Fanshawe|first3=Thomas R|last4=Begh|first4=Rachna|last5=Farley|first5=Amanda|last6=Lancaster|first6=Tim|title=Interventions to reduce harm from continued tobacco use|journal=Cochrane Database of Systematic Reviews|volume=10|pages=CD005231|year=2016|issue=12|issn=1465-1858|doi=10.1002/14651858.CD005231.pub3|pmc=6463938|pmid=27734465}}</ref>
== Public perceptions==
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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 web|title=Who Report On The Global Tobacco Epidemic, 2008|url=https://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf|access-date=21 April 2016|location=US}}</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
==Concerns around tobacco harm reduction strategies==
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