saving lives An advocate’s guide to tobacco harm reduction Part of the 2020 AHRA Advocacy Pack Contents 3 CHAPTER 1 INTRODUCTION 8 CHAPTER 2 DEFINING TOBACCO HARM REDUCTION 18 CHAPTER 3 NICOTINE, A MISUNDERSTOOD MOLECULE 25 CHAPTER 4 PRODUCTS USED IN TOBACCO HARM REDUCTION 37 CHAPTER 5 UNDERSTANDING NICOTINE CONSUMERS 48 CHAPTER 6 REGULATORY ASPECTS OF TOBACCO HARM REDUCTION 59 CHAPTER 7 THE SCIENTIFIC EVIDENCE FOR TOBACCO HARM REDUCTION 71 CHAPTER 8 BARRIERS TO TOBACCO HARM REDUCTION 83 CHAPTER 9 THE VALUE OF ETHICS IN TOBACCO HARM REDUCTION 91 CHAPTER 10 CONCLUSIONS 96 GLOSSARY OF TERMS 99 APPENDIX A Tobacco Harm Reduction 2020 is an online, free-content publication to raise SUPPORTING STATEMENTS ON awareness and support tobacco harm reduction (THR) as a means to prevent TOBACCO HARM REDUCTION tobacco-related disease and premature death in adult smokers. Any part of the publication may be downloaded for use, and attribution is 103 APPENDIX B appreciated. TOBACCO HARM REDUCTION CASE STUDY IN THE NORTHERN HEMISPHERE (ENGLAND) Our request to readers is two-fold: first, to challenge the scientific arguments in this book, and with us help strengthen evidence-based policy. Secondly, that this content is used to empathetically support persons who smoke, who cannot or will 117 APPENDIX C not quit. Encourage them to switch from the most harmful cigarettes to less harmful, TOBACCO HARM REDUCTION CASE STUDY IN THE non-combustible nicotine-based products. SOUTHERN HEMISPHERE (AFRICA & MIDDLE EAST) This publication is dedicated to the alliance of vapers worldwide. 142 APPENDIX D THR 2020 was written collaboratively by multiple authors, for the Africa Harm TOBACCO HARM REDUCTION ADVOCACY Reduction Alliance and supported by Delon Human and Health Diplomats. GUIDE AND OBJECTION HANDLER CONTENTS__ 2 CONTENTS__ CHAPTER 1 Tobacco Harm Reduction: An Introduction The World Health Organization (WHO) states that tobacco products have caused 100 million deaths in the 20th century alone. Every year, there are seven million tobacco-related deaths worldwide, of which 80% are tobacco users in the world’s low-and middle-income countries. If current trends persist, another BILLION people are predicted to die from tobacco-related diseases during the 21st century.[1] Photo by Kelly Sikkema on Unsplash Tobacco Harm Reduction: An Introduction SMOKE KILLS, NOT THE NICOTINE Unfortunately, the public health community has been so intent on Although nicotine is the major addictive substance in tobacco products creating a “tobacco-free” world, that THR has simply not been given it is also, unfairly, given the blame for the disease and death caused by a chance. In many ways, this is the elephant in the room for health tobacco products. professionals – a truth that most know but are reticent to discuss. “It is the smoke that kills, not the nicotine” [2] HEALTH PROFESSIONALS’ CRITICAL ROLE is a refrain that you will often read in this book, because this erroneous IN REDUCING TOBACCO-RELATED HARM belief is an obstacle to reducing the harm caused by tobacco products. Another key element in the THR story is the role of health professionals, especially physicians. Health professionals play a vital It is so important to understand that the inhalation of toxicant-filled smoke, role in the health related decision-making processes of their patients. – produced by combustible tobacco products (mostly cigarettes) – is Moreover, they care for and advise many tobacco consumers. overwhelmingly responsible for tobacco-related disease and premature deaths. There is a common belief that all tobacco products are the same, This book is primarily aimed at health professionals and the active and that the risk in smoking a cigarette is the same as from chewing tobacco, passive smokers they care for. Patients and their physicians have a using Swedish style “snus” or even vaping an E-cigarette. relationship that differs from that in any other profession. In a world of information overload, patients turn to their physicians to provide them Yet, science does not support this belief. with reliable and science-based advice. The The many tobacco and nicotine products family physician also often becomes a confidante available to consumers vary widely in their and friend. The advice physicians provide to risk and functionality. “The field of tobacco smokers most frequently is to stop smoking altogether, which of course, is sound advice. This continuum of risk needs to be harm reduction (THR) researched, clarified and, most importantly, However, with more than one billion people communicated to consumers. Only then will can offer a respite smoking worldwide, it is unlikely that every individuals be able to make an informed patient who visits their medical practitioner will choice and use nicotine more wisely. to smokers who are value or heed a straightforward quitting message. SMOKE-FREE (NON-COMBUSTIBLE), unwilling or unable to COMMUNICATING TOBACCO NICOTINE-BASED PRODUCTS ARE PART HARM REDUCTION OF THE ANSWER, NOT THE PROBLEM quit smoking.” What if physicians or other attending health The field of tobacco harm reduction (THR) professionals also communicated the benefit can offer a respite to smokers who are of harm reduction to smokers? Are we not unwilling or unable to quit smoking. Several new categories of non- effectively harming patients by neglecting to tell them about other combustible, nicotine-based alternative nicotine delivery systems are potential options that are available to help them to break their habit? substantially less harmful than cigarettes. The most famous medical dictum enshrined in the Hippocratic Oath, THR science and products provide an evidence-based method for “First, do no harm”, is a vital reminder of our responsibility towards our smokers to reduce the harm caused by their use of tobacco. It does this patients. Yes, the health of the society we live in is important, but it is by incrementally substituting less hazardous products for those more also imperative that every health professional serves the best interests likely to cause harm to their bodies. of each individual patient for whom they are providing care. Photo by Caique Silva on Unsplash CHAPTER 01__ 4 Tobacco Harm Reduction: An Introduction If that patient happens to be an inveterate smoker of 30 to 60 cigarettes a day who has no intention or capacity to quit, are we not harming them by The famous dictum enshrined refraining from telling them about the concept of tobacco harm reduction and the different products KEY DETERMINANTS FOR GROWTH in the Hippocratic Oath, that can be used? This is one of the ethical issues that IN TOBACCO HARM REDUCTION ‘First, do no harm’, is a this book will cover. Tobacco harm reduction is, and will always be, about shifting tobacco users down IMPRECISE HEALTH COMMUNICATION the risk continuum to the least harmful products or as an aid to cessation. At this REGARDING TOBACCO PRODUCTS haunting reminder of our point, THR has not been universally adopted, either by public health, or by the A major obstacle for tobacco harm reduction is the consumer in the street. To some extent, this fact results from the imbalance of four responsibility towards our imprecise use of language and inaccurate information key factors: disseminated to consumers of tobacco and nicotine patients. It is imperative that products. The World Health Organization (WHO) has consistently advocated “All tobacco kills” or “Tobacco, SCIENCE: POLICY: deadly in any form or disguise”. There has been an overemphasis on (Combustible) tobacco control has we serve the best interests of the science of combustible tobacco dominated all forms of regulation, products and a lack of emphasis on especially since the adoption of the It is intended to amplify the tobacco cessation or each individual patient for the science of the safety or risks, Framework Convention on Tobacco quitting message, which is laudable, but it also functionality and efficacy of non- Control (FCTC) ignores other health promotion messages that could combustible, nicotine-based products whom we are providing care.” be communicated to both consumers and health PRODUCTS: professionals. Often, this leads to further bad choices. CONSUMERS: The most unhelpful element of The (tobacco) abstinence-only tobacco control is the lack of Imagine if we used this type of non-specific health and risk communication during the current COVID-19 pandemic. Just as message has caused confusion differentiation between the risks among consumers. Greater emphasis of different types of tobacco and not all viruses are the same, there should be a clear distinction made between the various categories of tobacco and nicotine should be placed on consumer nicotine products. Placing a greater products, and their relative risk communicated to policymakers and consumers. understanding, gaining acceptance emphasis on the development of of the reduced harm concept and innovative new nicotine products that DON’T BLOCK THE FIRE ESCAPE consequential use of new nicotine act faster and more effectively, would Health practitioners practise harm reduction every day. Consumers and patients are provided with simple health prevention products greatly benefit the growth of THR. advice on how to avoid disease or reduce harm. Mothers are advised to sterilise bottles used for feeding infants, youngsters always to wear helmets when they ride bicycles, the use of condoms is encouraged for “safer” sex and road users are warned about the consequences of the not using safety belts. Some of these recommendations are even backed up by law. Yet when TOBACCO & it comes to tobacco, it seems as if the public health community is only singing the abstinence tune. PUBLIC HEALTH NICOTINE WORLD INDUSTRIES Consider a fire breaking out in a hall containing 1.1 billion people. Officials block the fire escape doors because they cannot REGULATORY CONSUMER guarantee safety outside. POLICY TOBACCO This analogy is a rather accurate description of how tobacco control has erred in its approach to nicotine and harm reduction.