//Harm Reduction and Health: In Conversation with Starbene

DR GRANT O’CONNELL, STRATEGIC SCIENCE & POLICY ENGAGEMENT DIRECTOR AT IMPERIAL BRANDS, TALKS TOBACCO HARM REDUCTION (THR),  NICOTINE AND NGP RESEARCH.

Earlier this month Dr O’Connell sat down with Italian health and lifestyle magazine, Starbene, to explain the current state of THR and why new independent research affirms Next Generation Products (NGPs) like vapes present significant public health potential. You can read the original article here (in Italian, web browsers such as Google Chrome can auto translate), and selected edited excerpts below in English.

—

Starbene: First of all, how do you explain the concept of harm reduction and why it could be so crucial in enhancing public health? Can you please provide some examples of governments that have already embraced it? And why, in your opinion, some other nations and health institutions refuse to give it the credit it claims?

O’Connell: Harm reduction is a well-established concept in public health that is simple and compelling: to provide  a range of policies, regulations and actions designed to reduce health risks directly by encouraging less risky behaviours. Face masks during the current COVID-19 pandemic, sun cream and seat belts are all everyday examples of harm reduction. They don’t eliminate risk completely but they do reduce it, improving outcomes for both individual and public health. Tobacco harm reduction works in the same way: to provide adult smokers, who would otherwise continue to smoke, the option to transition to less harmful products that deliver nicotine – but with fewer and substantially lower levels of toxicants than associated with burning tobacco. These nicotine products, which either do not contain tobacco leaf or do not combust tobacco, are termed  Next Generation Products (NGPs). NGPs include vapes, heated tobacco and oral nicotine pouches. A growing number of public health bodies, regulators and governments fully endorse and advocate for tobacco harm reduction to reduced smoking-related risks. For example, the UK, New Zealand and Canada actively endorse and encourage those adult smokers who are uninterested or unwilling to quit smoking to transition to vaping products.

Why some other nations have felt unable to endorse tobacco harm reduction, or in some cases outright rejected it (Australia, India and Singapore being notable examples of the latter) is a complex issue. An important factor is likely to be the attitude and influence of the World Health Organisation whose uncompromising position remains smokers ‘quit or die’. There are also some who have a vested interest in rejecting NGPs. For example, state-owned tobacco companies are an important source of revenue for some countries, while pharmaceutical companies see NGPs as a major competitor to the medically licensed nicotine replacement therapies (NRTs like patches and gums). Despite NRTs being available for decades and demonstrating negligible product innovation and limited acceptance by adult smokers, they still provide a not insubstantial source of revenue.

Starbene: We are in front of a wave of new generation products. For this reason, studies could mainly examine the short and mid-term horizon. How can people be sure that vaping is not dangerous in the long term, that it is really another world compared to cigarettes?

O’Connell: Vapes have not been around long enough to generate epidemiological data, which looks at potential health impacts after decades of use, and more research in this area is certainly needed. However, the long term – health impacts of smoking tobacco are well known. Meanwhile, the scientific evidence to-date indicates the potential long-term health risks associated with transitioning to vaping, providing the devices and e-liquids are manufactured to robust quality and safety standards, are highly likely to be considerably lower than continued smoking.

What else do we know? Firstly, vape aerosols (the ‘vapour’ inhaled) contain fewer and substantially lower levels of harmful chemicals compared to tobacco smoke, and clinical studies with adult smokers have demonstrated when they transition to vaping they experience rapid and significant reductions in exposure to toxicants and carcinogens – not dissimilar to the levels in found in NRT users and never smokers.  Secondly, clinical data has shown adult smokers who transition to vaping have generally experience improvements in pulmonary and cardiovascular health. Thirdly, no serious adverse effects have been reported in adults who transitioned from smoking to vaping for up to 2 years. In fact, a recent Cochrane Review which evaluated the effect and safety of vaping in helping adult smokers achieve long-term smoking abstinence was published on 14 October 2020 (“Electronic cigarettes for smoking cessation”). ¹ Cochrane Reviews, which are generally seen as the gold standard of scientific evidence, concluded that [1] e-cigarettes do help people to stop smoking (even among those who do not intend to quit smoking) and work better than NRTs or willpower alone; and [2] and are not associated with serious unwanted effects or harm with up to 2 years of usage. The totality of the scientific and medical evidence to-date is reassuring for adult smokers considering vaping as an alternative to combustible tobacco. The Cochrane Review did however commented that further research is required further substantiate vaping’s longer-term tobacco harm reduction potential. As stated earlier, Imperial Brands agrees and our scientific research in this area continues.

Starbene: Are e-cigs a valid plan b only for people that can’t or don’t want to quit smoking or are they useful also for those who want to stop forever?

O’Connell: The best course of action any adult smoker can take to improve their health is to stop smoking and nicotine consumption completely. For those that uninterested or unwilling to quit smoking, a growing number of public health bodies and regulators are clear and advocate that adult smokers transition to NGPs remains the next best course of action. The recent Cochrane Review suggested vapes can – and do – help adult smokers stop smoking even if they don’t necessarily intend to at the outset. For those who actively want to stop smoking, vaping is shown to be even more effective.

At the same time, there is growing evidence that adult smokers’ misperception of the risks surrounding vaping may be preventing adult smokers potentially transitioning. Last week, the UK charity Action on Smoking & Health (ASH), which campaigns against smoking, published survey data showing vaping in the UK had stagnated as a percentage of the total smoking population after year-on-year growth. The charity blamed “unfounded concerns about the relative safety of e-cigarettes are a likely cause – just 39% of smokers in Great Britain correctly believe vaping is less harmful than smoking in 2020.” Given public health authorities in the UK actively support and champion vaping as an alternative to smoking, that statistic shows how damaging inaccurate media coverage – in our opinion largely based on poorly conducted science and sensationalist reporting – can be.

Starbene: Let’s speak about nicotine. It is an addictive stimulant and it creates addiction in consumers. Is it a reasonable policy to give emphasis to products based on it? If yes, why?

O’Connell: We believe it’s important to continue honest, science-based discussions about nicotine. Nicotine is an addictive chemical, and although not completely risk free, is not the primary cause of smoking-related disease. The highest risk of smoking-related disease actually comes from burning tobacco and inhaling the smoke (nicotine is one of several thousand chemicals present in tobacco smoke). Until recently, the only way to consume nicotine was by burning tobacco. Today, driven by the availability of new and emerging technologies, we’re able to de-couple nicotine from tobacco combustion and revolutionise how it’s enjoyed by adult smokers. Science-based education to regulators, public health bodies and adult smokers alike needs to continue to extricate nicotine from its current synonymity with cigarettes, tobacco and smoking-related disease.

Importantly, scientific research suggests another key focus area for NGPs to maximise their harm reduction potential has to be nicotine delivery. Specifically this means ensuring NGPs deliver satisfaction to adult smokers in a manner akin to tobacco cigarettes. That said, it’s important to note there are no obvious public health benefits to be derived from NGPs that exceed the nicotine delivery of a tobacco cigarette.

Finally, we believe the decision to use nicotine-containing products is a choice reserved for adults. Children and vulnerable populations should never smoke or use any nicotine-containing product. We fully support sanctions against anyone who sells nicotine-containing products to youth. We play our part by ensuring our products and associated marketing activities only reach intended adult smoker/NGP user audiences.

Starbene: Can studies be considered reliable if they are paid by the same manufacturer of the products they are trying to analyze? How is it possible to find an honest balance between the need of a new wave in research (with its costs on a large scale) and its credibility?

O’Connell: As a responsible manufacturer we invest heavily in the scientific research that underpins our NGPs and substantiates their tobacco harm reduction potential. We remain fully committed to making all our research publicly available. This includes publications in peer-reviewed scientific literature, presentation at conferences, through our dedicated science website, and via regulatory engagement. We believe openness, transparency and collaboration enhance the scientific understanding of NGPs and best serve the world’s billion-plus adult smokers.

We also believe that to maximise the public health benefits of NGPs, regulation should be risk proportionate and reflect the scientific evidence base on the relative harms of cigarette alternatives and their potential for harm reduction. Others agree too. For example, when the UK Parliament’s influential Science & Technology Committee recently reviewed the totality of the scientific evidence on NGPs, it recommended the UK Government should move to risk-proportionate regulatory environment; where regulations, advertising rules and tax duties reflect the evidence of the relative harms of NGPs compared to combustible cigarettes. The UK Government has invested a lot of resource to understand the science behind NGPs, which has informed their pragmatic and progressive approach to vaping regulation in particular. The results have been impressive, suggesting it would be a strong regulatory model for other countries to consider. Given competing current public health priorities, we appreciate that’s not always as simple as it sounds, but we believe other key opinion leaders and decision-makers should dedicate sufficient time and resource into understanding the science around NGPs and their potential to significantly improve public health.

Starbene: What is the role of Imperial Brands in this picture? What kind of contribution is it giving to harm reduction and to a trustworthy progress in the research?

O’Connell: Imperial Brands understands society’s concerns about the health risks of smoking, and recognises our important role in helping to reduce the harm caused by combustible tobacco. All of our NGPs are manufactured to robust quality and safety standards and we continue to invest significantly in scientifically substantiating our NGPs (without animal testing) and assessing their tobacco harm reduction potential. This has significant benefits upon wider population health. This has yielded a number of important and seminal studies including our 3D “lung in the lab” study (video below) that demonstrated, under the test conditions, the impact of the vapour from our e-cigarettes on human airway tissue was similar to ambient air, even up to 400 continuous puffs . Please visit our scientific research archive to learn more.

Starbene: What are your goals in the long term? What kind of features will be present in the next generation products? Let’s make a comparison with the smartphones that now can fold their screen. Will e-cigs of the future be very different in shapes and functions and, first of all, able to put the health of their consumers at the very center?

O’Connell: Innovation remains important in the NGP space alongside continued investment in trusted brands, best-in-class manufacturing, the highest quality standards and rigorous scientific research. In 2019 Imperial Brands was among the European Patent Office’s (EPO) top 100 applicants. We can’t go into too much detail as our R&D programme is proprietary. However, to provide a flavour areas of interest include next-generation batteries and charging; novel heated tobacco innovations; novel oral nicotine delivery platforms and sustainable materials and packaging. It’s an ongoing process but we are confident our investment in R&D will help us validate NGPs with regulators, and importantly offer more adult smokers more satisfying choices to combustible tobacco to accelerate tobacco harm reduction.

After all, if adult smokers don’t find NGPs appealing or satisfying, and don’t choose them over combustible tobacco, or if regulators and public health bodies don’t endorse them, this precious public health opportunity will be lost.

1. Hartmann-Boyce, J., McRobbie, H., Lindson, N., Bullen, C., Begh, R., Theodoulou, A., Notley, C., Rigotti, N., Turner, T., Butler, A. and Hajek, P., 2020. Electronic Cigarettes for Smoking Cessation Cochrane Database of Systematic Reviews