September 01, 2021 By Kevin C. Limjoco

Electrified Tobacco Harm Reduction

The “Burning” Issue on Non-Combusted Alternatives to Cigarettes

Knowledge and perspective are the most powerful instruments that ultimately define and separate the human race from any other living organisms on the planet since the discovery and management of fire. Along with the power of intelligence is our mammalian instinct and behavior of pleasure seeking in all its infinite permutations. Managing personal rewards and punishments begins with the initial spark of life, first by the instinct to survive followed by adaptation to our environment. Ironically, in our time of instant enlightenment and information at our fingertips, the most challenging effort today with knowledge is sorting out the levels of truth as our world population continues to grow exponentially despite the current global pandemic. 

Throughout recorded time, change and evolution occurs relentlessly, however, the acts of man did not begin to impact the planet in a global scale until the industrial age that began towards the end of the 18th century. Until that period, even the most devastating historic battles and human bloodshed did not adversely affect the climate and nature as a whole. Certainly, it can be argued successfully that mankind has been wiping out species of animals as well as fellow human races as far back as about 125,000 years ago; however, there are more immediate examples that come to mind: the Dodo bird from Mauritius in the 17th century and Mexico’s Aztec nation by the end of the 16th century. Ultimately, neither the Dutch nor the Spaniards intended with forethought to wipe out either, but the circumstances became a direct result of their actions and presence. 

Growing up in the Philippines in the 70’s and 80’s, it seemed like everyone was smoking cigarettes while the more seasoned gentlemen smoked pipes and cigars. Since we were young children, our parents and elders told us to be careful when we played, as the activities were all fun and games until someone got physically or emotionally hurt. Everyone has the right to be happy and have fun but not at the expense of others. When it comes to cigarette smokers, for example, what bothered me in the past was the smell, how the smoke would bother my eyes, and most profoundly was how the butts were commonly disposed of callously and wastefully. We will never be able to fully quantify how much of our forests, homes, and businesses have literally gone up in smoke because of the careless disposal of a lit cigarette. 

I remember the days when smoking was still allowed on the plane and it was practically torture for non-smokers who shared the same recycled air. Even with dining out in the past when there was no division between smokers and non-smokers, the whole experience would get compromised. On one extreme occasion in Milan, Italy in the early 2000’s during a dinner at a very posh restaurant with a low ceiling, I almost blacked out from not being able to breathe since every single table but ours was filled with smokers. I even folded in two huge international poker tournaments for the same reasons; every single player was smoking practically non-stop in poorly ventilated rooms and it wrecked my gaming experience. 

All throughout recorded history, industry, survival, expansion, and power management have dictated the rules and regulations for people to live by in almost infinite measures. So many of our younger generations across the globe today have forgotten nor care about the events of the past not realizing that by learning from both the triumphs and failures of the past they have the power to form their future into a better and brighter one too. Yes, indeed such a statement can be summed up and recognized as a representation of every generation from an elder’s perspective; however, the scale today is completely different. We have never had a human population as large and as diverse as today with access to information. It is so easy to ridicule the youth but they are not in power, we are, and yet misinformation exists exponentially more today than ever before.  

Even coffee has had a very colorful history dating back over a thousand years before the Western world began to consume it in the early 16th Century before it finally became almost universally accepted by the 1920’s. Any form of excess consumption can be harmful to us humans, yet why is it that some of the most damaging substances are freely available today while others are not? Historically, power and wealth management has been the consistent answer. There are thousands if not millions of volumes of books and articles published around the world that are now available online but they are not read because of the lack of interest or simply outright laziness. So, it is more vital than ever that responsible people of influence and science share their data and perspectives so that individuals have the tools to make their own decisions and regulate their own consumption, but they must also accept the responsibility of their actions. In a utopian world, that idea of complete freedom of choice would be wonderful; however, us humans are consistently our own worst enemy, hence why we need structure and enforcement as well for those who cannot manage themselves while being sensitive and conscientious to their fellow man around them.

Before I get into a light history lesson, let us briefly look at alcohol and cocaine as examples. From 1920 to 1933, there was a nationwide constitutional ban on the production, importation, transportation, and sale of alcoholic beverages in the United States, famously known as the National Prohibition Act, aimed to heal the nation of violence, corruption, and alcoholism. The end results, however, have been famously documented in movies, television shows, and books. The ban did not work and instead had the reverse effect and created many more troublesome issues to say the least. From 1886 to 1903, a huge soda brand, actually contained cocaine derived from the Coca-leaf and Caffeine from the African Kola nut combined in its soda when it was marketed and sold as a medicinal “temperance drink”. During the 19th century, cocaine was used for medicinal purposes, as a local anesthetic in dentistry, eye surgery, minor operations, lozenges and pastilles to relieve a sore throat. For years, cocaine voice tablets were advertised to public speakers and singers, with the promise that it would soothe the throat and remove vocal hoarseness. 

Whole nations and peoples were built and destroyed in the name of progress and commerce. In 19th century North America, Manifest Destiny and Expansionism were the cultural ideologies that emboldened the powers that be at the time to justify genocide against Native Americans, slavery, and the Mexican-American war, even if the mindsets did not accurately represent the morality and beliefs of the majority of the population. The two Opium Wars between the Qing dynasty of China and the Western powers of Great Britain, the East India Company, Russia and France in the mid-19th century formed Hong Kong, treaty ports in Shanghai and Canton among others, outer Manchuria ceding to the Russian Empire and so much more. And what was the most profound commodity that triggered the wars to begin with? You would think it was Opium but it was actually Tea, which would be another primary reason after the two wars for the East India Company to expand further and more profoundly in India under the British Raj (1858–1947). The little tealeaf was also famously the catalyst that sparked the beginning of the end of British rule over the original 13 colonies in America with the Boston Tea Party protest in 1773. In fact, the New World, The Philippines, and other Asian countries and territories would not have been discovered by the West in the 15th century had it not been for the Spice Trade. 

Which brings me back to Tobacco, which was introduced to Europe by Spain in the 1520’s from the Americas where it was swiftly embraced by the French, Spanish, and Portuguese even referring to the plant as the “sacred herb”. The British eventually began using Tobacco in the 1570’s with initial resistance from even the Stuart King James VI and I who denounced it. But its popularity, claimed medicinal advantages, and commercial success simply could not be denied. In Asia, Japan was introduced to Tobacco by the Portuguese in the 1540’s while the Spaniards introduced it in 1565 during Miguel López de Legazpi’s expedition to finally make a permanent settlement in Las Islas Filipinas. Spain had a Tobacco monopoly in the Philippines from 1782 to 1883 while the Dutch employed a forced cultivation system in Indonesia from 1834 to 1870. In the Philippines in current times, Virginia, Burley, Turkish, and Native tobaccos are grown in 23 provinces, covering approximately 30,352 hectares. 

It’s a known fact that smoking is “dangerous to your health,” as what the familiar warning says on each cigarette pack. Despite the known associated risk of death and serious diseases from smoking, however, there are about 1.1 billion tobacco users worldwide according to the World Health Organization. The WHO also reported that smoking tobacco “kills more than 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.” The bulk of smokers, over 80 percent of them, are from low and middle-income countries, including the Philippines.

In the country, the 2015 Global Adult Tobacco Survey implemented by the Philippine Statistics Authority (PSA), in coordination with the Department of Health (DOH) reported that there are 16 million Filipino smokers. While 76.7 percent of current smokers planned to or were thinking about quitting, those who actually quit are at a measly 4 percent. 

To address the continuing smoking epidemic, the government has employed stricter tobacco control measures through the years, including the implementation of very graphic health warnings on cigarette packs, restrictions on advertising, banning of smoking in public places and conveyances, and imposition of hefty taxes that increase annually. Despite this, people still continue to smoke. The WHO projected that the number will remain the same in 2025.

 

Alternative Approach: Tobacco Harm Reduction 

In his 1991 paper, titled The Future of Nicotine Replacement, British psychologist Michael Russel posited that people smoke mainly for the nicotine but they die from the tar, carbon monoxide and other harmful gases taken in alongside nicotine. He said, “It seems logical to offer either a cleaner product or, better still, an acceptable source of purer, less contaminated nicotine.”

Russel was among those who triggered the exploration of less harmful nicotine delivery systems. The concept of tobacco harm reduction (THR) or the reduction of smoking-related deaths and diseases without the complete elimination of exposure to tobacco subsequently began gaining traction. Specifically, THR refers to strategies designed to reduce the health risks associated with tobacco smoking but which may involve the continued use of nicotine. 

The Australian Tobacco Harm Association in its paper submitted to the Australian government said the “main purpose of tobacco harm reduction (THR) is to reduce (not necessarily eliminate) the harm from smoking. The aim is not to stop nicotine as nicotine causes little harm. Tobacco harm reduction involves encouraging smokers to switch from high-risk combustible (burnable) cigarettes to a lower-risk nicotine alternative such as vaping.” 

Across the Atlantic, UK’s Public Health England (PHE), an executive agency of the Department of Health and Social Care, in 2015 published an expert independent evidence review titled “E-Cigarettes: a new foundation for evidence-based policy and practice” that concluded e-cigarettes are around 95 percent less harmful than smoking. 

Professor Kevin Fenton, Director of Health and Wellbeing at PHE said though e-cigarettes are not completely risk free, when compared to smoking, “evidence shows they carry just a fraction of the harm. The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting.” He urged local shop smoking services to support e-cigarette users in their journey to quitting smoking completely.

To date, several countries including the Philippines are in the process of passing a law that will regulate and control the importation, manufacture, sale, packaging, distribution, use and consumption of vaporized nicotine products or VNP, such as e-cigarettes and heated tobacco products (HTPs). The House of Representatives, last May, has already passed their version of the proposed law, while the Senate is deliberating on its version as of this writing. 

 

Eliminate Burning, Reduce Harm 

The quest for a less harmful nicotine delivery system has come a long way with thousands of pages of scientific findings coming from both independent and industry studies concluding that the combustion process, not nicotine, is the primary cause of smoking-related deaths and serious health problems. According to the American Lung Association, cigarettes, when burned, “create more than 7,000 chemicals. At least 69 of these chemicals are known to cause cancer, and many are toxic.” Meanwhile, the US FDA debunks the long-standing myth about nicotine. On its website, the health agency clarified that though most people know that cigarettes and other tobacco products are addictive, many people do not understand the role of nicotine in tobacco addiction, disease, and death. 

Nicotine, though addictive “is not what makes tobacco use so deadly. Tobacco and tobacco smoke contain thousands of chemicals. It is this mix of chemicals—not nicotine—that causes serious disease and death in tobacco users, including fatal lung diseases, like chronic obstructive pulmonary disease (COPD) and cancer,” the US FDA said.

 

Better Options to Cigarettes

Eliminating combustion or the burning process has been the direction of innovative nicotine delivery systems also called non-combustible alternatives (NCAs). Considered as less harmful options to smoking tobacco, NCAs include HTPs and vapes. Both HTPs and vapes deliver nicotine without combustion, though some vapes do not contain nicotine at all. A heated tobacco device, such as Philip Morris International’s IQOS heats tobacco wrapped in paper to 350 °C. Sans burning, it creates an aerosol and not smoke. A vaping device on the other hand heats an e-liquid that usually contains nicotine, glycerin, propylene glycol and flavorings to produce an aerosol.

Another NCA is Swedish snus, a moist tobacco in a small pouch usually placed under the lip. Both IQOS and snus were authorized by the US FDA for marketing in the United States as modified risk tobacco products.

Innovation or Ideology

Despite the mounting scientific evidence on the merits of THR, and validations of several health agencies from multiple countries, anti-THR advocates insist on the prohibition of all tobacco products even if, historically, such restrictive methods produce minimal gains in reducing smoking prevalence. In the case of banning NCAs, international health policy experts noted that taking this path would only push those who have switched to less harmful alternatives back to smoking, while depriving smokers from accessing these better options.

Meanwhile, countries who have espoused THR are showing gains in their tobacco control efforts. In Japan, cigarette sales dropped 42 percent since the introduction of HTPs in the market, according to David Sweanor, chair of the Centre for Health Law, Policy and Ethics and an adjunct professor of law at the University of Ottawa. 

“When Norway allowed Swedish snus products to be more widely available, cigarette smoking fell by half in just 10 years. When Iceland allowed both vaping products and snus into the market, it appears that smoking fell by about 40 percent in just three years,” he added.

On the prevalence of youth uptake, a study by Tottori University Medical School funded by Japan’s Ministry of Health and Welfare showed that the initiation to HTP use among 60,000 Japanese junior high school students was very low at just 0.1 percent. In the UK, PHE’s study concluded that there is no evidence so far that e-cigarettes are acting as a route into smoking for children or non-smokers. 

Further, a third-party study by Dr. Kanae Bekki of the National Institute of Public Health showed low levels of toxic agents in the aerosol of HTPs. Hiroshi Ike, Senior Manager of Transformational Health at Frost & Sullivan, said the Health Promotion Law was recently amended to introduce new indoor smoking rules to allow the use of HTPs while dining in designated rooms, while the use of conventional cigarettes in dining areas remains prohibited.

The apparent gains from THR, however, continue to receive opposition from anti-tobacco organizations—even reaching the halls of policy makers and regulators. Just recently, the House of Representatives concluded an investigation on the Philippine FDA’s admission of accepting money from The Union, a Bloomberg Philanthropies-funded organization, to hire job order personnel who will craft the regulations on vapes and HTPs. 

The investigation aimed to determine whether the FDA issued specific and pre-defined policies on e-cigarettes and HTPs in exchange for funding from foreign private organizations. During one of the hearings, Rep. Jericho Nograles revealed a pattern of government agencies’ issuance of regulations following receipt of a total of US$2.5M from Bloomberg since 2009.

 

Tobacco Control: A Multi-Sectoral Effort

Significant progress in addressing the global smoking problem entails a collective effort from all stakeholders: the government, industry, science and health sectors, including the consumers. As Dr. Derek Yach, president of the Foundation for a Smoke-Free World said during the 8th Global Forum on Nicotine held virtually from the UK, a commitment from all parties to prioritize the end of the tobacco epidemic would be needed.

“Industry must commit to ending the sale of combustible cigarettes and act accordingly through their investments. Industry must commit to ending youth nicotine use in all forms and there are many strategies that could be done to achieve that,” he said.

In conjunction with the industry effort, the health authorities and the governments should build a risk proportionate regulatory system according to Dr. Yach. He noted that when it comes to harm reduction, policy lags far behind the science. 

“For years, decades, even, politicians and health authorities who should know better have ignored, derided and undermined such measures, stuck in a past in which the tobacco industry played a big, bad role. The result is that much of the public wrongly believes that nicotine causes cancer, e-cigarettes are more dangerous than combustible ones, and there is no leeway between the extremes of ‘quit or die’,” he said.

Dr. Yach called it tragic, “because important sectors of the industry are in the process of transformation and investing heavily in research that is helping to create one of the most profound public health shifts in history, namely, the elimination of combustible cigarettes altogether.”

Dr. Yach said, the world is experiencing a revolution in nicotine delivery technology, and this presents an opportunity to reduce millions of deaths from smoking each year. 

Harm reduction is defined by the 2021 Global State of Tobacco Harm Reduction report as “a range of pragmatic policies, regulations and actions which either reduce health risks by providing safer forms of products or substances or encourage less risky behaviors.” According to the report, Tobacco Harm Reduction (THR), or “using safer nicotine products (SNP) [or electronic vapor products], offers new choices to millions of people worldwide who want to switch away from smoking or other dangerous forms of tobacco use, but have been unable to with the options previously available.”

Photo Courtesy of IQOS.com

In conclusion, there are so many of these fascinating stories and facts of open commercial usage of substances in the past especially during World War I and II. The huge soda company and the tobacco companies are some long-standing enterprises that continually evolve and adapt to the times while remaining true to their core of pleasing their customers while removing harmful ingredients. The entire mobility industry of flight, automobiles, motorcycles, mass transit, trains, and buses; every sector has been working on alternative fuels and electrification to reduce fossil fuel dependence and help our environment.

Because of so much public awareness and access to information, the awareness of how much harm the human race is doing to our planet is undeniable but global knowledge loses all meaning without immediate global action. It is literally the equivalent of an individual identifying that a fire started, then telling everyone about it just to stare at the fire until it consumes everything including the original observer.

Fast forward to today, and I am very happy to see that my friends and family who do still consume tobacco now use alternative heated devices that do not have the offensive characteristics that affect non-smokers of the past! Every measure counts. Everyone has the right to have joy and individual indulgences especially during these extremely difficult times.

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