The uncelebrated triumphs of tobacco harm reduction
By Cheryl K. Olson
U.S. smokeless tobacco users are no more likely to die from cancer than people who never touched tobacco products. This unexpected news comes courtesy of the National Longitudinal Mortality Study. Compared to those who never used tobacco, current users of smokeless products do not have elevated mortality risks from all cancers combined.
This was just one happy fact I ran across when writing articles for doctors summarizing alternative nicotine product risks and benefits. I felt a similar “Wow! Really?” writing recently for this magazine about today’s astonishingly low youth smoking rates.
It’s time to stop, notice and give a cheer for good news about tobacco harm reduction (THR) that doesn’t get enough attention. Interesting evidence from research studies, natural experiments and everyday life observations ought to be shared.
This is not just about raising smiles. The accumulated weight of these bits of information can change mindsets. They can influence how future studies are framed and which policies are proposed and implemented.
I asked colleagues involved in harm reduction to suggest examples to celebrate. They include:
- reduced-risk options that knocked down smoking in a particular nation or subgroup;
- unexpected positive shifts in behavior, such as people who try vaping and notice one day that they no longer smoke;
- harmful behaviors we were worried about that, to our relief, don’t seem to be happening (i.e., vaping as a gateway to youth smoking);
- and finally, personal observations about the effects of THR.
Transforming the Map
We can’t say it often enough: cigarette smoking is still the leading preventable cause of disease and death in the U.S. It kills millions worldwide every year. Preventing cigarette use and helping people who don’t quit to consider lower-harm alternatives are medical and moral imperatives.
As pioneering nicotine researcher Karl Fagerstrom has said, “Realistically, no single alternative nicotine product category will be able to reduce smoking rates and the associated disease burden.” Individuals and nations will find different options appealing and acceptable. His article “Can Alternative Nicotine Products Put the Final Nail in the Smoking Coffin?” highlights five nations’ successes. In the U.K., Sweden, Norway, New Zealand and Japan, higher uptake of alternative nicotine products has meant lower smoking rates compared to their neighbors.
According to the Associated Press, “Sweden, which has the lowest rate of smoking in the Europe Union, is close to declaring itself ‘smoke-free’—defined as having fewer than 5 percent daily smokers in the population.” As of 2022, they had reached 5.6 percent. Thanks in large part to snus, Sweden has the lowest tobacco-related mortality among men in Europe.
David Sweanor of the Centre for Health Law, Policy and Ethics at the University of Ottawa regularly monitors tobacco company behavior. When Japan Tobacco released their second-half results in July, he noted the “extraordinary” shift in Japan’s tobacco use.
“Overall, the cigarette market has declined by half since heated products were introduced,” Sweanor says. “It is important to note that Japan has achieved this dramatic decline in cigarette smoking without policies actively encouraging the change.”
Roberto Sussman of the National Autonomous University of Mexico UNAM challenges us to look at the inverse proposition. “In the last 20 years, is there one case—a country, a subpopulation—of a significant reduction in smoking prevalence in which any effect or influence from usage of noncombustible products can be absolutely ruled out?” he asks. “I doubt there is a single case.”
Natural experiments created by bans on e-cigarettes in some U.S. states offer added noteworthy support for vaping as an effective substitute for smoking. Compared to “control” states with no full or partial e-cigarette bans, the states of Massachusetts, Washington and Rhode Island saw increased cigarette sales.
Personal stories and research have shown that taking up vaping can mean putting down cigarettes—for people who initially had no plans to quit. This includes analyses by Karin Kasza and colleagues of widely respected ongoing studies such as the Population Assessment of Tobacco and Health (PATH) and the International Tobacco Control Four Country Smoking and Vaping surveys (of the U.S., Canada, Australia and England).
A recent systematic review by Elias Klemperer and colleagues found little evidence that conventional smoking cessation methods induce quit attempts among those without plans to do so. “The optimal treatment (or treatment combination) for this population remains unclear,” the authors state.
“No one ever ‘quit by accident’ with a nicotine patch, nicotine gum, nicotine lozenges, nicotine inhalers, Chantix/Campix, bupropion or smoking cessation counseling,” says Charles A. Gardner of Harm Reduction Strategies. “But millions of smokers who had no intention to quit have ‘quit by accident’ with nicotine vapes.”
Gardner believes this point deserves more attention. “If 75 percent of smokers claim they want to quit, then obviously 25 percent have no intention to quit,” he says. “No approved smoking cessation intervention will ever reach them. Nicotine vapes do.”
A related finding that deserves notice: Researchers at the U.S. Food and Drug Administration’s Center for Tobacco Products published evidence that mint/menthol ENDS users were more likely to switch and quit than tobacco-flavored e-cigarette users. The authors refer to additional research that identified better switching odds with nontobacco-flavored products.
Gateway or Diversion?
I previously reported on the unanticipated and little-lauded plunge in U.S. youth smoking rates (“Where’s the Parade?,” Tobacco Reporter, March 2023). The 2022 National Youth Tobacco Survey found that one in 10 (10.9 percent) high school students had ever tried a cigarette. Just 2 percent reported smoking in the past 30 days.
Although youth vaping is down from its 2019 peak, e-cigarettes are the most common nicotine product used by teens. Past-month use stands at 14.1 percent. Concerns have persisted among researchers and policymakers that vaping could lead youth who wouldn’t otherwise smoke to start.
Recently, more sophisticated assessments have challenged that connection. PATH study analyses by Kenneth Warner of the University of Michigan and colleagues show that few teens become established smokers regardless of previous e-cigarette use. When other known risk factors for youth smoking are taken into account, it turns out that ever-use of e-cigarettes makes a trivial difference.
Rather than leading teens down a path to smoking, e-cigarettes seem more likely to divert teens away. A new article by Christine Delnevo and Andrea Villanti of Rutgers University does a deep dive into national trends in high school student smoking since 1991. They found that “the most rapid declines in cigarette prevalence have occurred in the past decade, when e-cigarettes emerged as a popular product among youth.”
THR in Daily Life
A scientist who has worked in harm reduction inside and outside of industry points to an under-praised behavior shift in one important subgroup: people who work in nicotine product companies. At both the offices of a large e-cigarette maker and at a legacy multinational tobacco company, “I’ve never seen or known someone to smoke,” they said. “Even at a bar or outside of the office. But plenty of people vape or use other alternatives. And most, if not all, were former smokers.”
Their conclusion? “Reduced-risk product availability and a culture of acceptance actually change behavior.”
Christopher Greer, CEO of TMA and president of The GTNF Trust, described how tobacco harm reduction principles benefited his health in unexpected ways. “When I met my wife, I was very heavy—coming up on 260 pounds. I had a dependency on food for stress relief, and a stressful job.” He found that the typical advice from health professionals (e.g., cut out junk foods and fast food) didn’t fit his situation. Nor did a pharmaceutical option.
“Utilizing principles I knew from THR, I crafted a risk reduction plan for my eating,” Greer says. For example, he identified and targeted situations that put him at high risk for overeating. “It was incredibly difficult, but a decade later, I’m a much healthier, stable weight.”
Greer likens his transformation to transitioning to reduced-risk tobacco products: “another form of people finding agency in their own health decisions, when standard treatment isn’t working.”
Chang JT et al. (2023). Characteristics and patterns of cigarette smoking and vaping by past-year smokers who reported using electronic nicotine-delivery systems to help quit smoking in the past year: Findings from the 2018–2019 Tobacco Use Supplement to the Current Population Survey. Nicotine & Tobacco Research. https://doi.org/10.1093/ntr/ntac199
Delnevo CD & Villanti AC (2023). Dramatic reductions in cigarette smoking prevalence among high school youth from 1991 to 2022 unlikely to have been undermined by e-cigarettes. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph20196866
Fagerstrom K (2022). Can alternative nicotine products put the final nail in the smoking coffin? Harm Reduction Journal. https://doi.org/10.1186/s12954-022-00722-5
Kasza KA et al. (2021). Association of e-cigarette use with discontinuation of cigarette smoking among adult smokers who were initially never planning to quit. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2787453
Kasza KA et al. (2023). Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers’ plans to quit: longitudinal findings from the International Tobacco Control Four Country Smoking and Vaping Surveys. Addiction. https://onlinelibrary.wiley.com/doi/10.1111/add.16050
Klemperer EM et al. (2023). A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit. Experimental and Clinical Psychopharmacology. https://psycnet.apa.org/doi/10.1037/pha0000583
Sun R et al. (2023). Association of electronic cigarette use by U.S. adolescents with subsequent persistent cigarette smoking. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802764
Sun R et al. (2022). Is adolescent e-cigarette use associated with subsequent smoking? A new look. Nicotine & Tobacco Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8962683/
Timberlake DS et al. (2017). A longitudinal study of smokeless tobacco use and mortality in the United States. International Journal of Cancer. https://onlinelibrary.wiley.com/doi/10.1002/ijc.30736
Xu Y et al. (2022). The impact of banning electronic nicotine-delivery systems on combustible cigarette sales: Evidence from U.S. state-level policies. Value in Health. https://doi.org/10.1016/j.jval.2021.12.006