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Safer alternatives to tobacco cigarettes


Text by Henrylito D. Tacio

Photos taken from medicalydaily.com and iqos.com

Smokers who want to quit smoking can find an ally in electronic cigarettes (e-cigarettes).

“E-cigarettes are way less harmful than cigarettes, and they can and do help smokers switch if they can quit,” Dr. David Abrams, a New York University professor of social and behavioral sciences in the College of Global Public Health, told CBS This Morning Tony Dokoupil.

E-cigarettes, which Public Health England describes as “at least 95% less harmful than tobacco cigarettes,” are battery-powered devices that release a vapor of flavored nicotine from a liquid heated by a coil.

Research on it is mixed. But in the last three to four years, science has gotten strong. “Probably the most powerful study is the randomized trial which is the gold standard that showed that in 12-month follow-up e-cigarettes doubled the successful quit rate among smokers compared to nicotine replacement therapy,” said Dr. Abrams, who has researched smoking cessation for 40 years.

A study conducted in 2019 showed that 19% of participants who used e-cigarettes to quit smoking were no longer smoking a year later. In comparison, those who used nicotine replacement therapy quit smoking at a rate of 9%.

Nicotine replacement therapy, which is approved by the US Food and Drug Administration (FDA), is a treatment to help stop smoking. It uses products that supply low doses of nicotine. The goal of therapy is to cut down on cravings for nicotine and ease the symptoms of nicotine withdrawal.

The Geneva-based World Health Organization (WHO), however, considered e-cigarettes “harmful” and called for better regulation for their use. But Dr. David Abrams said that anti-vaping policy and rhetoric might do more harm than good by preventing cigarette smokers from switching to the safer alternative.

“Completely discouraging vaping, without also discouraging smoking, is doing more harm than good,” Dr. Abrams said. Vaping is the term used for e-cigarette smoking.

But there’s a better device than e-cigarettes. “Heat not burn” or “smokeless tobacco” products are electronic devices that, unlike e-cigarettes, contain tobacco. The tobacco is heated to a high temperature without setting it alight and creating “smoke” that the user sucks in.

Because the tobacco is heated and not burned, the average levels of harmful chemicals which tobacco contains are significantly reduced compared to cigarette smoke.

“There’s some evidence that ‘heat not burn’ products may be less harmful than smoking,” explained Dr. Ed Stephens, a researcher at the University of St. Andrews in the United Kingdom, whose work has compared the health impact of tobacco, e-cigarettes, and heat tobacco products (HTPs).

Dr. Rafael R. Castillo, a cardiologist with the Manila Doctors’ Hospital, considers HTPs as “a pragmatic middle ground” for smokers, particularly those who are described as “recalcitrant.” 

Unlike nicotine replacement therapy or e-cigarettes, HTPs still contain tobacco. As such, it still has a degree of addiction. So much, so that legislative and regulatory control measures are necessary to prevent the youth and nonsmokers from being “seduced” into trying them.

“These regulatory measures should not be more stringent than what are currently imposed on tobacco smoking since it would defeat the purpose of getting current smokers out of this deadly device,” says Dr. Castillo, who led a study on HTPs at the time when the country was experiencing the coronavirus disease 2019 (COVID-19) pandemic.

Some heated tobacco products

Collaborators of the study were Marie A. Barrientos-Regala, Ma. Joan Dymphna Reaño, and Reginald Arimado. All three are connected with the cardio-metabolic research unit of the Makati-based FAME Leaders Academy.

“Smoking and COVID-19 definitely make a killer combination leading to a complicated clinical course and worse outcomes,” said the study, which was published in Cardiology and Cardiovascular Medicine journal.

A total of 1,726 patients were involved in the study. The majority of them have smoking histories of more than 20 pack-years and have mild to moderate chronic obstructive pulmonary disease (COPD), a major risk for developing severe COVID-19.

The researchers know that it would be hard for these recalcitrant smokers to quit smoking. “Our main goal is still to make them quit (smoking) permanently,” Dr. Castillo said. “From a non-negotiable policy, we have decided to shift to whatever pragmatic middle-ground we could find for recalcitrant smokers.”

One patient told them about HTPs. They conducted some research on it, and after some thorough investigation, they allowed their smoker-patients to shift to this alternative, “but always reminding them that quitting smoking is the ultimate goal.”

“The jury is still out on its long-term benefit or harm,” Dr. Castillo said. “From where we stand now, HTPs appear to be a relatively less harmful middle-ground than traditional smoking.”

The United Nations health agency admitted that there is no available evidence to conclude whether HTP use is associated with any long-term clinical outcome – positive or negative – from exposure to the mainstream or secondhand emission.

With current data, it looks evident that HTPs are likely less harmful than traditional smoking but are still more harmful than not smoking. “This has to be thoroughly discussed with an open mind by not only the medical or scientific community, but the legislators and regulators as well,” Dr. Castillo urged. “After all, the lives of tens of millions of recalcitrant smokers may depend on the options we offer them if they really cannot quit smoking.”

Dr. Castillo and his research team agreed that HTPs should not be recommended among the younger generation and those who have not smoked yet.

“HTPs are better alternatives to cigarettes but not completely risk-free so minors should not use them,” concurred Dave M. Gomez, communications director of PMFTC Inc., an affiliate of the Philip Morris International, Inc.

The core of the matter is nicotine, which is highly addictive. “(Nicotine) causes you to crave a smoke and suffer withdrawal symptoms if you ignore the craving,” said Dr. Michael Joseph Blaha, director of clinical research at the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, in a statement.

Since nicotine is a toxic substance, there is where legislation and regulation come in. “It is essential to have a strict but balanced regulation,” Dr. Castillo and his team said. “Strict control measures must be put in place to prohibit sales of HTPs to nonsmokers and youth.”

As for current smokers, they “must be given free choice to shift to it, if they wish to, and especially with the guidance of their physician,” Dr. Castillo suggested.

Although HTPs are smoke-free, Dr. Castillo believed they should not be allowed in public. “Although the harmful particulate pollution they cause is relatively less compared to passive cigarette smoking, the potential harm to secondhand smoke could not be completely discounted,” he said. 

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