Smoking remains a worldwide public health problem because it is very difficult for smokers to quit and smoking cessation medications have limited effectiveness. For smokers unable or unwilling to quit with approved smoking cessation medications, tobacco harm reduction could be a third-line option.
This was the key message of Dr. Konstantinos E. Farsalinos in his lecture during the Asian Pacific Society of Cardiology Congress 2019, which was held recently at the SMX Convention Center and Conrad Hotel in Pasay City. Organized by the Philippine Heart Association (PHA), the annual congress gathered local and international cardiologists, as well as internists, primary care physicians, and other healthcare professionals in the region with an interest in cardiovascular disease prevention and management.
“The cigarette is the most effective and most harmful nicotine delivery system ever developed. Tobacco harm reduction is a public health strategy aimed at lowering smoking-related health risks to individuals who cannot or do not want to quit by themselves or with currently-approved methods through the use of less harmful nicotine delivery systems,” explained Farsalinos, a research fellow at the Onassis Cardiac Surgery Center, University of Patras, and National School of Public Health in Greece.
Farsalinos has been conducting research on electronic cigarettes (e-cigarettes or vapes) as principal investigator since 2011. His research findings were among the references used by the European Union in drafting the EU regulatory framework on e-cigarettes. E-cigarettes are the most common type of electronic nicotine delivery systems (ENDS), which refer to devices that do not burn or use tobacco leaves but instead vaporize a solution the user then inhales.
Growing body of evidence
A cardiologist himself, Farsalinos presented congress delegates with official position statements of the American Heart Association and American Cancer Society, as well as independent reviews by Public Health England and the Royal College of Physicians, supporting e-cigarettes as a significantly less harmful alternative to conventional cigarettes and viable smoking cessation aid.
“Currently available evidence indicates that e-cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to e-cigarettes,” said Farsalinos, citing the key finding of a systematic review he co-authored and which was published in 2014 in Therapeutic Advances in Drug Safety.
The Greek thought leader in tobacco harm reduction shared the results of a cross-sectional study, which compared exposure to nicotine, tobacco-related carcinogens (cancer-causing chemicals) and toxicants among British cigarette-only smokers, and smokers and ex-smokers with long-term e-cigarette use or with nicotine replacement therapy (NRT) use. Published in 2017 in Annals of Internal Medicine, the study found that ex-smokers with long-term e-cigarette-only use or NRT-only use may achieve approximately similar nicotine intake to cigarette-only smokers. Long-term NRT-only and EC-only use, but not dual use with cigarettes, is associated with substantially reduced levels of measured carcinogens and toxicants relative to cigarette-only smoking.
Farsalinos presented the results of a prospective study published in 2016 in Discovery Medicine. The study assessed the long-term benefits of smoking abstinence and reduction in asthmatic smokers who switched to e-cigarettes. It found that asthmatic smokers who switched to e-cigarettes had significant improvement in asthma condition as shown in spirometry, with benefits even after 24 months of use.
He also discussed the key findings of another study he co-authored published in 2016 in Internal and Emergency Medicine. The prospective study looked at the effect of continuous smoking reduction and abstinence on blood pressure and heart rate in smokers switching to e-cigarettes. It found that smokers who reduce or quit smoking by using e-cigarettes may lower their systolic blood pressure in the long term, with the reduction particularly apparent in smokers with elevated blood pressure. “By showing BP reductions when reducing or stopping smoking for a sufficient period of time, this study adds to the current evidence that EC use appears to be a less harmful alternative to tobacco smoking,” Farsalinos said.
Strike the right balance
Farsalinos concluded his lecture by framing tobacco harm reduction in the context of public health benefit.
“Public health benefit is not about finding the safest option that perhaps no one will use,” said Farsalinos. “Rather, this requires striking the right balance between risk reduction—not necessarily risk elimination—and popularity. This approach will accelerate the decline in smoking rates.”