A fresh look at tobacco harm reduction: the case for the electronic cigarette

Tobacco smoking is a global pandemic, affecting an estimated 1.2 billion people, that poses substantial health burdens and costs. With nearly six million deaths annually, smoking is the single most important cause of avoidable premature mortality in the world, mainly from lung cancer, coronary heart disease, chronic obstructive pulmonary disease and stroke. As also underscored by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the key to reducing the health burden of tobacco in the medium term is to encourage cessation among smokers. Unfortunately, smoking is a very difficult addiction to break, even for those with a strong desire to quit. It has been shown that approximately 80% of smokers who attempt to quit on their own relapse within the first month of abstinence, and only about 5% achieve long term abstinence. Moreover, currently available smoking cessation medications such as nicotine replacement therapy, the antidepressant bupropion and the partial agonist of the α4β2 nicotinic acetylcholine receptor, varenicline, at best double or triple this quit rate under the ideal circumstances of an experimental setting but have had low uptake and inferior efficacy in the community. Furthermore, varenicline and bupropion have come under increasing scrutiny due to reports of serious adverse events that include behaviour change, depression, self-injurious thoughts, and suicidal behaviour. The Tobacco Advisory Group of the Royal College of Physicians acknowledges that the development of addiction includes modifications in behaviour together with changes in brain structure and function that impair the ability to achieve and sustain abstinence. They note that some of these changes may not be entirely reversible. Lastly, even tobacco control policies – particularly when not integrated and well supported by adequate funding – are not very effective.

Consequently, many smokers will keep smoking because, when given only the options of smoking or completely giving up nicotine, many will not give it up. Bearing in mind that nicotine per se does not cause much risk when separated from inhaling smoke, it is important to consider that a third option is also available to smokers; the reduction of smoking-related diseases by taking nicotine in a low-risk form. Tobacco harm reduction (THR), the substitution of low-risk nicotine products for cigarette smoking, is likely to offer huge public health benefits by fundamentally changing the forecast of a billion cigarette-caused deaths this century.