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The Road ahead for Tobacco Harm Reduction in the 21st Century

Jul 21, 2020

Dr. Renée O’Leary and Prof. Riccardo Polosa

Tobacco smoking is one of the leading causes of deaths worldwide. It kills half of its users, 80% of whom live in low-and middle-income countries. [World Health Organization (WHO), 2019, tobacco facts]. One of the six primary tactics adopted by the WHO to counter the tobacco epidemic is promoting cessation – asking people to quit tobacco use.1

But achieving high levels of cessation in the tobacco smoking population is an unrealistic goal. Successful quit rates are abysmally low, relapse rates are high and many wish to smoke.

Consequently, there is a pressing need for alternative and more efficient means to reduce or prevent harm in those who return to smoking.

The article highlights why harm reduction is important, what are the ways to achieve harm reduction, particularly the use of snus, heated tobacco products and e-cigarettes and what are the barriers to use of such alternatives. This article is not a systematic or narrative review; it is an overview of recent studies on these products or devices. Industry conducted or funded studies were excluded from the review.

A big reason people return to smoking tobacco is that, it is pleasurable, and has seemingly positive effects on cognitive processes, due to presence of nicotine.

According to PhD scholar R. Niaura, nicotine can improve attention, fine motor coordination, concentration, memory and speed of information processing. It can help relieve stress, anxiety, depression, and other mental health and medical conditions, including schizophrenia and Parkinson’s disease.2

But combustible tobacco products like cigarette or cigars, consumed over a long period of time for nicotine is responsible for major damage. Can nicotine use, thus, be separated from cigarette smoking?

What is Harm Reduction?

The term Harm Reduction is used for a public health strategy to reduce the harms caused by behaviors, including drug use. The tactics include revising regulations and bans that increase harm, empowering people with accurate information and offering alternatives such as the adoption of risk reduced modes of use (for example, clean needles) and the substitution of lower-risk drugs (for example, methadone maintenance – an opioid alternative with a lower addiction potential used to treat opioid addiction).

Similarly, tobacco harm reduction seeks to prevent or reduce the damage caused by the toxins from tobacco smoke for smokers unable or unwilling to stop, rather than aiming at complete abstinence from nicotine use (Zeller and Hatsukami, 2009).3

The WHO’s Framework Convention on Tobacco Control (FCTC) acknowledges harm reduction as an integral part of a comprehensive approach, but it does so only in reference to eliminating or reducing consumption. Displacing combustible tobacco products with non-combustion products that deliver nicotine with a lower toxic and risk profile is key to tobacco harm reduction and may promote the cessation of cigarette smoking.

In the 21st century, three classes of products can fulfil this role, namely, snus (oral use tobacco), e-cigarettes (vapor products) and heated tobacco products (heat-not-burn).

Alternative products and their role in harm reduction


Snus is an oral tobacco product with processed tobacco in a paper pouch that the user places in the mouth between the gum and cheek. The oral form of tobacco consumption is noted to be less harmful than smoking in three ways. One – the population who used snus vs. smoking were less prone to tobacco related diseases, and even lung cancer. A comparison of snus using Swedish men and other European men who had similar daily tobacco use had lower rates of lung cancer deaths for men 60–69 years of age, at 87 per 100,000 compared to the European Union average of 220 and lower rates of cardiovascular death at 72 compared to 170 per 100,000, respectively.4

Second, the quit rates in this population was higher than smokers at over 70%. Third, oral tobacco users progressing to using cigarettes appeared to be lower in the youth, at 8.2% for girls and 17.6% for boys.5

In 2019, the USFDA announced that “the available scientific evidence, including long-term epidemiological studies, shows that relative to cigarette smoking, exclusive use of these specific smokeless tobacco products poses a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema and chronic bronchitis”. In addition, the USFDA observed that the levels of N-Nitrosonornicotine (NNN) and nitrosamine ketone (NNK), two major carcinogens, are much lower in the Swedish snus products than in smokeless products sold in the USA.6

The value of smokeless products in harm reduction can be seen through an extensive study of over 46,000 US men 40–79 years of age from 1987 to 2010 (US National Health Interview Survey) that found no increases in mortality amongst smokeless-tobacco-users compared to never-tobacco-users for cardiovascular diseases, all cancers and malignancies.7Another astonishing study in Alaska found that users of Iq’mik, a smokeless tobacco produced with tree ash, had a lower risk for negative cardiometabolic health than non-smokers, as indicated by multiple biomarker tests.8


In this case, a device is used to heat tobacco, rather than burn it, and has been noted to carry less percentage of harmful chemicals like aldehydes, less elevation in eCO in the body and other toxic chemicals. Heated tobacco products are another category that is gaining popularity in countries including Japan, South Korea, Italy and Russia.9


Electronic cigarettes are products that operate by heating an element that vaporizes a solution (e-liquid) mainly consisting of glycerol, propylene glycol, distilled water, and flavourings and which may or may not contain nicotine. It is available in three designs – a disposable product, a reusable, refillable device filled with liquid by the users (tank system); a reusable device, which attaches to pre-filled cartridges. Most come with a mechanism where user can control the amount of heat. This has quickly gained popularity – increasing from about seven million users in 2011 to 41 million in 2018.

E-cigarettes have a high harm reduction potential. In an RCT in the UK the quit rates were noted to be 18.0% for e-cigarettes compared to 9.9% with NRT (nicotine replacement therapy). A study in 181 individuals tested biomarkers of chemical exposure.  A 97% reduction in e-cigarette was observed as compared to combustible cigarette–only users. More importantly, lowered biomarker of 1,3–butadiene for e-cigarette-only-users was 11.0% that of smokers. BDE is the greatest source of cancer risk in cigarettes. The prevalence of being quit in the last six years, was also three times higher in the e-cigarette group vs those who had never used it. 10

Patterns of use for tobacco harm reduction: Dual use of cigarettes and e-cigarettes has been noted to be ineffective in harm reduction. The users must either decrease the number of cigarettes used or completely switch from smoking to other alternatives. Studies on prevalence of dual users, switching and quit rates are limited.  This highlights the need for research to understand the motivation behind dual use and its impact on harm reduction. Let us now understand what prevents the uptake of these products.11,12,13

Barriers to tobacco harm reduction

For tobacco harm reduction to make maximum impact, it must be widely and properly understood first. Fear of addiction to these products, misinformed sensational media headlines lead to a regulatory ban on these products leading to decreased access.

  1. Bans, regulations and taxes

Tobacco harm reduction products are subject to bans in various countries. Snus is banned in Australia, New Zealand and the European Union except for Sweden. 30 countries have banned all and seven countries have banned nicotine-containing e-cigarettes. As of the beginning of 2020, 14 counties have placed taxes on e-cigarettes.14,15

Studies show that bans of reduced-risk products either lead to their black marketing or users returning to smoking. Minnesota (US), where e-cigarettes have been heavily taxed since 2010 saw “an increase in adult smoking rates and reduced quits”. The study concludes that taxing e-cigarettes at the same rate as tobacco would increase the baseline smoking rate in the US by 8.1% and decrease the quit rate by 25%.16

  • Misperceptions about Nicotine

Studies have long established the fact that for adult smokers, nicotine per se may cause addiction, but not disease, therefore substituting non-combustion modes of nicotine delivery for smoking results in harm reduction.

But misperceptions to nicotine use prevail to no end. Some believe it is a high-risk factor for heart attack and stroke, while others, even medical professionals, believe it causes cancer and atherosclerosis. Dr Neil Benowitz, a leading researcher in nicotine pharmacology, states that “nicotine plays a minor role, if any, in causing smoking-induced diseases”.17

Numerous studies prove smoke is the cause of disease risk and cancer, and not nicotine, and therefore the need to separate the two.18There is a desperate need for better education of medical professionals on the effects of nicotine during their training and through continuing medical education, and through them, the delivery of accurate information to smokers and the public as well.

  • Misperceptions of relative risks

For tobacco harm reduction to be a workable strategy, the public must be persuaded of the evidence for the lower relative risks of e-cigarettes and snus compared to smoking. Studies conducted in the US show only 17% of cigarette users perceive snus to be less harmful.19

  • Media sensationalism

Media misrepresentations of e-cigarette studies are causing the public to disbelieve the lower relative risks of products for tobacco harm reduction. In a recent incident, commercial vaping products were blamed in numerous newspapers, TV and radio for outbreak of acute severe cases of lung injury and deaths in the US. The media failed to report that 82% of cases (66% male) were amongst users of illegal tetrahydrocannabinol (THC) cartridges available in illegal/black markets. Notably, no cases were reported after USFDA shut down these sites.20

Sadly, months of sensationalized reporting that erroneously implicated all vapourproducts appears to have persuaded large numbers of the public and clinicians around the world to erroneously believe that commercial e-cigarettes are extremely dangerous.

  • Fears of youth nicotine addiction

The fear that e-cigarette use by youth use will lead to nicotine addiction and thereby increase the uptake of tobacco products is probably the most powerful barrier to tobacco harm reduction.

Studies show a large percentage of youth admitted to vaping one to five days in a month, but less than 3 per cent of those vaping 3–5 times a month use nicotine, which shows its low prevalence.21

Closing comments and future research

In conclusion, to reduce smoking and to save millions of lives, tobacco harm reduction in the form of cigarette substitution with low-risk products appears to be a promising path. The obvious fact so often overlooked is that smoking is rewarding, and people like to do it. Giving smokers an alternative with efficient nicotine delivery means that they might prefer one of these products over cigarettes. However, given the barriers to use of e-cigarettes, a strong advocacy is needed to bring facts on harm reduction to our patients, families, friends and fellow world citizens.

These products, although not completely risk-free, offer an alternative solution. And finally, sound research in these areas will be required to make this strategy a success. We especially need to understand the difference in risk profiles of non-combustion nicotine products, equip regulatory and clinical personnel to appreciate the difference and to understand the long-term effects of these products and their potential benefits or limitations.

Link to the study: “Tobacco Harm Reduction in the 21st Century”

Link to the press release:


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