Need to reimagine tobacco control, harm reduction: Dr Peter Harper

Tobacco harm reduction products
The world plagued by tobacco-related illnesses needs novel harm reduction strategies to fight smoking and its consequences

In the battle against tobacco-related illnesses, it is important to explore the views that challenge the conventional approaches to tobacco harm reduction. Drawing from a background steeped in medical expertise, the call for innovative strategies to address the global tobacco epidemic opens a new chapter in the public health discourse.

The awareness about tobacco-related diseases increased during the era when small cell lung cancer cast a pall over the medical community, offering patients a grim prognosis. While advocating for smoking cessation was a clear imperative, the spectre of addiction loomed large. Through affiliations with pharmaceutical companies and extensive involvement in clinical trials, valuable insights into harm reduction emerged, born out of a genuine desire to prevent cancer, rather than treating its catastrophic consequences.

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Why harm reduction techniques

At the heart of the advocacy for harm reduction lies an emphasis on identifying the sources of carcinogens and implementing measures to reduce exposure through behavioural changes. Smoking, it is unequivocally stated, remains the primary risk factor for lung cancer. Although environmental pollution compounds this issue, the persistent smoking habits of a significant portion of the population necessitate a more in-depth examination of the composition of smoke and the carcinogenic components within.

Studies reveal that a significant portion of individuals diagnosed with lung cancer continue to smoke. The complexities of addiction and the profound stress involved often render quitting an insurmountable challenge. This presents a sizable number of individuals who either cannot or will not quit, emphasising the need for a nuanced and multifaceted approach.

It becomes abundantly clear that unless we address the prevalence of smoking, we cannot hope to reduce the incidence of cancers and chronic respiratory diseases. This serves as the clarion call for innovation in tobacco harm reduction — a call that is growing ever more urgent. But what innovative measures can be deployed to combat this enduring issue?

Globally, a staggering one billion individuals are at risk due to tobacco use — an untenable burden that no nation can afford. The solution, as postulated, lies in harm reduction, a concept deeply ingrained in various aspects of our daily lives.

Crucially, it is important to dispel a common misconception. Nicotine, although highly addictive, is not a carcinogen. Nicotine replacement therapy (NRT) has long been a tool employed under medical supervision to facilitate smoking reduction. However, the question remains: what alternative strategies can be explored? Three distinct strategies emerge as noteworthy: snus, e-cigarettes, and heated tobacco products.

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Harm reduction alternatives

Snus, an oral tobacco product, offers a stark departure from its more perilous counterparts. Lacking heavy metals and subjected to pasteurisation, snus provides nicotine without the destructive force of combustion. The compelling case study of Sweden reveals a noteworthy reduction in smoking rates, attributable in part to snus.

The advent of e-cigarettes and vaping serves as an amplification of the harm reduction narrative. Public Health England boldly asserts that vaping is at least 95% less harmful than traditional smoking—an assertion that still eludes mainstream awareness.

Enter heated tobacco products, epitomised by iQOS. These innovations, by heating tobacco rather than incinerating it, yield significantly fewer toxicants. The Japanese experience with iQOS tells a compelling story: a remarkable decrease in cigarette sales paralleled by a reduction in smoking-related diseases.

As the war against smoking and its attendant public health challenges, prominently cancer, continues unabated, the need for innovative harm reduction strategies grows ever more pressing. While the ultimate goal remains smoking cessation, it is evident that such approaches are vital. The current status quo has proven insufficient in curbing smoking prevalence. The time has come to embrace these novel solutions, navigating the complex terrain of addiction and carcinogenic exposure. With these efforts, we aspire to relegate tobacco-related diseases to history.

In the battle against tobacco-related afflictions, we stand at a crossroads infused with the wisdom of those dedicated to public health. The need is to illuminate the path forward in our struggle for tobacco harm reduction. Emphasising the imperative of innovation, we unveil an arsenal of strategies such as snus, e-cigarettes, and heated tobacco products. These alternatives, rooted in meticulous research and bolstered by the discerning eye of public health authorities, offer not a mere palliative but a potent force against the grip of addiction and the spectre of carcinogens.

This call beckons us to challenge the status quo to venture beyond conventional boundaries, and to bridge the chasm between addiction and cessation. In this era of tobacco harm reduction, we are called to recognise nicotine addiction without vilifying it as the harbinger of cancer. We must seize the opportunity to liberate those ensnared by addiction while navigating the labyrinth of carcinogens.

(Dr Peter Harper is a medical oncologist and a founding partner of the London Oncology Clinic. This article is the edited transcript of Dr Harper’s presentation at a roundtable on Lung diseases in the post-Covid era – Challenges for India, organised by Policy Circle at the India International Centre on September 23.)