Most frequent questions and answers
Harm Reduction recognizes that lowering risk – rather than attempting to eliminate it entirely – is more achievable, compassionate, and effective at improving public health than outright prohibiting risky behaviors. Instead of attempting to persuade or force people to stop doing something, harm reduction promotes education and provides people with safer alternatives.
No. Safer does not imply completely safe. While reducing harm does not completely eliminate it, significantly lowering risks has a net positive effect on both individual and public health.
Tobacco Harm Reduction (or THR) is simply harm reduction applied specifically to tobacco users.
It includes promoting the use of safer nicotine products, which can assist smokers in quitting cigarettes while still consuming nicotine. Safer nicotine products eliminate the majority of the health risks associated with smoked tobacco products by eliminating combustion.
THR is no different to other harm reduction strategies which are generally very effective and widely accepted. These include car seat belts; condoms and most recently face masks.
Since 2003, South Africa became a signatory to the World Health Organisation Framework Convention on Tobacco Control.
The FCTC provides an obligation on governments to not only allow reduced-risk products but actively promote them as part of implementing their tobacco control policies.
Low-risk nicotine products come in many forms. Here is a list of examples:
- Smokeless tobacco (Swedish snus)
- Electronic cigarettes (vaping)
- Nicotine Replacement Therapy (NRT) (such as patches, lozenges, and gum)
- Nicotine pouches (similar in form to snus, but do not contain leaf tobacco)
- Heat Not Burn devices
Yes. Over the last few decades, a significant number of people in Sweden (mostly men) have switched from smoking cigarettes to using “snus” (a Swedish smokeless tobacco product). What has come to be known as “The Swedish Experience” is the result of an organic social process that resulted in a massive public health victory, rather than any anti-smoking campaign.
Swedish men have a very low rate of cancer and other smoking-related diseases – the same rates you’d expect to see in a population that has stopped smoking. The evidence suggests that the widespread use of smokeless tobacco does not pose a significant risk of disease. Similar trends are now being observed in Norway, and even the United Kingdom has seen a significant decline in adult and adolescent smoking as the popularity of cigarettes has declined whilst an increase in e-cigarette use.
Nicotine is a relatively benign drug. Although it is addictive, it presents very little risk to the user.
Because of its association with smoking, many people (include health professionals) incorrectly believe it is the harmful ingredient in tobacco smoke. However many independent expert bodies disagree:
- UK Royal College of Physicians, “Use of nicotine alone, in the doses used by smokers, represents little if any hazard to the user”
- The Royal Society for Public Health has concluded that nicotine is a mild recreational stimulant and is “no more harmful to health than caffeine”
- Public Health England “nicotine use per se represents minimal risk of serious harm to physical health and that its addictiveness depends on how it is administered”
Nicotine has shown mild effects such as temporary increases in pulse rate; blood pressure and narrowing the blood vessels. However, it should be noted that nicotine can impair wound healing and raise blood glucose levels.
Based on decades of use of Swedish snus which releases high levels of nicotine as well as traditional nicotine replacement therapy (nicotine gums; patches; sprays and lozenges), long-term use of nicotine is regarded as low risk.
The addictiveness of nicotine alone is also overstated. There are additional ingredients in tobacco smoke which make nicotine more addictive (monoamine oxidase inhibitors) and coupled with the efficiency in delivery, smoking increases the addictiveness of nicotine.
The behavioural, sensory and social aspects of smoking also enhance its addictiveness.
When people use the term “addiction,” they usually mean a habitual behavior that has a negative impact on someone’s health, well-being, and ability to function in life.
This category does not include the use of safer nicotine products. The more accurate term is “dependence,” which typically means that someone is physically or mentally reliant on a product – but it is not negatively affecting their life. Many people admit to being caffeine dependent, but we wouldn’t call it an addiction because coffee does not ruin lives, break up families, cause financial problems, or pose a threat to public health.
People who use safer nicotine products may become addicted to nicotine, but it is usually no more problematic than needing that first cup of coffee in the morning.
VAPING & ELECTRONIC CIGARETTES
Most frequent questions and answers
Vaping is a less harmful alternative for adult smokers who are often unable to quit smoking on their own or with other methods. Vaping delivers nicotine and mimics the familiar hand-to-mouth action and sensations of smoking.
Nicotine EVPs (e-cigarettes) heat a liquid nicotine solution into an aerosol which is inhaled and exhaled as a visible mist. This is known as ‘vaping’.
All EVPs consist of a rechargable battery, a tank to hold the e-liquid and a coil or heating element to heat the liquid to create the vapour.
There is no tobacco and no combustion, almost all the toxic chemicals in smoke are absent from vapour. The chemicals that are still present are in far lower doses than in tobacco smoke. (https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update)
Some smokers use vaping for a short time to quit tobacco smoking and then cease vaping. Others continue vaping long-term to prevent relapse to smoking.
Vaping should not be used by non-smokers including young people who don’t smoke.
There is overwhelming scientific agreement that vaping is far less harmful than smoking. Vaping does not produce smoke. It is the 7,000 toxic chemicals in smoke released from burning tobacco which cause almost all the deaths and disease from smoking.
In contrast, EVPs heat a liquid into an aerosol, without tobacco, combustion and therefore smoke. There are some potentially harmful toxins are present in aerosol but at much lower levels than in cigarette smoke.
According to the UK Royal College of Physicians:
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”
A comprehensive review by Public Health England concluded:
“While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger.”
A review by the US National Academies of Sciences, Engineering and Medicine concluded:
“There is substantial evidence that completely switching from regular use of combustible tobacco cigarettes to e-cigarettes results in reduced short-term adverse health outcomes in several organ systems.”
Surprisingly, according to a study from Rutgers University, approximately 80.5% of physicians believe that nicotine causes cancer. The truth is that nicotine does not cause cancer and the cancer risk from vaping is only a tiny fraction of the risk from smoking. The vast majority of harm from smoking comes from tar, carbon monoxide, toxic gases and solid particles released by burning tobacco.
The overall cancer risk from vaping nicotine is estimated to be <0.5% of the risk from smoking (PUBMED). Switching from smoking to vaping dramatically reduces the risk of developing cancer.
‘Popcorn lung’ (bronchiolitis obliterans) is a serious, but rare lung disease first detected in popcorn factory workers. It was linked to very high levels of ‘diacetyl’ which is used to create a buttery flavour.
Some earlier e-liquids contained diacetyl, however the levels found in vapour were hundreds of times lower than in cigarette smoke and there has never been a case of bronchiolitis obliterans due to smoking or vaping. Diacetyl is now rarely used. There has not been a single case linking vaping to popcorn lung.
In 2019, there was an outbreak of serious lung injury (EVALI) in the US in people who had recently vaped. This condition has now been clearly associated with black-market THC(cannabis) oils contaminated with Vitamin E Acetate, purchased from street dealers.
Not a single case has been linked to commercial nicotine vaping for smoking cessation.
Researchers were only able to find a correlation, not a cause. Furthermore, many of those reporting a heart attack or stroke were already at high risk due to decades of smoking, and the event occurred before they began vaping. More information is available here.
There are clinical studies that show that vaping helps people quit smoking, but there are also tens of thousands of testimonials from adults who smoked for decades and were able to quit by switching to vapor products. There is a reason why there are 85 million adult vapers across the world. More information is available here.
Unlike second-hand smoke, the risk to bystanders from passive vaping appears to be minimal.
As per Public Health England’s review in 2018, “to date there have been no identified health risks of passive vaping to bystanders”. Royal College of Physicians stated in 2016 “There is, so far, no direct evidence that such passive exposure is likely to cause significant harm.”
This is because the vaper absorbs most of the inhaled aerosol. Less than 10% of the chemicals are exhaled and they are at very low levels in the air. Due the way EVPs operate(on/off functionality), there is no ‘side-stream’ vapour, which accounts for at least 80% of second-hand smoke from a cigarette.
Furthermore, the liquid aerosol droplets from vapour evaporate and disperse in seconds, much more quickly than the solid particles in smoke, reducing risk further.(PUBMED)
Passive smoke from combustible tobacco is estimated to be five orders of magnitude (50,000x) greater that than of vapour created by EVP’s.(PUBMED)
The precise long-term health effects of vaping nicotine have yet to be established (as seen in all new products). Based on the wealth of information collected over 14 years, and an understanding of the ingredients in vapour, the biomarkers (toxins in urine and saliva), The Royal College of Physicians estimates the long-term risk is likely to be no more than 5% of the risk of smoking. There are now an estimated 68 million people vaping in dozens of countries.
Some opponents of EVP’s argue that we should pause until long-term risk (if any) have be established. However, this is a double standard only applied to vaping and not used for any other medicine or treatment.
It is possible that some harms may emerge over time and ongoing monitoring of vaping should continue for any new side-effects. However, it may never be possible to completely separate the effects of smoking from those due to vaping as almost all regular vapers are former smokers.
Over and above this, medical science in the 21st century knows more about chemistry, toxicology, physiology and causes of disease than when cigarettes went into mass production some 120 years ago. There is a greater understanding of the toxic effects of most chemicals and scientists can assess them against occupational and environmental health and safety standards.
The advancements in scientific methods, analytical techniques and equipment are far superior to that available in the past.
No. Smoking rates have reached record lows across all age groups as vaping rates have increased over the last decade. If vaping led to smoking, smoking rates would rise rather than fall. As a result, there is no evidence that vaping causes smoking. More information is available here.
Unfortunately, we do not have any data on the South African situation, which needs to be addressed. However, there has been a significant decline in vaping rates by the youth in the US by 60% from 2019 to 2021 (27.5% to 11.3%). What is more alarming is that many young people in the US are vaping cannabis instead.
A mere 0.4% of never-smokers reported vaping regularly (≥20 days in the last 30 days). Nicotine dependence is rare in never-smoking youth who vape. Less than 4% of never-smokers reported symptoms of nicotine dependence in 2018.
The US has seen a steady decline in youth smoking rates since the introduction of EVP’s in 2008. Since 2014 when vaping became mainstream, the rate has declined a further 200 to 400%. From 2018 to 2019, US youth smoking rates (12th grade) fell by an unprecedented 30% (8.1% to 5.7%). As per NYTS conducted by the CDC for 2021 the youth smoking rate has dropped to a historical low of 1.9%
After analysing the data in detail, Robert J. West (Professor of Health Psychology, Department of Epidemiology and Public Health, University College London) concluded:
“Data from the NYTS [National Youth Tobacco Survey] do not support claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes, nor concerns that declines in youth tobacco addiction stand to be reversed after years of progress”the youth
Nicotine has been linked to harmful effects on the adolescent brain in animal studies. However, most animal studies use chronic, high-dose exposure to nicotine which does not accurately reflect the nicotine exposure that would occur from vaping in humans. The same effects found from nicotine in animals are also found in animal tests with caffeine.
Also, there is no long-term evidence of impaired brain function in the hundreds of millions of adults who smoked as adolescents and then stopped.