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Misconceptions about THR abound

Published : Wednesday, 3 July, 2024 at 12:00 AM  Count : 894
Dr Konstantinos Farsalinos
For countries with limited smoking cessation resources like Bangladesh, Tobacco Harm Reduction (THR) is the only viable solution for aiding smokers in quitting when other methods fail. THR is relevant now more than ever as even after six decades of established evidence, smoking remains a significant global public health issue. Unfortunately, the crucial facts about smoking are often overlooked by scientists and politicians when discussing THR. This leads to the misconception that harm reduction is part of the smoking problem rather than the solution.

Many misconceptions about THR stem from the "demonization" of nicotine. Even healthcare professionals in developed countries such as the United States, the United Kingdom and Norway, often mistakenly believe that nicotine significantly contributes to smoking-related cancer. However, nicotine is not even classified as a carcinogen (cancer-causing agent). The general populations misconceptions are even greater, complicating the debate on nicotine-containing harm-reduction products with exaggerated claims about potential risks.

The misuse of the precautionary principle, focusing on uncertain and theoretical long-term effects, is unreasonable. If this has to apply to any novel commercial or pharmaceutical products, everything would have to be banned. Besides, it is impossible to generate long-term epidemiological evidence before marketing a product. Such an approach rather prevents the generation of any evidence. In clinical practice, such widespread misconceptions keep many smokers from quitting, while proper communication and a balanced approach can lead to successful cessation through THR products. Even long-term smokers have quit by switching to THR products, supported by significant scientific evidence of their effectiveness.

It is important to emphasize the main difference between harm-reduction products and smoking, which largely determines the far lower risk potential of these products, the lack of combustion. We know since the 1970s that smokers smoke for nicotine but die from tar, meaning the products of combustion that are inhaled by the smoker. Some products such as electronic cigarettes and nicotine pouches do not even contain tobacco; they contain pharmaceutical-grade nicotine, the same nicotine that is used in medicinal nicotine replacement therapies.

Today it is absolutely clear that all tobacco harm reduction products are by far less harmful than smoking, due to the lack of combustion. But the exact quantification of the risk reduction will take many years considering that the products have not been available for many years. However, evidence is growing every day supporting the potential health benefits for smokers. As for their smoking cessation potential, this is now undisputed. High-quality research shows that they do not only increase the odds of quitting smoking but are twice as effective as pharmaceutical nicotine replacement therapies.

Its perplexing that some anti-smoking advocates oppose THR, akin to opposing seatbelts because they don eliminate, but reduce injury risk from car accidents. In an ideal world, there would be no smoking, as well as no traffic accidents and victims, no crime and no obesity, just to mention a few typical public health issues. But we neither live nor will we ever live in an ideal world! So harm reduction for tobacco is common sense. It is not different from other harm-reduction strategies and behaviors that we accept and use in our daily lives.

The initial steps in integrating THR into a national strategy of any country like Bangladesh are to follow the totality of scientific evidence, to examine success stories and failures in other countries, and to provide balanced and appropriate information about knowns and unknowns to smokers so that they can make informed decisions. Healthcare professionals need to be more focused on eradicating unjustified confusion between nicotine effects and smoke (combustion) harms. Regulators need to follow the principle of risk-proportionality for devising any regulatory framework. The higher the risk, the more the restrictions. Today, we have examples of countries that allow the sale of tobacco cigarettes and at the same time ban the sales of low-risk products such as electronic cigarettes. This is a paradox that no one can convincingly explain.

Authorities unfamiliarity with THR products fosters fear and uncertainty, yet countries such as the UK and Sweden have successfully used THR in their anti-smoking strategies. The UKs promotion of electronic cigarettes has accelerated the smoking decline, and Swedens use of snus has made it the only smoke-free country globally. The Philippines is also making strides by adapting European Union regulations.

The main challenge for any country, including Bangladesh, is to convince authorities that prohibition on THR products, while tempting, will have unintended adverse public health effects. A characteristic example of such an approach in the region is India, where the decision to ban harm-reduction products resulted in the creation of an uncontrolled black market, with the country being "flooded" with illicit products of unknown origin and quality. It is a typical case of a regulatory framework that created problems that did not exist before, an example that should be avoided.

Prohibiting THR products, as seen in India, leads to uncontrolled black markets and public health risks. Effective regulation should differentiate THR products from tobacco cigarettes regarding availability, marketing, pricing, and restrictions. Youth sales must be prohibited, while adult smokers should have easy access and financial incentives to choose THR products over cigarettes.

In conclusion, integrating Tobacco Harm Reduction into public health strategies is essential for reducing smoking-related harm and supporting smokers in quitting. Recognizing the difference between nicotine and combustion-related harms and adopting evidence-based regulatory frameworks will lead to better public health outcomes for Bangladesh.

The writer is a Cardiologist and Researcher, University of Patras and University of West Attica, Greece



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