Tobacco in Australia Facts & Issues A comprehensive online resource tobaccoinaustralia.org.au Book excerpt List of chapters available at tobaccoinaustralia.org.au Introduction Chapter 1 Trends in the prevalence of smoking Chapter 2 Trends in tobacco consumption Chapter 3 The health effects of active smoking Chapter 4 The health effects of secondhand smoke Chapter 5 Factors influencing the uptake and prevention of smoking Chapter 6 Addiction Chapter 7 Smoking cessation Chapter 8 Tobacco use among Aboriginal peoples and Torres Strait Islanders Chapter 9 Smoking and social disadvantage Chapter 10 The tobacco industry in Australian society Chapter 11 Tobacco advertising and promotion Chapter 12 The construction and labelling of Australian cigarettes Chapter 13 The pricing and taxation of tobacco products in Australia Chapter 14 Social marketing and public education campaigns Chapter 15 Smokefree environments Chapter 16 Tobacco litigation in Australia Chapter 17 The economics of tobacco control Chapter 18 Potential for harm reduction in tobacco control Chapter 19 The WHO Framework Convention on Tobacco Control Appendix 1 Useful weblinks to tobacco resources Tobacco in Australia: Facts and Issues. A comprehensive review of the major issues in smoking and health in Australia, compiled by Cancer Council Victoria. First edition published by ASH (Australia) Limited, Surry Hills, NSW, 1989 Second edition published by the Victorian Smoking and Health Program, Carlton South, Victoria (Quit Victoria), 1995 Third (2008) and fourth (2012) editions, and ongoing updating, published by Cancer Council Victoria in electronic format only. ISBN number: 978-0-947283-76-6 Suggested citation: Scollo, MM and Winstanley, MH. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from www.TobaccoInAustralia.org.au OR <Author(s) of relevant chapter section>, <Name of chapter section> in Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; < date of latest update of relevant chapter section> Available from < url of relevant chapter or section> Tobacco in Australia: Facts and Issues comprises chapters written and reviewed by authors with expertise in each subject area. Tobacco in Australia: Facts and Issues is available online, free of charge. A hard copy version of this publication has not been produced. This work has been produced with the objective of bringing about a reduction in death and disease caused by tobacco use. Much of it has been derived from other published sources and these should be quoted where appropriate. The text may be freely reproduced and figures and graphs (except where reproduced from other sources) may be used, giving appropriate acknowledgement to Cancer Council Victoria. Editors and authors of this work have tried to ensure that the text is free from errors or inconsistencies. However in a resource of this size it is probable that some irregularities remain. Please notify Cancer Council Victoria if you become aware of matters in the text that require correction. Editorial views expressed in Tobacco in Australia: Facts and Issues are those of the authors. Production of editions 2 to 4 of this publication has been funded by the Australian Government Department of Health and Ageing. Ongoing updating is also being funded by the Australian Government Department of Health, with contributions from Cancer Councils in all states and territories. Cancer Council Victoria 615 St Kilda Road Melbourne VIC 3004 Project manager: Elizabeth Greenhalgh, Cancer Council Victoria . Website design: Creative Services, Cancer Council Victoria Tobacco in Australia Facts & Issues A comprehensive online resource tobaccoinaustralia.org.au Chapter 18 Potential for harm reduction in tobacco control Chapter 18: Potential for harm reduction in tobacco control i Chapter 18 Potential for harm reduction in tobacco control Dr Elizabeth Greenhalgh Table of contents Dr Michelle Scollo 2016 18.0 Introduction 18.1 Assessing the harmfulness of tobacco and tobacco-like products 18.1.1 Constituents of tobacco products 18.1.2 Constituents of cigarette smoke 18.1.3 Biomarkers 18.2 Regulation to disclose or reduce harm from tobacco products 18.2.1 FDA regulation 18.2.2 EU regulation 18.3 Smoking reduction 18.4 Low nicotine – nicotine reduction 18.5 Chemoprevention of tobacco–related disease 18.6 Screening InDepth 18A Smokeless tobacco (with Dr Coral Gartner) 18A.1 Forms of smokeless tobacco and how they are regulated 18A.2 Prevalence of use of smokeless tobacco in Australia 18A.3 Health effects of various forms of smokeless tobacco 18A.4 Snus as a potential harm reduction strategy 18A.4.1 The ‘Swedish experience’ 18A.4.2 Cultural adaptability 18A.4.3 Ethical issues 18A.4.3 Individual and population level harm 18A.4.4 An unnecessary distraction? 18A.4.5 How does smokeless tobacco compare to nicotine replacement therapy? 18A.4.6 What should the public health response be? Last updated: August 2016 Tobacco in Australia: Facts and issues InDepth 18B Electronic cigarettes (e-cigarettes) ii 18B.0 Introduction 18B.1 Development of products 18B.1.1 Start-up companies 18B.1.2 Major international companies 18B.2 Development of markets 18B.2.1 Lobbying for favourable regulation 18B.2.2 Promotion 18B.3 Extent of use 18B.4 Public perceptions of products 18B.5 Safety and health risks of e-cigarettes 18B5.1 Nicotine addiction 18B.5.2 Nicotine toxicity 18B.5.3 Nicotine exposure in pregnancy 18B.5.4 Nicotine exposure in adolescence 18B.5.5 E-cigarette use and possible cardiovascular disease risk 18B.5.6 E-cigarette use and possible cancer risk 18B.5.7 Possible health effects of other constituents of e-cigarettes 18B.5.8 Exposure to second-hand vapour 18B.5.9 Explosions and fires 18B.5.10 Environmental impact 18B.6 Usefulness in quitting 18B.6.1 Usefulness in reducing consumption of conventional tobacco products 18B.7 Potential public health impact 18B.8 Legal status in Australia 18B.9 International regulatory overview 18B.9.1 Bans on sales 18B.9.2 Bans on sales to minors 18B.9.3 Bans on use in public places 18B.9.4 Product safety 18B.9.5 Taxation 18B.9.6 Advertising and promotion 18B.10 Key Australian and international position statements on e-cigarettes, health, and options for regulation 18B.10.1 Australian agencies 18B.10.2 Global agencies 18B.10.3 Overseas agencies Last updated: August 2016 Chapter 18: Harm Reduction » 18.0 Introduction 18.0 Introduction Last updated: August 2016 Suggested citation: Greenhalgh, EM, & Scollo, MM 18.0 Introduction. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter­18­harm­reduction/18­0­introduction Harm reduction is an approach within public health that aims to reduce the harmful consequences of drug use, without necessarily eliminating or even reducing consumption.1 This approach has been successfully and widely adopted within the areas of alcohol and illicit drug use. For example, needle exchange programs are now considered best practice, and have led to reduced rates of infection transmission among injecting drug users.2 Other examples include opioid substitution therapy with methadone or buprenorphine for heroin dependence, and blood alcohol limits and random breath testing for drivers to reduce harms of alcohol use.3 Robust evidence demonstrates that quitting smoking leads to significant health benefits. Large­scale cessation would likely lead to benefits greater than any other public health effort. However, many smokers fail to quit, despite knowledge of the substantial health risks from tobacco use.4 For these smokers, harm reduction has been proposed as an alternative to what has been termed a ‘quit or die’ strategy, which promotes cessation as the only viable alternative to smoking in order to reduce health risks.5 Harm reduction within the framework of tobacco control was first considered in the 1950s, when evidence of the harmfulness of smoking first came to light. For decades, attempts were made to develop cigarettes that were less harmful, such as “light”, “low­tar”, and “low­nicotine” products,6,7 which ultimately failed to reduce health risks due to compensatory smoking,8 and were used deceptively by the tobacco industry to keep smokers smoking.9,10 The concept of harm reduction then became salient again in the 1990s, when public health experts proposed a range of regulatory approaches to minimise the enormous harms caused by tobacco. A seminal article by Warner, Slade, and Sweanor suggested that, rather than banning the use of all nicotine delivery products, a more realistic approach might be to discourage use of the most dangerous products (cigarettes), while making less hazardous products readily available to adults.11 Reducing the addictiveness, rather than harmfulness, of cigarettes was a contrasting approach that was proposed about the same time. A report presented by the American Medical Association (AMA) Council on Scientific Affairs in 1998 recommended that cigarettes be modified to contain less nicotine, and therefore be less addictive.12 In a 1999 review, Australian researchers floated the idea of a single regulatory framework for tobacco and all other nicotine delivery systems; one that reduced secondhand exposure to tobacco products, reduced the risk of young people becoming addicted to nicotine, and changed the design of existing cigarettes and alternative nicotine products so that they