People smoke for nicotine but they die from the tar.
IT was his golden rule to never smoke when asleep and never refrain when awake. Yet, giving up the habit was the “easiest thing to do in the world” for Mark Twain as he had “done it thousands of times” before.
Not much has changed since the iconic father of American literature’s death 114 years ago - smoking cessation remains one of mankind’s hardest accomplishments. Like Twain, countless individuals have tried to give up smoking repeatedly, only to return to the addictive habit.
But as the saying goes, if at first you don't succeed, try, try again - every fresh quit could be “it”. For individuals who find quitting smoking completely a daunting task, there are always nicotine alternatives one could use to gradually reduce reliance on cigarettes.
Is nicotine the true villain?
We have all heard that “smoking kills”, and with good reason. The World Health Organisation (WHO) reported that in 2020, 22.3% of the global population used tobacco, despite smoking killing up to half of its users.
Yes, smoking kills - but not nicotine, often blamed as the primary culprit. As Michael Russell, the pioneer in tobacco harm reduction once said, "people smoke for nicotine but they die from the tar”.
So, what is nicotine? According to the PMI Science, nicotine comes from plants in the Solanaceae family or also known as the nightshade. This family includes tomatoes, potatoes and egg plants. Research estimates that people eat about 1,400 ng of nicotine every day in ordinary food. To put that into perspective, a single cigarette contains ~12mg of nicotine – around 18,000 times more nicotine than a potato, by mass. But only a fraction (<2mg) of nicotine is transferred into the smoke of cigarette.
While nicotine is addictive, and while not risk-free, it is important to emphasize that it is not the primary cause of smoking-related illnesses. The real harm comes from the tar and toxic gases released when tobacco is burned. Smoking cigarette combusts tobacco, producing smoke that exposes users to over 6,000 chemicals, of which about 100 are linked to diseases such as lung cancer, cardiovascular issues, and emphysema.
The U.S. Food and Drug Administration (FDA) Commissioner and the Center for Tobacco Products (CTP) Director stated in 2017, “Nicotine, though not benign, is not directly responsible for the tobacco-caused cancer, lung disease, and heart disease that kill hundreds of thousands of Americans each year. The FDA’s approach to reducing the devastating toll of tobacco use must be rooted in this foundational understanding: other chemical compounds in tobacco, and in the smoke created by combustion, are primarily to blame for such health harms.”
The U.S. FDA also noted that combusted tobacco products like cigarettes are the most harmful. Non-combusted alternatives such as e-cigarettes and other smokeless tobacco products carry significantly lower health risks in comparison to cigarettes.
Recognising this, the tobacco industry has responded to the evolving demands of a better environment by developing smoke-free products that still deliver doses of nicotine to those who are looking to switch to better alternatives.
These products are categorised into heat-not-burn products, which heats tobacco instead of burning it to produce a nicotine-containing aerosol that is fundamentally different to cigarette smoke; and e-cigarettes and vapes (e-vapour products) which are handheld battery-powered devices that heat an e-liquid to produce an aerosol, commonly referred to as vapour. The absence of the combustion process results in an elimination of harmful byproducts directly associated with burning, such as tar.
There are also oral smokeless products such as nicotine pouches (without tobacco) and snus (with tobacco), both of which allow nicotine to be absorbed when placed between the gum and the cheek or upper lip.
Nonetheless, one must always keep in mind that these products do still contain nicotine, which is addictive, and are not without risks. However, the absence of smoke and reduction in harmful chemicals compared to cigarettes makes them a better choice than continued combustible smoking.
Turning to the lesser evil
It is often preached that if one does not smoke, don’t start. If one does smoke, quit. If one don’t quit, then change. Given the range of options available on the market now, smokers intending to begin their transformation journey could opt for alternatives to satiate the nicotine pangs in a less harmful manner, and potentially eliminate the cravings entirely.
Research led by the University of Oxford, and funded by Cancer Research UK, has found that e-cigarettes help people to quit smoking better than traditional nicotine replacement therapies (NRT), such as patches and chewing gums.
The publication reported that there is high-certainty evidence that e-cigarettes are even more effective at helping people quit smoking than traditional NRTs like patches or gums.
“In studies comparing nicotine e-cigarettes to nicotine replacement treatment, significant side effects were rare. In the short-to-medium term (up to two years), nicotine e-cigarettes most typically cause throat or mouth irritation, headache, cough, and feeling nauseous. However, these effects appeared to diminish over time,” it stated.
Ultimately, Oxford’s study did not find evidence of substantial harms caused by nicotine containing electronic cigarettes when used to quit smoking. However, due to the small number of studies and lack of data on long-term nicotine-containing electronic cigarette usage - ones that are over more than two years - questions remain about long-term effects.t
Separately, a paper titled Novel tobacco and nicotine products and their effects on health, published by the European Parliament’s Policy Department for Economic, Scientific and Quality of Life Policies has also noted that alternative nicotine delivery systems are less harmful than tobacco sticks.
“The presence of certain harmful substances in the emissions (vapour) of electronic cigarettes (vapour products) can be lowered by around 90% to 95% compared to tobacco cigarettes, although the composition of aerosols depends on the devices, settings used and the composition of the liquid itself.
“For heated tobacco products, the presence of certain harmful substances in the emissions of these products can be lower by around 80% to 90% compared to tobacco cigarettes, although the composition of aerosols also depends on the devices, settings used and the composition of the tobacco sticks,” stated the report.
The paper, however, does warn that a reduction of 95% of certain harmful chemicals contained or emitted is not equal to a 95% reduction in health risks.
Meanwhile, PMI has conducted studies on aerosol emissions from smokefree products, measuring several harmful chemicals in the aerosol of their Tobacco Heating System (THS) and comparing these levels to those in the smoke of a standard reference cigarette. Because the tobacco is not burned, the levels of harmful and potentially harmful chemicals (HPHCs) inhaled are significantly reduced, with research showing an average reduction of 90% to 95% in HPHC levels in THS aerosol compared to those found in cigarette smoke.
Robust regulations needed
Dubbed psychological reactance by experts, the inner rebel in each person awakens when we believe our choices are being limited - leading us to question or do the opposite of what we're told.
This is why punitive actions like an outright ban on smoking would only boost its popularity, especially in the black market. To tackle the greater issue of smoking in general, the widespread sale of illegal cigarettes in the country must be curbed first, while adjustments in regulations and law are required.
For example, Saudi Arabia’s Public Investment Fund established the Badael Company in May 2023 to develop and manufacture tobacco-free nicotine delivery products.
This was after Saudi’s tobacco black market saw an estimated 300% rise in the use markup on cigarettes and hookah products when its government issued a religious ruling (fatwa) against the use of tobacco products.
At present, Badael’s products are expected to help nearly one million people, or 25% of Saudi’s smokers, switch from smoking by 2032.
Malaysia could also take a cue from the British government and our neighbour, the Philippines, which emerged as the first country in Asia to enact legislation that distinguishes combustible tobacco products with those that do not burn (vaporised nicotine and non-vaporised nicotine products).
The British government has implemented the “swap to stop” scheme, where vape device starter kits are provided to smokers to support and help them quit the habit.
Meanwhile, the Philippines’ Vaporised Nicotine and Non-Nicotine Products Regulation Act allows its government to regulate the importation, sales, manufacturing, packaging, distribution, and use of vaping products.
In summary, smoking is a significant global health problem. Here is where the aforementioned smoke-free delivery products play a role in, at the very least, reducing harm to the nicotine-users and the people around them.
Studies have already demonstrated that nicotine alternatives are effective and widely used methods to help individuals quit. Hence, one should ponder if nicotine is so harmful, why are governments permitting the sale of nicotine patches?
References:
1 https://www.pmiscience.com/en/smoke-free/nicotine/nicotine-from-plants-to-people/
2 https://www.nejm.org/doi/full/10.1056/NEJMp1707409
3 https://www.fda.gov/tobacco-products/health-effects-tobacco-use/relative-risks-tobacco-products
5.https://www.europarl.europa.eu/RegData/etudes/IDAN/2022/740068/IPOL_IDA(2022)740068_EN.pdf
