Harm Reduction in Tobacco is a global possibility

The forum was addressed by four speakers: Prof. David Khayat, the Head of Medical Oncology Department at Hospital in Paris and also Professor at the University of Pierre and Marie Curie; Dr. Efrain Cambronero Moraga, a leading specialist in medical oncology at the Costa Rica Cancer Center; Prof. Georgi Momekov, Chairman of the Bulgarian Scientific Society of Pharmacy and lecturer in the Department of Pharmacology, Pharmacotherapy and Toxicology at the Faculty of Pharmacy of the Medical University of Sofia; and Dr. Rada Prokopova, Head of the Cardiology Section and Biomedical Engineering at the European Society of Cardiology/Hypertension.

The conference came against the backdrop of the decision by the U.S. Food and Drug Administration (FDA) authorizing marketing of the Philip Morris IQOS Tobacco Heating System with ‘Reduced Exposure’ on July 7th 2020.

It featured presentations and Q&A panel discussions, centered around latest scientific evidence backing smoke-free products as better choices for smokers who would otherwise continue smoking, public health policies in tobacco and nicotine, tobacco harm reduction strategies in the 21st century and the latest regulatory decisions on smoke free products, such as the Philip Morris IQOS Tobacco Heating System with ‘Reduced Exposure’.

In his opening remarks, the moderator, Prof. Borislav Georgiev, Head of Cardiology Clinic at National Cardiology Hospital, Sofia, Bulgaria said: “Despite countless attempts of many countries to reduce smoking incidents, it continues to be one of the main factors for many diseases and affects all organs in the human body. It is therefore not a coincidence that global health systems are coordinated to reduce its effects and fatal consequences. Smoking causes serious harm and we, as doctors, have to do something to tackle this problem that doesn’t only affect distinct smokers but the whole global population which includes both active and passive smokers”.

On his part, Prof. David Khayat, highlighted facts from rigorous research and proven evidence of tobacco harm, effects and the possibility of smoking being one of the main causes of cancer in the global population.

“Since 1990, when smoking was first discovered as a risk factor for cancer, the upshots remain the same even after 20 years. This has led to 100,000 deaths every year that can be attributed to smoking-related diseases and the existing policies for tobacco harm reduction don’t seem to be effective. To understand danger of smoking, we need to understand the process. Burning tobacco generates smoke which contains more than 6000 chemicals and ultrafine particles of which 93 are listed by the U.S FDA as Harmful and Potentially Harmful constituents (HPHCs). Almost 80% of these are carcinogens or potential carcinogens and we have proof that the more time one is exposed to chemicals and carcinogens the higher their risk of developing cancer”.

Prof Khayat explained that although risk reduction has not yet been demonstrated, a substantial and measurable reduction in morbidity and mortality is reasonably likely in subsequent studies if active smokers take on new less harmful products.

“The innovation of tobacco and e-cigarettes can lead to a path of new and safer alternatives for the smokers than can’t or don’t want to stop smoking,” he added.

Dr. Efrain Cambronero gave a brief on tobacco harm reduction in the 21st century and how it can save lives.

Dr Cambronero stated: “The Tobacco Harm Reduction Concept is the hottest and divisive issue in the tobacco control camp /landscape nowadays. Studies show that almost 80% of the approximately 1.3 billion tobacco users worldwide are from low and middle income countries while 8 million deaths are expected by 2030 due to tobacco-related diseases worldwide thus the morbidity and mortality rate induced by tobacco smoking which has caused a tremendous financial burden to many countries health care system”.

What can be done to decrease morbidity and mortality induced by tobacco use?

This is how the Concept of Tobacco Harm Reduction was born. The goal is to lower the health risks to individuals and wider society associated with using tobacco products. However, there are still many criticisms against the concept, some of which include continued promotion of an addictive substance (nicotine), unproven long term safety, unclear efficacy for smoking cessation and reduction and gateway to attract the youth.

“All these arguments are valid, as we need to remember that all forms of tobacco are hazardous and there is no safe level of exposure. There is no magic wand to make people quit smoking but we should use everything at our disposal to prevent smoking initiation and to help smokers quit ” said Dr. Cambronero, citing smokeless tobacco products among the less toxic products. There is a need to promulgate clear information on existing science-based alternatives, according to Dr. Cambronero

Prof. Georgi Momekov stated that although nicotine is the main cause of addiction, however it is the “toxicants associated with burning that are the primary cause of smoking-related diseases. The high temperatures in the lit end of a burning cigarette, above 600C, cause a large number of chemical reactions to take place, breaking down the tobacco into the thousands of chemicals that appear in cigarette smoke. Many are considered harmful, and together they are recognized as the main cause of smoking-related diseases. A significant number of them are toxic (poisonous) and can damage our cells and many of them are carcinogenic (cause cancer). One of the most dangerous is the  carbon monoxide. This is a poisonous gas. It has no smell or taste plus the body finds it hard to differentiate carbon monoxide from oxygen and absorbs it into the bloodstream. Everything we smoke goes straight to the lungs,” he explained.

Comparing cigarettes against IQOS, he clarified that traditional cigarettes contain tobacco, nicotine and through burning produce smoke while heated tobacco products such as IQOS contain natural tobacco and nicotine and heat the tobacco to produce an aerosol (vapour) instead of smoke. In addition, they are the only ones officially recognized by the Food and Drug Administration (FDA) as reduced risk products. They work through an electronically controlled sheet that precisely heats a specially designed tobacco bar at temperatures below 350°C. The experience lasts about 6 minutes or 14 inhalations, similar to a cigarette. The carbon monoxide exposure from IQOS aerosol is comparable to environmental exposure, and levels of acrolein and formaldehyde are 89% to 95% and 66% to 91% lower than from combustible cigarettes, respectively. This data, Dr Momekov said, has been verified by independent studies and although there is still a lot of work to be done, IQOS is a reference example.

The last discussion was led by Dr. Rada Prokopova, a specialist in cardiology, hypertension and heart failure. Her take was on the same path as the other speakers. She expounded on real life data from her cardiology practice, stating that few people realize that toxic irritants are associated with cardiovascular and respiratory diseases, while symptoms such as memory loss and anxiety come as a result of the smoking addiction.

“There is not a single doctor who has not tried to persuade their patients to stop smoking, but it is a very difficult problem to solve. The current alternatives for smoking cessation as heating tobacco products are leading the way to meet the needs of people who cannot quit smoking by reducing their exposure to toxic substances,” Dr Prokopova added.

Summarising the rationale for the Harm Reduction Strategy Dr. Efrain Cambronero said

Harm reduction can work anywhere. It can be implemented in any country, but the regulators have to adapt their control programs because people who don’t want to quit nicotine because they are addicted need highly advanced measures. This approach might be more helpful in low income countries where the mortality rate can be reduced but this method needs a lot of years to work. For a tobacco program to be successful we need to reduce morbidity and mortality among smokers, unwilling or unable to quit and prevent addiction to a whole new generation of tobacco products. Unfortunately, tobacco consumption around the world is still prevalent and in certain areas is growing. I can’t foresee change in the near future so I guess, this is the best strategy we could come up with for now but there is still a lot of work to do for us as doctors. Tobacco Harm Reduction can diminish the negative effects for health but it is still a discussion because IQOS or other similar products might help but we need more evidence and time.”

Regarding the impact of FDA’s decision, Dr Cambronero clarified: “IQOS is already in many markets. Everybody sees this organization (the FDA) as a reference point. So this big decision will push the product spread in many other markets. The FDA made it clear that they didn’t endorse IQOS as a safer alternative, but it is clear that it has less exposure to harmful substances. What is important to mention is that this product is aimed at adults who want to quit smoking and not at young people.”

Prof. Borislav Georgiev closed the conference, stating that: “I would just like to add that there is currently a lot of speculation about tobacco use and its link to COVID-19. While some claim that smoking can protect against the virus, others hypothesize that smokers are at greater risk of contracting the disease. We must be very careful with these statements and be very cautious, we do not have enough information to test the hypotheses that have emerged”.

From the discussions, it is clear that quitting tobacco smoking is by far the best option. However with such enthusiasm from medical professionals and other concerned stakeholders to protect the global population from tobacco smoking effects, could emerging innovations with reduced exposure be the hope for both active and passive smokers globally? Given scientific studies identifying the innovations as containing less toxic chemicals while delivering nicotine in levels close to combustible cigarettes, does this suggest likelihood that users of smoke-free products may be able to completely transition away from combustible cigarettes?