In the fight against the harmful effects of tobacco over several decades, there has been real progress, although slow and incomplete. This observation has, over the past several years, pushed the public health community to ideological reform. The paradigm of abstinence as the single solution has been overturned, in favor of a risk-reduction approach consisting of promoting “intermediate” behaviors: less satisfying than stopping completely, but generating a substantial health benefit.
Harm reduction: from AIDS to tobacco
Historically, the risk-reduction debate experienced a turning point at the time of another scourge: AIDS. In the 80s, when the epidemic was raging, certain conservative regions of the United States favored the promotion of abstinence, particularly in schools. The reasons were religious: sex outside of marriage was reprehensible whatever the situation may be, and condoms were rejected by many churches. In the same period, the drug addict community paid a heavy price to the epidemic, due to the frequent sharing of needles. Even then, for moral (and political) reasons, repression was prioritized.
But certain dissonant voices started to make themselves heard. While recognizing that abstinence is the best protection against AIDS (and also against unplanned teenage pregnancies), public health authorities called for the education of young people in the use of condoms. While not perfect, particularly if used improperly, they represent a lesser evil. And recognizing that the heroin epidemic is a scourge, numerous associations have called for help with used needle exchanges and supervised injection sites, so as to not add disease on top of addiction.
Smokeless cigarettes are safer than combustible tobbacco
Reducing risks, even if it is not ideal; and abandoning a moralizing position and “settling” for a lesser evil: the intellectual bases of a new doctrine have been laid down. With the arrival of e-cigarettes, the debate on the struggle against tobacco addiction has taken a new shape. This is because we have long understood that it is the nicotine that makes smoking addictive, and it is the tar and the numerous chemical components present in burning smoke that cause cancer and death. As the tobacco specialist, Michael Russel, stated concisely in 1976: “People smoke for the nicotine but they die from the tar.”
From this point of view, independent scientific research is unambiguous. A point of view summarized by Kenneth Warner, University Professor of Public Health and Former Dean of the University of Michigan School of Public Health, during a Forum on E-cigarettes at the School of Public Health Harvard, in April 2015: “We know that these alternative products, when compared to the dangers of combustible tobacco products, are dramatically less dangerous. There’s just no question about that.”
A recent study published in the key journal, Tobacco Control, and conducted by academics from Georgetown University Medical Center, furthermore concluded that more than 6.6 million lives could have been saved in the United States if current smokers were encouraged to switch to e-cigarettes. A far-reaching conclusion, which prompted David Levy (one of those responsible for the study) to say that the “Old policies need to be supplemented with policies that encourage substituting e-cigarettes for the far more deadly cigarettes”. Other common estimates from various scientific sources also contribute to the assertion that e-cigarettes represent a risk reduction of 95% in comparison to a burning cigarette. Not ideal, but surely a lesser evil.
Heat nor burn: a reduced risk product too
Among e-cigarettes, the “heat-not-burn” products occupy a special place. Because they do not burn tobacco, they do not produce smoke or tar from combustion, all the while offering an experience very close to the traditional cigarette. In a continuum going from the traditional cigarette to the complete stopping of tobacco, they are presumably positioned somewhere close to the liquid e-cigarette, but where? Several recent studies have attempted to clarify this.
As chance would have it, two governmental scientific organizations have just published results, a few days apart, from extensive studies specifically focused on heat-not-burn products.
The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (CoT) is “a UK independent scientific committee that provides advice to the Food Standards Agency, the Department of Health and other Government Departments and Agencies on matters concerning the toxicity of chemicals.” Its last mission statement was “to assess the toxicological risks from novel heat-not-burn tobacco products, and compare these risks to those from conventional cigarettes.” It delivered its report on December 12, focused on the two products available in England: the IQOS by Philip Morris and IFUSE by BAT.
While bearing in mind that any comparison remains clearly in favor of total tobacco cessation, the CoT experts indicate that “it was recognized that these products [heat not burn] could provide harm reduction for people who would otherwise smoke cigarettes” and that:
“There would likely be a reduction in risk for conventional smokers deciding to use heat-not-burn tobacco products instead of smoking cigarettes.”
(report of the Committee on Toxicity)
The CoT also took a position on passive smoking and smoking during pregnancy. For the former, the experts logically join the majority of studies already conducted on the subject of e-cigarettes, very favorable in comparison to smoking cigarettes: “A reduction in risk would also be experienced by bystanders where smokers switch to heat-not-burn tobacco products.” For pregnant women, of course, total cessation must be aimed for (because nicotine is harmful for prenatal development), but the CoT notes that in the event of failure to stop, heat-not-burn would likely represent a reduced risk on the grounds of the absence of smoke from combustion.
In summary, the CoT concludes its analysis by indicating that “the exposure to compounds of concern in using heat-not-burn tobacco products is reduced compared to that from conventional cigarette smoke. It is likely that there is a reduction in overall risk to health for conventional smokers who switch to heat-not-burn tobacco products.”
At the same time, the German Federal Institute for Risk Assessment (BfR) led some laboratory research to analyze the results provided by Philip Morris International, manufacturer of the IQOS. The BfR is a scientific research organization dependent on the Federal Ministry for Food and Agriculture, and “has the task of providing scientific advice to the federal government on issues relating to food safety, product safety, chemical safety, contaminants in the food chain, animal protection and consumer health protection.”
Prior to the complete publication of the results, the BfR communicated the key points of its report to the press. Firstly, the scientists indicated that their results “largely coincide” with the studies conducted by PMI, a detail that had been eagerly awaited. Indeed, due to the checkered past of the tobacco industry with the scientific community, the studies produced by PMI were received with an understandable suspicion, even if renowned scientists had supported certain analyses.
Overall, the BfR (in parallel with the CoT analyses) states that its research has allowed it to conclude that “it is likely that a significant reduction in the release of substances suspected of harming health will be associated with lower health risks compared to conventional cigarettes.” All the same, the German organization does not intend to encourage consumers to switch to such products on the whole.
Towards a new paradigm?
These publications mark a watershed. From here on out the “burden of proof” switches sides. In demonstrating that heat-not-burn, like traditional e-cigarettes, represents a risk reduction in comparison to burning cigarettes, the independent scientists have reshuffled the cards.
For supporters of harm reduction, the situation is clear. In this public health continuum between total abstinence (often impossible) and traditional cigarettes (and its millions of deaths), heat-not-burn introduces new products for smokers who wish to minimize the impact on their health, and for those who feel unable to stop. More specifically, it becomes more and more difficult to not recognize that, in terms of public health, e-cigarettes and heat-not-burn are positioned far closer to abstinence than the cigarette on this theoretical line. Allowing nicotine, and eliminating smoke from combustion in the long term, seems a reasoned and reasonable choice, with demonstrative and overwhelming health benefits.
On the other hand, for the supporters of an endgame consisting entirely of complete global tobacco cessation, it is now down to them to demonstrate that the public policies they support (on price, plain packaging and all other levers) are more effective than a strategy of harm reduction. And judging by the track record of the struggle against tobacco to date, one has every right to doubt it.