"Harm reduction" – no effective tobacco control strategy

Health experts criticize the harm reduction strategy as useless in the fight against tobacco.

Rainer M. Kaelin / August 08, 2019 –

According to health experts, mitigation should not be part of the strategy to combat the tobacco epidemic.

Red. Dr. Rainer M. Kaelin was Vice President of the Swiss Lung Association and Vice President of Oxyromandie, an association dedicated to the protection of non-smokers and the prohibition of tobacco advertising, as provided for in the Convention. -framework of WHO.

On 12 and 13 August, the Council of State's Social Security and Health Commission (SGK-SR) is consulted on the Tobacco Products Act (TabPG). A controversial law, particularly because of the regulation on alternative tobacco products. The tobacco industry and the opponents want to formulate the legal text in their sense: economic interests and public health.

Recently, the tobacco industry has seen a decline. After being pressured by the media, politicians and health experts, Foreign Minister Ignazio Cassis denied the tobacco company "Philip Morris". The cigarette manufacturer wanted to participate as a sponsor with about 1.8 million francs at the Swiss pavilion of Expo 2020. Finally, Cassis took over because he feared that "the controversial partnership, the general objective of the Swiss presence, namely the communication of forces and a positive image of Switzerland, can be questioned ".

However, the "Republic" has demonstrated to what extent the tobacco sector and Swiss politics are linked, explaining how the FDFA intervened in Moldova in the interest of Philip Morris.

But now, the health experts are also intervening, they question the thrust of TabPG. They criticize the risk reduction strategy put forward, as if it were a recognized public health strategy, ignoring the aspect of the spread of nicotine addiction.

What is meant by harm reduction in tobacco control?

The harm reduction strategy is to advise smokers to use alternative nicotine products (e-cigarettes, heated tobacco products, oral forms, etc.) instead of traditional tobacco-based cigarettes. This would replace a very harmful product with a presumed less harmful product. The concept seems appealing to smokers, doctors and politicians. The problem is complex.

While methadone opioid substitution treatments are prescribed by a physician only to drug addicts and highly vulnerable people, alternatives to smoking are mass produced. In most countries, e-cigarettes and heated tobacco products are readily available to the general public, even to those who have never been nicotine addicts. Although it is estimated that only 0.4% of European adults take high risk opioids, nearly one in four adults is a European smoker.

Seven arguments against harm reduction

A European Society of Respiratory Society (ERS) synthesis paper presents seven arguments as to why "risk reduction" can not be a strategy for tackling the tobacco epidemic:

1. The strategy of repairing damage caused by smoking is based on the assumption that smokers can not or will not quit smoking.

The majority of smokers want to quit. A European study showed that only 10% of smokers absolutely did not want to quit. Millions of people around the world have stopped smoking without using nicotine replacement therapy. The main goal of smoking cessation is to motivate and help smokers to quit. The goal is relapse prevention to achieve long-term abstinence. Alternative nicotine products, including e-cigarettes and heated tobacco products, promote nicotine addiction.

2. The "harm reduction" strategy is based on the undocumented hypothesis that nicotine replacement products, such as electronic cigarettes, are very effective in helping to quit smoking.

Until now, very few randomized studies have shown low efficacy and hardly lasting. Electronic cigarettes are effective in a clinical setting in conjunction with repeated counseling. However, less than 5% of UK smokers and about 1% of Danish smokers use free national smoking cessation programs, although they are well developed in these countries.

In many parts of the world, professional advice is scarce, suggesting that e-cigarettes have no negative impact on smoking cessation. There is no evidence that electronic cigarettes or forms of oral tobacco, other than the accompanying advice, are an effective way to quit smoking. Instead, in a real environment, use seems to compromise quitting. Manufacturers of "Juul" and "IQOS" claimed that their products were not intended to quit.

3. The "harm reduction" strategy is based on the assumption that smokers replace traditional tobacco cigarettes with alternative nicotine delivery products such as electronic cigarettes.

However, the majority of electronic cigarette users (about 60 to 80%) continue to smoke (double users), although less. Many smokers use e-cigarettes or heated tobacco products as a supplement to conventional tobacco and not as an alternative to smoking. Therefore, for the majority of smokers, the health benefits will be low. for some, there may even be an increased risk of harm. Until now, only a few studies have examined the health effects of the dual use of electronic cigarettes and conventional cigarettes.

4. The "harm reduction" strategy is based on the undocumented hypothesis that the substitutes for nicotine delivery are harmless.

Traditional cigarettes undoubtedly have devastating consequences for health. Therefore, all products to which they are compared will be less harmful. Less harmful, however, is not trivial. The use of electronic cigarettes instead of conventional cigarettes can reduce exposure to pollutants, but this reduction does not lead to a dramatic reduction in damage to humans. Evidence shows that low exposure to conventional tobacco smoke (that is, a few cigarettes a day or occasional use) causes ischemic heart disease. Because the dose-response relationship is not linear and the residual risk of only five cigarettes per day is around 50%. To reduce the health risks associated with smoking, smoking must be stopped completely, with the residual risk associated with previous smoking slowly decreasing.

There is no safe use of tobacco. According to current knowledge, vapors of electronic cigarettes or aerosols of heated tobacco products contain fewer toxic and carcinogenic pollutants than conventional tobacco smoke. However, e-cigarettes and heated tobacco products can not be considered safe. In particular, there is currently a lack of systematic toxicological data on all substances inhaled using a fog heated with propylene glycol or glycerin.

5. Alternative tobacco products have a negative impact on public health

The harm reduction strategy targets only smokers, who are not the majority of the population. The spread of nicotine replacement products in the majority of the non-smoking population (ie, non-smokers and former smokers) must be taken into account, as well as the risk of normalization of smoking in society.

Although it is difficult to predict the long-term effects of other nicotine delivery products on the health of the population, advertising can have a negative impact on society. For example, in Australia, a quarter of young electronic cigarette users have never smoked and a recently published meta-analysis has shown that teens who "smoke" electronic cigarettes are three to four times more likely to start smoking. to smoke later. Electronic cigarettes with candy or fruit flavors appeal to children and teens.

6. Smokers view e-cigarettes and heated tobacco products as an alternative to evidence-based smoking cessation programs.

A survey conducted in 28 countries of the European Union showed that the use of electronic cigarettes to quit smoking had increased over the past five years, while the use of drugs and counseling had decreases.

7. The strategy to repair the damage caused by tobacco is based on the assumption that the tobacco epidemic can not be controlled.

Strategies to reduce smoking at the population level are effective. The reduction in smoking due to consistent tobacco control measures under the WHO Framework Convention on Tobacco Control is one of the greatest achievements of public health. In countries where tobacco control is strong (high tobacco prices, neutral packaging, stalls, strict minimum age enforcement, complete bans on advertising and promotion, consistent regulations on passive smoking, anti-tobacco campaigns, free national smoking cessation programs), the share of tobacco increases Strong smoking in the population.

In countries where the smoking rate was previously high, for example Norway, Sweden, Canada, Brazil, Hong Kong and the State of California smoke only 10 to 20% of adults. In countries where tobacco control is low, such as Denmark and Switzerland, the smoking rate does not decrease. In France, one million smokers quit smoking in one year thanks to an improvement in tobacco control. Tobacco use has also decreased among youth and low-income individuals. Secure information is available, but it takes health politicians and courageous authorities to implement scientifically proven effective methods.

Response of the tobacco industry to the decline of tobacco consumption

Nicotine replacement products, such as heated tobacco products and electronic cigarettes, are the tobacco industry's response to the decline in tobacco use, which threatens to reduce its profits. Health and tobacco professionals, public health experts, and health policy makers who recommend the mitigation strategy do so with the best of intentions. They view damage limitation as a pragmatic way of mitigating the health consequences of the tobacco epidemic.

Until now, however, evidence of the safety and efficacy of e-cigarettes and heated tobacco products as a smoking cessation tool is inadequate. Even by taking advantage of "alternative products" for individual smokers, it can not be considered to imply benefits for public health. The increasing prevalence of nicotine-containing electronic cigarettes in children and adolescents, which is being established, proves that the danger of spreading nicotine addiction and its trivialization in society is realized.

Harm reduction products should be reserved for a minority of high-risk divers who need professional advice without any advertising.

Alternative products of nicotine administration are now mainly marketed by the tobacco industry. She is interested in wide dissemination among smokers and non-smokers. Since the 1950s, the group has repeatedly sold "safer" tobacco products (with filters, light, sweet, ultra-light and low-tar cigarettes) – to a broader and younger target audience. of the tobacco industry show that tobacco companies are trying to stop smokers from quitting smoking with less harmful, less addictive or socially acceptable products.

The tobacco industry is also adapting today. Following the launch of the "IQO", Philip Morris announced in 2018 that he would stop producing cigarettes and opt for "smoke-free" products. For Philip Morris, a "smoke-free world" will in the future consist of users of his latest product "IQOS" – an abbreviation of "I Quit Ordinary Smoking" – which claims to produce no harmful smoke, but only a "safe steam". The tobacco industry is trying to act responsibly in solving the problem of self-inflicted tobacco. With this reasoning, he influences political decision-makers. Tobacco companies do not intend to abandon conventional cigarettes. On the contrary, they provide considerable resources against all efforts to reduce the smoking of traditional cigarettes and to extend the sale of conventional cigarettes to low-income countries.

What does the European Pulmonary Society recommend?

The tobacco reduction strategy is based on undocumented assumptions. E-cigarettes and heated tobacco products that can potentially mitigate losses are insufficient to mitigate damage. Vera Luiza da Costa, Chief of the Secretariat of the WHO Framework Convention on Tobacco Control (FCTC), declared at the opening of the eighth meeting of the Conference of the Parties (COP8): "The Parties should accelerate and ensure the implementation of the guiding principles in Article 5.3 that they apply to all commercial interests of the tobacco industry, including the treatment of unproven claims for mischief ". Nearly 40 countries have banned electronic cigarettes and / or liquids containing nicotine electronic cigarettes.

The oath of Hippocrates requires above all no damage ("primum non nocere"). The physiology of the human lung is created to breathe clean air – not "a reduction of levels of toxins and carcinogens". The human body is not intended to create an addiction. The European Respiratory Society (ERS) can not recommend a product that is harmful to the lungs and human health. Therefore, the ERS strongly supports the implementation of the WHO FCTC and does not recommend "harm reduction" to combat the tobacco epidemic.

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Infos Sperber-DOSSIER:

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The full article was published in the Schweizerisches Ärztezeitung.

Teacher. Dr. med. Jürg Barben, Chief Medical Officer in Respirology, Ostschweizer Children's Hospital, St. Gallen *, PD Dr. med. med. Macé Schuurmans, Chief Medical Officer in Respirology, KS Winterthur *, dr. med. Alice Zürcher, Deputy Director of the Department of Pneumology, Uster Hospital *, Dr. Thomas Schmid, Pulmonary Specialist at Soleure, MD Med. Rainer Kälin, pulmonologist at Morges *