The role of smoke-free products in tobacco harm reduction

What is tobacco harm reduction? 

In the case of cigarette smoking, harm reduction has been defined as “minimizing harms and decreasing morbidity and mortality, without completely eliminating tobacco and nicotine use”. This includes the risk of developing diseases like lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular disease.  

Quitting tobacco products altogether is the best way to reduce the risk from smoking. However, according to World Health Organization (WHO) estimates, around 1 billion people worldwide will continue to smoke for the foreseeable future. For adult smokers, switching to a smoke-free alternative that is scientifically substantiated to be less harmful than continued smoking could reduce the risk of harm.  

Reducing tobacco-related harm at the population level depends on two factors:  

1. The risk profile of the available smoke-free alternatives being significantly less than that of cigarettes, and  
2. Their adoption by significant numbers of adult smokers.  

Both factors matter. The more that adult smokers who don’t quit switch to lower risk options instead of continuing to smoke, the bigger the impact on reducing population harm. This is why smoker acceptance is an important component of the harm reduction equation. After all, even a very low risk product will not reduce harm if no one uses it.  

Smoker acceptance of smoke-free alternatives requires products that are satisfying for current adult smokers so that if they don’t quit, they completely switch.  

The overall goal, therefore, is to develop smoke-free alternatives that present significantly less risk of harm than continued smoking, that are acceptable to current adult smokers who would otherwise continue to smoke cigarettes, and do not appeal to youth, nonsmokers, or former smokers. 

The role of nicotine in tobacco harm reduction 

Nicotine is a well-known component of tobacco and tobacco-containing products. Nicotine is part of what makes cigarettes addictive and is one of the reasons that people smoke, along with taste, and ritual, and sensorial experience.  

While nicotine is not risk free, it is not the primary cause of smoking-related diseases. The U.S. Food and Drug Administration has pointed out that, “It’s the thousands of chemicals contained in tobacco and tobacco smoke that make tobacco use so deadly. This toxic mix of chemicals—not nicotine—cause the serious health effects among those who use tobacco products." 

In fact, nicotine is an important part of tobacco harm reduction. Because it is one of the reasons people smoke cigarettes, nicotine’s presence in products that are scientifically substantiated to be less harmful than cigarettes can help adults smokers who don’t quit switch instead of continuing smoking cigarettes. 

How smoke-free products can reduce harm 

Smoke-free products don’t burn tobacco, and so they don’t release the high levels of harmful chemicals found in cigarette smoke. When a cigarette is burned, it reaches temperatures above 400 °C, and as high as 800 °C or more at the tip. The high temperatures cause a chemical reaction called combustion, which produces cigarette smoke. This smoke contains more than 6,000 chemicals, around 100 of which have been classified by public health authorities as Harmful and Potentially Harmful Constituents (HPHCs).  

The high level of HPHCs generated by burning tobacco is associated with smoking-related diseases such as lung cancer, heart disease, and emphysema.  

We have shown through testing that if tobacco is heated to temperatures below the ignition temperature of the tobacco, as in our Tobacco Heating System (THS), similar amounts of nicotine to those found in cigarette smoke can be released without combustion.  

Because the tobacco is not burned, the levels of HPHCs generated and inhaled are greatly reduced. Research has shown an average reduction of 90-95% in the levels of HPHCs measured in the aerosol of THS compared with those found in the smoke of a standard research reference cigarette.  

Other smoke-free products, such as our oral nicotine pouches and e-cigarettes, do not contain tobacco and provide nicotine in an alternative way. For example, e-cigarettes use aerosol formers like glycerol that produce HPHCs only under certain conditions. 

Most smoke-free alternatives still contain nicotine, which is addictive and is not risk free. However, because these products do not burn tobacco, they have the potential to present less risk of harm than continued smoking.  

Scientific evidence for the potential risk of smoke-free products 

To identify the extent of potential risk from our smoke-free products compared with continued smoking, we use a robust scientific assessment program. This program has generated more than 500 publications since 2008, most of which are open access.  

At each step of our assessment program, we apply rigorous standards according to internationally recognized research guidelines, principles, and practices, and the program is aligned with the 2012 draft guidance issued by the U.S. Food and Drug Administration’s Center for Tobacco Products. 

Assessing the risk reduction potential of a smoke-free product involves five “steps,” although each product progresses through the assessment program differently. These steps include: 

• Aerosol chemistry and physics studies to confirm that burning does not take place, and that, in products which produce aerosol, the resulting aerosol contains lower levels of harmful chemicals compared with cigarette smoke.  
• Toxicology research to estimate the risk-reduction potential for each product in laboratory models. 
• Clinical research to provide human data on whether switching to smoke-free products reduces exposure to toxic compounds and has a positive effect on clinical risk markers associated with smoking-related diseases. 
• Perception and behavior research for insights on how people think about and use smoke-free products, which can impact population health. 
• Long-term research, which tracks the impact of each product on population health over time. 

Smoke-free products as part of a comprehensive harm reduction strategy

The best way for adult smokers to reduce the risk of harm associated with smoking is to quit tobacco and nicotine altogether. For those adults who do not quit, switching to a scientifically substantiated smoke-free alternative is a better choice for reducing the risk of smoking-related harm than continuing to smoke cigarettes.  

In recent years, an increasing number of adult smokers have switched from cigarettes to smoke-free alternatives such as e-cigarettes, heated tobacco, or oral tobacco products to reduce the risk of harm to their health compared with continued smoking.  

Smoke-free products can be used to complement existing tobacco control efforts, including smoking prevention and the encouragement of cessation. As such, they could be an important part of an overall harm reduction strategy and a benefit to public health.