Tobacco Harm Reduction in the 21st Century
Bottom line: This review examines how e-cigarettes can displace smoking and how government barriers to e-cigarettes impede this substitution to safer alternatives. These barriers must be addressed if tobacco harm reduction is to make the maximum impact on the tobacco epidemic.
This paper examines the need for tobacco harm reduction, the consumer products that facilitate tobacco harm reduction, and the barriers to its implementation. The worldwide epidemic of tobacco smoking results in the death of over seven million smokers a year.
Cigarette quit rates are very low, from 3%–12%, and relapse rates are high, from 75%–80% in the first six months and 30%–40% even after one year of abstinence. In addition, some smokers do not desire to quit. Achieving high levels of cessation in the tobacco smoking population is an unrealistic goal.
Cigarette substitution in tobacco harm reduction is one strategy that can reduce the burden of morbidity and mortality. E-cigarettes have been subjected to regulatory bans and heavy taxation and are rejected by smokers and society based on misperceptions about nicotine, sensational media headlines, and unsubstantiated fears of youth addiction.
The US National Academies of Sciences book, Public Health Consequences of E-Cigarettes (2018), states that there is conclusive evidence that completely switching from smoking to e-cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes. There is substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.
E-cigarettes help smokers quit at about double the rate of nicotine replacement therapy. Based on combined data from the 2014 and 2015 US National Health Interview Surveys, the prevalence of quitting smoking during the prior six years was significantly higher among daily e-cigarette users compared to those who had never used e-cigarettes (52.2% vs 28.2%).
A qualitative study of 40 UK vapers (20 male, 20 female) suggests that “for some, e-cigarettes can substitute the physical, psychological, social, cultural and identity-related dimensions that were previously enjoyed about tobacco smoking, and thus, may uniquely support long-term smoking relapse prevention."
The barriers to tobacco harm reduction originate in regulation and misperceptions. Smokers’ access to low-risk products is thwarted by product bans. The misperception of the risks of these products results in smokers rejecting them, misperceptions that arise from inaccurate information, and sensational media headlines.
The impacts of taxation and flavor bans require continued surveillance for their potential negative effects on product uptake. Cross country case comparisons between countries with and without bans on vapor products could shed light on their population-level effects on cessation, morbidity, and mortality rates.
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