Managing nicotine without smoke to save lives now: Evidence for harm minimization

Abstract

Tobacco control has made strides in prevention and cessation, but deaths will not decline rapidly without massive behavior change. Currently, inhaled smoke from combusting tobacco is chiefly responsible for prematurely killing 7.2 million people worldwide and 530,000 in the United States annually. An array of noncombustible nicotine products (NNPs) has emerged and has disrupted the marketplace. Saving lives more speedily will require societal acceptance of locating a "sweet spot" within a three-dimensional framework where NNPs are simultaneously: 1. Less toxic, 2. Appealing (can reach smokers at scale), and 3. Satisfying (adequate nicotine delivery) to displace smoking. For this harm minimization framework to eliminate smoking, a laser focus on "smoking control" (not general tobacco control) is needed. By adopting these economically viable NNPs as part of the solution, NNPs can be smoking control's valued ally. Synthesis of the science indicates that policy and regulation can sufficiently protect youth while speeding the switch away from smoking. Despite some risks of nicotine dependence that can be mitigated but not eliminated, no credible evidence counters the assertion that NNPs will save lives if they displace smoking. But scientific evidence and advocacy has selectively exaggerated NNP harms over benefits. Accurate communication is crucial to dispel the misperception of NNPs harms and reassure smokers they can successfully replace smoking cigarettes with NNPs. Saving more lives now is an attainable and pragmatic way to call for alignment of all stakeholders and factions within traditional tobacco control rather than perpetuate the unrealized and unrealizable perfection of nicotine prohibition.

Keywords: Electronic nicotine delivery systems; Harm minimization; Harm reduction; Mortality; Nicotine; Non-combusted tobacco; Public health impact; Smoking; Tobacco.

Figure 1.

Products along the harm minimization continuum. Adapted from Nutt et al., 2014 and reproduced from Abrams et al., 2018 The figure depicts four panels representing classes of products ranging from exceptionally low harm to exceptionally high harm. Panel 1 (left) depicts no use and thus no exposure. Panel 2 (left middle) depicts the class of nicotine delivery products without any tobacco (e-cigs/e-vapor products and nicotine replacement therapies - NRTs). Products containing tobacco are depicted as noncombusted or smokeless (panel 3, right middle) and combusted or smoked (panel 4, right). Panels 2 and 3 constitute the broader supra-ordinate category of non-combusted nicotine products (NNPs).

Figure 2.

Multidimensional framework for nicotine containing products, considering (1) harmfulness, (2) appeal, and (3) dependence. Reproduced from Abrams et al., 2018 The top, back, right corner depicts the most popular (appealing), highly satisfying (dependence), and toxic space (combusted products), whereas no use at all is zero on all three axes. The bottom, front, left space depicts products that have low toxicity but little appeal or satisfaction (e.g., nicotine replacement therapies - NRTs). Minimizing risk while making a net population health impact requires products to successfully compete with and replace smoking. Thus, the sweet spot, where ANDS or NNP’s products might fall, is depicted by high appeal and satisfaction but low toxicity along with products such as Swedish-type snus, which has successfully displaced cigarettes in Sweden.

Figure 3.

Markov state transition model of cigarette and non-combusted nicotine products (NNPs), or alternative nicotine delivery systems (ANDS) use. Adapted from Cobb et al., 2015 and reproduced from Abrams et al., 2018 Directed arrows represent transitions, whereas looped arrows at each state represent maintenance of that state. Traditional youth prevention and smoking cessation strategies reinforce the states of noncurrent and former use depicted by green circles, and complementary new harm minimization strategies facilitate movement away from deadly combusted tobacco smoking to substantially less harmful alternative NNP/ANDS products (blue arrow).