Spreading the word

This year’s Global Forum on Nicotine focused on how to take tobacco harm reduction mainstream.

By Stefanie Rossel

The sixth edition of the Global Forum on Nicotine (GFN), which took place in Warsaw, Poland, June 13–15, was once again the meeting point for multiple stakeholders, ranging from consumers and scientists, regulators and manufacturers to distributors, public health professionals, policy analysts and parliamentarians.

The theme of this year’s event, “It’s time to talk about nicotine,” examined how attitudes toward the use of nicotine are changing and considered some of the compound’s potentially beneficial uses. The three-day conference started with several satellite meetings that focused on topics such as the demystification of scientific modeling and the integration of tobacco harm reduction (THR) into everyday healthcare.

Being staged for the third time, the International Symposium on Nicotine Technology informed participants about the latest technological advances in the rapidly changing landscape of nicotine-delivery systems. Again, the GFN was accompanied by a film festival, which focused on the turnaround in New Zealand, where vaping has been acknowledged as a quit-smoking tool, and the role of nicotine around the world. Alongside the symposium, scientists provided poster presentations of the results of their work related to nicotine and smoking cessation.

The plenaries and partly parallel sessions of GFN 2019 investigated how reduced-risk products (RRPs) could best be taken mainstream, not only in geographical and socioeconomic terms but also with regard to vulnerable and hard-to-reach groups of society. The event made it clear that regulation will be key to the success of THR.

In order to shape realistic regulation of tobacco products and RRPs, however, GFN speakers agreed that a broader base of scientific evidence will be required. The harms and risks of nicotine are an essential consideration in assessing the public health impact of nicotine-based harm reduction. One of the science plenaries hence looked into understanding the effects of nicotine on the human body and the psyche.

Public perceptions of nicotine are at best cautious but mostly negative. Government positions on the substance and its delivery systems vary widely around the world. In the U.K., vaping is endorsed as a means of quitting in the “Switch” campaign. The United States is focusing on the prohibition of flavors in e-liquids. China, on the other hand, is the world’s largest producer of e-cigarettes, but vaping prevalence remains low there.

Smokers use nicotine because it offers positive effects. Nicotine can potentially affect every organ system of the body since it mimics the neurotransmitter acetylcholine. As numerous studies have shown, the substance provides a number of benefits, including anxiety relief, increased alertness and improved cognitive function. Without combustion, long-term nicotine use, while not harmless, is much less hazardous than cigarette smoking. The harms of long-term nicotine inhalation without tobacco combustion have not been determined yet and need to be studied. Major safety concerns for nicotine are related to addiction, cardiovascular disease and reproductive toxicity.

Despite these negative effects, experts generally have no concerns if smokers switch to e-cigarettes and stay with them for the rest of their lives. After all, nicotine-replacement therapy (NRT) products have been accepted as safe and an effective means to wean smokers off combustible cigarettes. This gives reason for hope that in a second step, vapor products will become acknowledged as the new, better products for smoking cessation. According to studies, even dual use could translate into significant harm reduction.

Correct research needed

To accelerate the cause of THR, it is essential to reverse the proliferation of junk science, according to GFN participants. Riccardo Polosa, director of the Center of Excellence for the Acceleration of Harm Reduction at the University of Catania, Italy, called for a resurrection of vigor in THR research. He singled out preclinical in vitro research and animal studies, clinical research, and epidemiology surveys as areas where corrective measures were needed.

To improve the quality of science, Polosa suggested taking advantage of big data and the internet of things. This would permit researchers to capture real-time data and create a cloud platform for behavioral research. Additionally, he recommended creating an expert working group to draft international guidelines setting recommendations for better, high-quality studies.

Brad Rodu, a professor of medicine and holder of the Endowed Chair of Tobacco Harm Reduction Research at the University of Louisville, Kentucky, USA, warned against forever preserving historical, flawed studies. He cited a 1981 U.S. study linking smokeless tobacco to oral cancer that triggered an enduring campaign against the entire product category. What is not widely known, according to Rodu, is that the researcher looked at powdered dry tobacco—a rare product used by only a handful of people. Even though subsequent studies found different results for more commonly used smokeless tobacco products, the findings of the 1981 study continue to taint the entire category.

Of good and bad examples

Almost two decades after the invention of the e-cigarette, the international perspectives of THR differ greatly. Japan, where heat-not-burn (HnB) products were introduced in 2014, continues to stand out as an example of risk reduction in action. According to Hiroya Kumamaru, vice director of the AOI Universal Hospital in Kawasaki, Japan, overall tobacco consumption kept decreasing in 2018 as cigarettes were quickly replaced by HnB products.

Cigarette consumption dropped from 197 billion units in 2012 to 133 billion sticks in 2018, whereas retail volume of HnB consumables stood at 34 billion in 2018. Studies in Japan have not shown evidence of a “gateway effect,” where users of HnB products migrate to combustible cigarettes. Nevertheless, physicians see even more potential in e-cigarettes—which are currently banned in Japan if they contain nicotine—as smoking cessation tools.

In the U.K., vapor products have been officially recognized as cessation tools, but many health professionals remain reluctant to support would-be quitters with e-cigarettes. At the other end of the scale is Australia, which takes a dim view of tobacco harm reduction. Despite its strict tobacco control policies, including plain packaging and the world’s highest cigarette prices, Australian smoking rates have not significantly declined since 2013. According to Alex Wodak, president of the Australian Drug Law Reform Foundation, 15.2 percent of Australian adults still smoke compared with 16 percent in 2015.

At the same time, Australia permits the sale and use of nicotine liquid only with a prescription—but doctors are hesitant to prescribe nicotine liquids because vapor products are regulated as tobacco products. Violators face fines of up to aud45,000 ($30,923) and two years in prison. In 2016, only 1.2 percent of adult Australians vaped, with 0.5 percent vaping daily.

An example of how increased consciousness of THR can be implemented in a low-income country comes from Malawi (also see “A Blank Slate,” Tobacco Reporter, June 2019), where social scientist and THR advocate Chimwemwe Ngoma has installed an information dissemination project on THR and science. One of its targets has been to source and disseminate evidence-based information on THR to the general public. The project has succeeded in igniting THR discussion in the African state. The project has created more than 15 partnerships with organizations and individuals.

Reaching the hard to reach

While bringing THR to lower-income countries will be a major challenge in the future, higher-income countries in which RRPs are already present are confronted with the question of how to best get safer nicotine products to vulnerable and hard-to-reach populations, which tend to have higher rates of smoking than other parts of society.

As Kevin McGirr, clinical professor at the University of California San Francisco School of Nursing, explained, it is vital to understand the meaning and the culture of smoking in these communities and to take a psychological and neurobiological approach. In contrast to the middle-class white population where the peer pressure to quit smoking is continuously growing, people from vulnerable populations, especially those with mental health issues, face less such pressure. In these communities, THR takes on another dimension, circling around questions such as how far mentally challenged people can handle vapor products as well as around questions regarding access and cost—and what happens if a program to make these populations switch to e-cigarettes ends?

Sarah Cox, trial manager at the London South Bank University’s Centre for Addictive Behaviours Research, looked at smoking and homelessness in the U.K. and found that smoking is considered a “nonissue” as there are so many other problems, meaning that the more problems a person seems to have, the less cessation help they will get. A positive outcome in THR, Cox’s studies have shown, is increased by person-to-person contact with the cessation helper as well as behavioral support. Barriers include an underestimation of the clients’ desire to change and little faith in their recovery on the helpers’ side; on the smokers’ side, contact with other smokers is the biggest obstacle.

Rebecca Ruwhiu-Collins, THR lead for New Zealand’s only indigenous Maori public health unit owned by tribes, presented her strategy to help the Maoris switch to RRPs. New Zealand is aiming to be smoke-free by 2025, which means that smoking prevalence is to be brought under 5 percent. Because stop-smoking support programs developed for white people turned out not to work for the indigenous population, Ruwhiu-Collins developed a dedicated Maori wellness-based model that empowers the people to lead. Instead of promoting NRTs that have not proven successful, the program recognizes that vaping is a legitimate tool to help established smokers quit. According to Ruwhiu-Collins, the model has helped many Maoris stop smoking. Last year, New Zealand became the first country where all RRP categories are available.

Once more, the GFN 2019 made it clear that the road to success for THR is tied closely to regulatory framework for reduced-risk products. Already, there is plenty of evidence showing that an accommodative legal framework results in higher levels of smoking cessation than a “quit-or-die” approach. As David Sweanor, chair of the advisory board of the Centre for Health Law, Policy and Ethics at the University of Ottawa in Canada, put it, “Where else do we permit a really deadly product but try to restrict access to safer ones? Unfortunately, the people who say, ‘our fight is against big tobacco companies’ are the ones who are protecting cigarettes.”