Text by Henrylito D. Tacio
Photos from WHO and iStock
A former official of the World Health Organization (WHO) recommends that smokers who cannot stop smoking should be allowed to use alternative tobacco products (ATPs) in order for them to kick the addictive habit.
“Like many other interventions in daily life – seat belts in cars, motorcycle helmets, safe needle exchange in drug addiction, to name a few – (the ATPs can help) reduce health harms linked to smoking,” said Prof. Tikki Ella Pangestu, who used to be the director of WHO’s Department of Research Policy and Cooperation.
Smokers are more likely than non-smokers to develop heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease, according to the US-based Centers for Disease Control and Prevention (CDC). Smoking also increases the risk for tuberculosis, certain eye diseases, and problems of the immune system, including rheumatoid arthritis.
The CDC says smoking increases the risk for coronary heart disease and stroke by 2 to 4 times. The risk of men developing lung cancer if they smoke is 25 times while it’s 25.7 times for women who smoke.
ATPs can lessen the damage that tobacco brings to those who smoke “simply by reducing as much as 90% to 95%” the harmful toxins released when a smoker lights and burns a cigarette.
The American Cancer Society (ACS) says tobacco smoke is made up of thousands of chemicals. The most common ones are hydrogen cyanide, formaldehyde, lead, arsenic, ammonia, benzene, carbon monoxide, and nicotine (the addictive drug that produces the effects in the brain that people are looking for).
Statistics available showed about 110,000 Filipinos die from tobacco-related diseases each year. About 21.8% of male deaths and 9.7% of female deaths are caused by tobacco smoke. More than 23% of male deaths and 12% of female deaths are caused by tobacco.
Prof. Pangestu cites e-cigarettes (vape) and heated tobacco products (HTPs) as examples of ATPs that may help smokers quit smoking. “Vape and HTPs do not burn tobacco and, therefore, are much less harmful,” the Singaporean professor says.
Electronic cigarettes, or e-cigarettes, are battery-powered smoking devices. They have cartridges filled with a liquid that usually contains nicotine, flavorings, and chemicals. The liquid is heated into a vapor, which the person inhales. That’s why using e-cigarettes is called “vaping.”
Quit smoking (WHO) 
After quitting smoking (WHO)
HTPs, sometimes called “heat-not-burn” products, typically use an electronic heating element, which heats specially designed sticks, plugs, or capsules containing tobacco. The tobacco doesn’t get hot enough to burn.
In the United States, some vape products and HTPs have already been approved by the Food and Drug Administration (FDA) and authorized these products to be marketed.
“Through the modified risk tobacco product application process, the FDA aims to ensure that information directed at consumers about reduced risk or reduced exposure from using a tobacco product is supported by scientific evidence and understandable,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products.
Data submitted by the companies to the FDA “shows that marketing these particular products with the authorized information could help addicted adult smokers transition away from combusted cigarettes and reduce their exposure to harmful chemicals, but only if they completely switch,” Zeller added.
The ACS states on its website that “no smokeless tobacco product has been proven to help people who smoke quit.” Prof. Pangestu says otherwise. “There is lots of data,” he points out. “For example, in the United Kingdom, it is estimated that between 20,000 to 30,000 smokers quit each year when they switch to e-cigarettes. In countries where these products are available, cigarette sales are falling.”
Prof. Pangestu and Dr. Rafael R. Castillo call this concept of helping smokers to quit smoking by allowing them to use ATPs as Tobacco Harm Reduction (THR).
“THR is a strategy to mitigate the health risk in smokers who use conventional cigarettes,” explains Dr. Castillo, a cardiologist and a professor in cardiovascular medicine. “Complete smoking cessation is still the primary goal but since this cannot be achieved in the far bigger majority of smokers, particularly those who are recalcitrant, then a pragmatic middle-ground alternative should be offered to them.”
Recalcitrant smokers are those who have an obstinately uncooperative attitude towards smoking cessation. “They may show initial efforts of following the smoking-cessation programs we implement (for them), but there is an utter lack of perseverance and will to persist until the end goal of complete smoking cessation is achieved,” Dr. Castillo says.
The Filipino doctor has met some of these recalcitrant smokers in his clinic. “(We) have tried all known measures of convincing them, that is, by persuasion, motivation, even combining them with threats on the health hazards they are likely to develop if they do not stop smoking.”
At best, “we are only successful in around three out of 10 cases,” Dr. Castillo admits.
When the coronavirus disease 2019 (COVID-19) hit the country, Dr. Castillo and his fellow doctors changed their strategy. “Majority of our recalcitrant smokers have smoking histories of more than 20 pack years, and already have mild to moderate chronic obstructive pulmonary disease, which is a major risk factor for developing severe COVID-19,” Dr. Castillo reports.
They tried to find a middle-ground for recalcitrant smokers, and they settled for HTPs. “Based on (available studies), the amount of toxic substances a smoker gets is up to 95% less, compared to traditional tobacco smoking,” he reports.
To get first-hand information, Dr. Castillo and his research group at the CardioMetabolic Research Unit (CaMeRU) of the FAME Leaders Academy conducted two systematic reviews and meta-analyses.
“(Our study showed) there is an improvement in some cardiovascular risk factor parameters such as less increase in heart rate, higher high-density lipoprotein (good cholesterol) and less constriction of arteries,” Dr. Castillo says. “Another study also showed significantly reduced harmful elements commonly obtained by conventional cigarette smoking.”
Heated tobacco products (Wikiwand) 
Lung with cigarettes (WHO)
Unfortunately, there is no data yet that will prove HTPs could help smokers quit smoking – as studies require a longer time period for these to be conducted. But based on modeling techniques and considering the beneficial effects of THR with alternative tobacco products, Dr. Castillo believes “millions will be quitting cigarette smoking and scores of thousands of lives will be saved annually with reduction of smoking-related complications.”
Recently, the Philippine Senate passed a bill that would legalize and regulate vaping and HTPs. It likewise eliminated the authority of the Food and Drug Administration over these products. The Vaporized Nicotine Products Regulation Act (SB 2239) was approved by a vote of 19-2, with two senators abstaining.
All these recent developments are taken into consideration by Prof. Pangestu and Dr. Castillo.
“These regulations are badly needed to facilitate wider use and access to these products to those smokers who want to quit,” Prof. Pangestu said.
“Regulation through legislation is crucial to make sure the use of HTPs and e-cigarettes redound to the benefit of public health,” Dr. Castillo says, adding that violations should be clearly defined, and there should be corresponding penalties. Under- and over-regulation will not be good, he adds.
The alternative tobacco products (ATPs) should not be made available to non-smokers, pregnant women, and, most especially to young people. “The main targets are smokers who want to quit, but, unfortunately, it has also become a fashionable trend among youth,” Prof. Pangestu cautioned.
In the Philippines, recent studies showed four in 10 students reported ever smoking cigarettes. Approximately one in 8 students who had smoked cigarettes reported smoking their first cigarette before age 10.
“These ATPs should be off-limits to the youth and those who are currently not smoking,” Dr. Castillo points out. “ATPs should also be subjected to appropriate sin taxes so it’s beyond the financial reach of the youth. ATPs should not be allowed to be promoted or advertised.”
Dr. Castillo also urges health officials to prevent the youth from joining the ranks of smokers. “The evil of smoking must be included in the curriculum of elementary and high school,” he suggests. “Teaching by example is also very important. Children tend to follow what they see their parents do. Smoking parents should refrain from letting their highly impressionable small children see them smoke.”
Dr. Castillo believes the battle against smoking is a long fight. “It may be a Pollyannic or blindly optimistic goal to completely eradicate cigarette smoking with ATPs, but even just a 10% reduction in smokers annually can go a long way in saving lives,” he says.
Prof. Pangestu said that ATPs should be promoted along with other options. “We need to see vape and HTPs as a complement to other available options such as education, quit lines, counseling and education and nicotine replacement therapies (such as nicotine patches, gum, and nasal sprays among others).”
Quitting smoking may be a herculean task, but it can be beaten. And doing so can have several health benefits.
“It’s never too late to give up smoking,” Dr. Castillo reiterates. “Some benefits like breathing more freely, less shortness of breath and less fast heart rates and increased blood pressure on exertion can be obtained in a matter of days or few weeks after cessation.”
Other changes in the heart, lungs, and arteries, he says, may take a longer time to improve, but at least the deterioration is already slowed down.
“There may be permanent damage in some long standing smokers that may no longer be reversible but the risk of developing complications subsequently like stroke and heart attack is significantly reduced after giving up cigarette smoking,” Dr. Castillo assures.
