the role of harm reduction in tobacco control

Le rôle de la réduction de dommages dans la lutte antitabac

The role of harm reduction in tobacco control

Lars M. Ramström

Institute for Tobacco Studies

Stockholm, Sweden

EMASH Portugal Seminar, Coimbra, 23-24 October, 2008

OVERALL GOAL for tobacco control:

Reducing tobacco-related morbidity and mortality as far as possible

INTERMEDIATE OBJECTIVES for practical measures in tobacco control

These will be specific for measures to help different target groups, for example:

Never tobacco users Current tobacco users

Objective of measures to help never-tobacco-users:

Preventing onset of tobacco use

Strength: In individuals for whom these measures have been successful, tobacco induced diseases will not occur

Weaknesses:

Measures to prevent onset of tobacco use have limited success rate

Even when successful: Virtually no reduction of disease in nearest 30–40 years

1950 2000 2025 20500

100

200

300

400

500

600

.520500

No interventionOnset of smoking in young people cut to half by 2020

.Estimated cumulative tobacco deaths (millions) 1950 - 2050 by different intervention policies

Source: World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. 1999 The World Bank, Washingon D.C.

1950 2000 2025 20500

100

200

300

400

500

600

.520500

340

No intervention

Adult smoking cut to half by 2020

.

.

Estimated cumulative tobacco deaths (millions) 1950 - 2050 by different intervention policies

Source: World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. 1999 The World Bank, Washingon D.C.

Onset of smoking in young people cut to half by 2020

#1 objective of measures to help current tobacco users:

Quitting all tobacco/nicotine use Strength: Disease risks decreasing substantially, eventually approaching never-user levels

Weaknesses: Treatments in clinical settings reach a limited fraction of smokers and have limited success rate

Quit attempts made outside clinical settings (the majority of all) get no or inadequate support

Occurrence of quit attempts in Sweden (% of all ever daily smokers)

Men Women

Not made any quit attempt 9% 8%

Made one or more quit attempts - but do still smoke 36% 47% - and have quit completely 55% 45%

Source: ITS/FSI surveys of the Swedish population

”Do still smoke” after latest quit attempt by level of nicotine dependence

Men Women

Low nicotine dependence 34% 36%

Medium nicotine dependence 40% 56%

High nicotine dependence 56% 66%

Source: ITS/FSI surveys of the Swedish population

#2 objective of measures to help current tobacco users

Switching to a nicotine product that is markedly less harmful

Strengths:

Realistic alternative even for highly nicotine dependent people Disease risks potentially decreasing almost as much as when quitting

Weaknesses: Continued exposure to nicotine Maintenence of nicotine dependence Limited availability of appropriate products

What is “markedly less harmful”?

Nicotine delivery products that do not require inhalation of combustion products and do not deliver concentrations of toxic chemicals likely to cause disease,

e.g. nicotine replacement therapy products and potentially low-nitrosamine smokeless tobacco products (e.g. snus, Ariva, Stonewall).

Cigarette smokers

Snus users

Never-smokers

0,0 0,5 1,0 1,5 2,0 2,5

Relative risk of death for male tobacco users (whole bar)

Green sector: Never-smokers' death risk (reference) Red sector: Excess risk (above Never-smokers)

Less than 9% of

Data derived from:Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarfettes per day. Tobacco Control 2005;14:315-320.Levy D T et.al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimats of a Panel of Experts. Cancer Epidemiol Biomarkers Prev 2004;13(12):2035-2041.

Reduction of life expectancy: Tobacco users, age 40, in comparison with ”Never tobacco users” Estimated number of years lost Men Women Current smokers who continue to smoke 5.04 4.09

Current smokers who quit all tobacco use 0.53 0.34

Current smokers who switch to snus 0.77 0.52

Current snus users who never smoked 0.28 0.19

Source: Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014

Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369: 2010-2014.

Excerpts from the Summary:

• For net harm to occur, 14–25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke.

• Likewise, 14–25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking.

Source: ITS/FSI surveys of the Swedish population 2004 and 2006

Slide from: Berzelius symposium 71The Swedish Society of Medicine, 24–25 April, 2008

The Tobacco epidemic - controlling one of the greatest threats to human health this century

Slide from: Berzelius symposium 71 (John Hughes)The Swedish Society of Medicine, 24–25 April, 2008

The Tobacco epidemic - controlling one of the greatest threats to human health this century

Gum onlyPatch onlySnus only

Gum onlyPatch onlySnus only

0 25 50 75 100

Quit smoking completelyQuit daily Continuing daily smoking

Outcome of latest attempt to quit smokingby type of cessation aid used

smoking, continuing to smoke occasionally

Men

Women

47%

32%

66%

37%

29%

55%

10%

2%

15%

8%

2%

16%

43%

66%

19%

55%

69%

29%

Data from 2001/2002 ITS/FSI study (Ramström & Foulds 2006)

Main area #4Helping those who cannot quit: considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.

Excerpt from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.

What is harm reduction, and how would it work for smoking? People smoke because they are addicted to nicotine, but

nicotine itself is not especially hazardous; it is the otherconstituents of tobacco smoke that cause most of the harm.

Harm reduction is therefore feasible in tobacco smokingby providing smokers with nicotine from a source thatdoes not involve inhaling tobacco smoke.

Use of smoke-free nicotine would benefit smokers directlyby reducing the personal harm caused by nicotine addiction.


What is the safest way to provide nicotine without smoke?The safest form of nicotine is medicinal or ‘pure’ nicotine,

such as that contained in nicotine replacement therapy(NRT) products including skin patches and chewing gum.

Medicinal nicotine is by far the safest alternative tosmoking, other than quitting nicotine use altogether.

However, although helpful, few smokers find NRT to bea satisfying alternative to smoking.

This is partly because NRT products deliver lower doses ofnicotine, and deliver them more slowly, than cigarettes.


What are the alternatives to medicinal nicotine? Nicotine can also be obtained without smoke from a range of

tobacco products, usually referred to as ‘smokeless’ tobacco.

All smokeless tobacco products are therefore more hazardous than medicinal nicotine, and in some cases especially so, but all are also substantially less hazardous than smoking.

In Sweden, the availability and use by men of an oral tobaccoproduct called snus, one of the less hazardous smokelesstobacco products, is widely recognised to have contributed tothe low prevalence of smoking in Swedish men andconsequent low rates of lung cancer.

However, the Swedish data provide proof of concept thatsubstitution of smokeless for smoked tobacco can be effectiveas a harm reduction strategy.

Summary and conclusions (1)

• Primary prevention policies are important

- but not enough

• Smoking cessation policies are important

- but not enough


Smokers who are unable or unwilling to

be without nicotine should be offered

less harmful alternatives to cigarettes,

such as medicinal nicotine or low risk

types of smokeless tobacco.


Alternative nicotine delivery products

should be strictly regulated in order to

safeguard that only products that are

markedly less harmful than cigarettes

are available.

the role of harm reduction in tobacco control

Health & Medicine