Wednesday, 30 May 2018 22:20

By Dr Farsalinos

May 31, 2018, the World No Tobacco Day. This is an(other) day to be reminded about the deadly effects of tobacco cigarette smoking. This global problem is not only related to the fact that 50% of smokers die prematurely (losing on average 10 years of life) from smoking related disease. It is even more importantly related to the large prevalence of smoking worldwide. There are more than > 1 billion smokers globally. And this is not only a problem of the developing world. The European Union still has a smoking prevalence of 26%, while Greece has a prevalence of almost 33% (according to my latest study).

Smoking has killed about 100 million people during the 20th century, but the problem for the 21st century will be much more intense. The WHO has estimated that while today 6 million people die prematurely every year, the number will rise to 8 million in a few years. One billion premature deaths due to smoking are expected in the 21st century. So, smoking is still a major public health threat and has a major burden in life expectancy and quality of life.

There are decades of intense efforts to combat the smoking epidemic. Obviously, smoking prevalence has decreased substantially since the first Surgeon General report in 1964, and there is no doubt that tobacco control efforts that have proven to be effective in reducing smoking need to continue and be implemented globally. But still we have a lot of things to do. The day that smoking will become obsolete does not appear to be near.

Smokers are today very well-informed about the harmful effects of smoking. They have the ability, at least in developed countries, to ask for professional help through organized smoking cessation clinics that offer medications and psychological support. Smokers should be convinced to ask for help. They need help to be convinced that quitting smoking is one of the best primary preventive measures for a variety of disease conditions and should be done as soon as possible. And they need help because quitting is a very difficult (and largely unsuccessful when done without any aid) task. The states should help by providing financial incentives (subsidize) for such treatment. These efforts should further expand, especially in developing countries. However, even in developed countries, smoking cessation clinics are not very popular among smokers, while all available approved smoking cessation methods fail in the majority of smokers who try them. At the same time, we need to remember that quitting smoking is the #1 priority.

Over the last few years, we are witnessing a major revolution in the smoking battle with the development and availability of tobacco harm reduction products. E-cigarettes have become very popular, especially after 2010. Their popularity is largely confined to smokers (when you look at regular/frequent use and not just experimentation), and there is a good reason for this. Their use resembles the rituals of smoking, and at the same time they deliver nicotine. But they do not deliver the products of combustion that are emitted in tobacco cigarette smoke. While e-cigarettes are not risk free, and thus not recommended to a non-smoker, they can literally be lifesaving for smokers who are unable or unwilling to quit by themselves or with currently approved methods. There is extensive evidence on their risk profile, and their public health impact is already evident in places where their use is actively endorsed by public health authorities as a smoking substitute (UK). E-cigarettes, however, are not successful for every smoker. Novel harm reduction products, heated tobacco products, have been developed and will increasingly become available, which may provide an additional opportunity for smokers to quit. While evidence on these products is still very limited and largely released by the manufacturers, we need to be open-minded, intensify our efforts to generate independent data and do our best to properly inform smokers about all available options and the difference in the risk between each option and in comparison with continuous smoking. We should not forget that snus, a proven tobacco harm reduction product with a large pool of hard epidemiological evidence supporting its role in reducing smoking related disease, is banned in the European Union depriving some smokers from another harm reduction option.

While the evidence is accumulating and compelling on the vastly reduced risk of harm reduction products, especially e-cigarettes, there is still a lot of conflicting views and intense debate among the public health community about their role in combating smoking. Of course there are reasonable concerns that create the need to continuously monitor patterns of use by specific population groups, particularly youth and non-smokers, current evidence is reassuring and suggests that e-cigarettes are complementing rather than contradicting other tobacco control efforts. Of course there is the need to intensify research and eventually generate long-term epidemiological evidence. But the "we don't know yet" attitude is a never ending and highly uninformative process, and a statement that smokers do not deserve when they are continuously exposed to the risks of smoking.

Smokers need to be provided with balanced and reliable information about all their options andbe advised on the best possible pathways of succeeding in quitting smoking (quitting by themselves or with approved medications). But they should also NOT be discouraged from using harm reduction products. The World No Tobacco Day reminds us that we are combating smoking, not smokers. On this day, official health organizations and scientific associations should focus on the ultimate goal, which is to enhance the chances of smokers to quit. I hope that the statements released by health associations on the 2018 World No Tobacco Day will be a polemic against smoking, not polemic against the unique prospects and hope that tobacco harm reduction offers. Otherwise, prestigious authorities risk being completely ignored by smokers and falling behind the developments and the evolution that we are witnessing. At the end of the day we will all know…