Smoking Alternatives

Smoking Alternatives

David T. Sweanor, Senior Legal Counsel of the National Non-Smokers' Rights Association, commenting on behalf of the World Health Organization, recommended taking a pragmatic, multifacted approach. "For people who cannot or will not be able to exit completely both the tobacco and nicotine markets we should be looking at ways of allowing them to move to alternative forms of nicotine." [1] 

Vaporized Nicotine

Personal vaporizers, also known as "electronic cigarettes" and "electronic cigars" are battery-powered devices that use an atomizer to vaporize a small amount of nicotine dissolved in a solution of water and propylene glycol, along with a flavoring agent. Propylene glycol (PG) is the substance used to produce artificial "smoke" in theatres and dance clubs. PG is Generally Recognized as Safe (GRAS) by the FDA as an additive for foods and medicines. [2] Vegetable glycerin is substituted for the PG in some liquids. Liquids come in varying strengths of nicotine, including zero nicotine. 
Safety: Health New Zealand conducted various tests on one brand of electronic cigarette, Ruyan, and concluded, "It is very safe relative to cigarettes, and also safe in absolute terms on all measurements we have applied." Because nothing is burned, the mist contains no smoke and is not harmful to bystanders. [3] When comparing the health effects of switching to an electronic cigarette versus continuing to smoke tobacco cigarettes some estimates of the risk reduction range as high as 99%. [4] Although long-term effects of inhaling propylene glycol are unknown, there is no evidence to date that this practice is harmful. Thus, it could be conjectured that vaporized nicotine has a similar safety profile to pharmaceutical nicotine products. 
 The stated purpose for the products is to function as a replacement for smoking tobacco. No studies of effectiveness for achieving nicotine abstinence have been published in medical journals. However, a poll of regular users found that over 81% have completely stopped smoking tobacco cigarettes, and another 18% have reduced the number of tobacco cigarettes smoked. [5]

Pharmaceutical Nicotine

Pharmaceutical nicotine products, also known as Nicotine Replacement Therapy (NRT), include patches, gum, and lozenges available over-the-counter, and nasal spray and oral inhalers that require a prescription in the US. Pharmaceutical nicotine products are designed to help users taper down and eventually off nicotine. Dosages of nicotine has been kept low in these products to discourage creating new addictions. 
Safety: "NRT has no known adverse health effects from long-term use." In the United Kingdom, warnings about smoking while using an NRT product have been removed. Although there has been concern that NRT products could trigger heart disease, in practice no such effect has been found. [6] 
Effectiveness: Quit rates at 6 months range from 8 to 30%. [7] A meta-analysis of NRT treatments found that quit rates at one year average 10.7% (6.6% to 14.8%) declining further to an average of 7.2% (3.8% to 11.3%) at 4.3 years follow up. The authors concluded, "Because the long-term benefit of NRT is modest, tobacco dependence treatment might be better viewed as a chronic disorder, requiring repeated episodes of treatment." [8]

Swedish Snus

Swedish snus is a moist smokeless tobacco product that has significantly lower concentrations of cancer-causing nitrosamines than other smokeless tobacco products. The product consists of finely ground tobacco encased in a small pouch. The pouch is placed between the upper lip and gum and the nicotine is absorbed through the mucus membranes of the mouth. 
Safety: Tobacco in snus is steam pasteurized, a process that kills microbes that create some of the cancer-causing toxins. There is little to no risk of lung cancer. Researchers have not found an increase in oral cancer among snus users. One study found that snus users have a risk for pancreatic cancer of 8.8 cases per 100,000, compared with 3.9 cases per 100,000 for non-users of tobacco.  However, smokers had the highest risk, at 13 per 100,000. [9]  Thus switching from smoking to snus reduces risks for all forms of cancer.
Effectiveness: Sweden has one of the lowest smoking rates in the world, while the use of snus is higher than in other countries. Swedish researchers examined data across the lifespan twin study (SALT). The Odds Radio for regular snus use and former smoking status was 3.7, indicating that men who used Swedish snus on a regular basis were over three times more likely to have quit smoking than to be dual users (continue smoking while using snus.) [10] Another study surveyed 6752 adult Swedes on tobacco use. They found that those who used snus were significantly less likely to start smoking. Among male smokers who later began using snus, 88% ceased daily smoking completely. Women using snus were significantly more likely to be able to stop smoking than those using nicotine patches or gum. "The main lesson of this study is that significant sections of the public would select a less harmful high-nicotine smokeless product over cigarettes and use it long term in place of smoking." [11]

Other Smokeless Tobacco Products

Smokeless tobacco products include chewing tobacco, snuff, moist snuff (snus), and dissolvables. 
Safety: British researchers reviewed 89 studies and found an increased risk for cancers of the mouth and throat for past smokeless tobacco use in the USA. However, of all tobacco-attributable deaths, those caused by smokeless tobacco would represent only 1.1% if the number of smokers and smokeless tobacco users were equal. [12] 
Effectiveness: Smokeless tobacco provides nicotine at levels smokers find acceptable. According to the Centers for Disease Control, one third of smokeless tobacco users in the U.S. are former smokers. ???

[1] Sweanor (2000). Is it the Nicotine or the Tobacco? Bulletin of the World Health Organization, vol.78 no.7.

[2] FDA Database of Select Committee on GRAS Substances (SCOGS) Reviews. Propylene Glycol.

[3] Laugesen (2008). Safety Report on the Ruyan??? e-cigarette Cartridge and Inhaled Aerosol. Health New Zealand Ltd. 

[4] Phillips (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments. Harm Reduction Journal 2009, 6:29.

[5] E-Cig Success Rate?

[6] ASH (2007). Guidance for Health Professionals on using Nicotine Replacement Therapy for smokers not yet ready to stop smoking.

[7] Kolawole (2006). Interventions to Facilitate Smoking Cessation. American Family Physician, July 15, 2006.

[8] Etter (2006) Nicotine replacement therapy for long-term smoking cessation: a meta-analysis. Tobacco Control 2006;15:280-285.

[9] Luo (2007). Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. The Lancet, Volume 369, Issue 9578, Pages 2015 - 2020

[10] Ferberg (2005). Is Swedish snus associated with smoking initiation or smoking cessation? Tobacco Control 2005;14:422???424.

[11] Ramstrom (2006) Role of snus in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006;15:210-214.

[12] Lee (2009). Systematic review of the relation between smokeless tobacco and cancer in Europe and North America. BMC Medicine 2009, 7:36.