Tobacco Harm Reduction: A (State) Capital Idea

When I published my book on tobacco harm reduction in 1995, Dr. Dean Edell described my strategy as “…credible, logical and eminently do-able.” (here).  Risk expert W. Kip Viscusi (now a University Distinguished Professor at Vanderbilt University here) wrote that “Dr. Brad Rodu's intent is not to abolish tobacco use but to expand the range of consumer options and to enable consumers to make more informed decisions. This option of informed choice should become the guiding principle of U.S. public health policy toward tobacco.” 

Now, lawmakers in a growing number of states are exploring how vastly safer tobacco products can help their smoking constituents lead longer and healthier lives.  In 2012, I was invited to participate in legislative committee meetings or hearings in Kansas (April), Indiana (September) and Oklahoma (October).  This year, legislators in Iowa, North Dakota (February), Kansas and Idaho (March) have heard the truth about tobacco harm reduction.  

While I was in Bismarck, North Dakota, I was interviewed by Dale Wetzel, former Associated Press writer, on his radio show, “The Legislature Today.”  Dale asked challenging questions that generated a lively discussion.  The interview is available here.   

Nicotine Increases Exercise Endurance

In my lectures on tobacco harm reduction I compare the properties of nicotine with those of caffeine (see slides at left).  Despite some obvious differences, the drugs have remarkably similar effects.  I have just found a study from 2006 showing that “…nicotine administration during moderate-intensity exercise delays fatigue, with a significant improvement of 17% [±7%] in time to exhaustion. This observation is similar to observations of the effects of caffeine supplementation.” (Available at the journal Experimental Physiology here).

Authors Toby Műndel and David A. Jones of the Human Performance Laboratory, School of Sport and Exercise Sciences, The University of Birmingham (United Kingdom), recruited 12 healthy non-smoking men and asked them to cycle in a laboratory setting at a moderate pace until exhausted on two occasions.  Subjects randomly applied either a 7 milligram nicotine patch or a placebo patch the evening before.  

Ten subjects who wore the nicotine patch cycled for 70 minutes – about 17% longer than the 62 minutes cycled by those with the placebo patch.  Nicotine had no effect on heart rate or respiratory parameters, and it “…did not alter the perception of effort… associated with progressive fatigue.”  The researchers noted that “…activity of dopamine pathways has

been suggested to be associated with improved endurance exercise performance.”  In other words, nicotine’s endurance boost stemmed from its effect on the brain. 

As I mentioned in 2011 (here), the World Anti-Doping Agency (WADA) is considering labeling nicotine a performance-enhancing drug.  However, WADA could treat nicotine as it has caffeine, summarized this way by the agency in 2012 (here):

“Caffeine was removed from the Prohibited List in 2004. Its use in sport is not prohibited.  Many experts believe that caffeine is ubiquitous in beverages and food and that reducing the threshold might therefore create the risk of sanctioning athletes for social or diet consumption of caffeine.  In addition, caffeine is metabolized at very different rates in individuals.”

Since using nicotine is a “social” choice and the substance is metabolized at very different rates, one can only hope that WADA applies such a reasoned, practical analysis to it as well.

American Dental Association Improves Mouth Cancer and Smokeless Tobacco Brochures

I have been critical of the American Dental Association’s distribution of misinformation about smokeless tobacco and tobacco harm reduction (discussed here and here).  New ADA brochures on mouth cancer and smokeless tobacco show significant improvement  over their past publications.

The new pamphlet on mouth (and throat) cancer (here) accurately describes the disease as occurring “…most often in people who smoke cigarettes, cigars, or pipes and drink heavily (30 drinks or more per week).  That combination is estimated to cause the majority of mouth and throat cancers diagnosed in the United States.  Here are some additional risk factors:

• “Current research shows that some types of human papillomavirus (HPV) can cause throat cancer, which affects the base of the tongue and tonsils. HPV is very common— many people have the virus in their bodies and don’t even know it.

• “People who often spend long periods of time in the sun are at higher risk for lip cancer.” (emphasis in the original)

The brochure mentions one other risk factor, “a diet with too few fruits and vegetables,” but this is relevant mainly for people in developing countries, not in the U.S.

The new brochure on smokeless tobacco (here) drops many of the unscientific allegations that appeared in earlier versions and focuses a good deal on cessation.  Mouth cancer goes unmentioned, which is appropriate, given that the risk is so low. 

Still, the brochure is flawed.  Here are some questionable statements:

1.  “One can of smokeless tobacco has as much nicotine as 60 cigarettes or three packs.”  This is about as meaningless as claiming that one bottle of bourbon has as much alcohol as 19 cans of beer.  Just as responsible drinkers modulate their alcohol intake when using different products, smokeless users and smokers modulate their nicotine intake based on the products they use, attaining nearly the same peak nicotine blood level regardless of the source.  In comparing product nicotine levels, the ADA demonizes nicotine, which, while addictive, is not a major factor in any smoking-related illness.

2.  “Smokeless tobacco … has over 3,000 chemicals, including 28 cancer-causing substances.”  This is technically accurate but meaningless. One could also make the factual statement: “Coffee has over 1,000 chemicals, including 21 cancer-causing substances.” (here)  Any food or drink is composed of thousands of chemicals, some of which are or may be carcinogens.  Focusing on these is a scare tactic, described by renowned biochemist Bruce Ames as “hysteria over tiny traces of chemicals that may or may not cause cancer.” (here). 

3.  “People may think that smokeless means harmless, but nothing could be further from the truth.”  No credible tobacco harm reduction scientist or advocate claims that any tobacco product is absolutely safe; suggesting otherwise is nothing but a straw-man argument. 

The truth about smokeless is readily apparent: A wealth of scientific data show that smokeless means almost no measurable health risk.

Truthful “Action” on E-Cigarettes in the United Kingdom

Action on Smoking and Health (ASH), a British “campaigning public health charity that works to eliminate the harm caused by tobacco,” has published a landmark report on e-cigarettes acknowledging that they “provide effective nicotine delivery” and present “little real-world evidence of harm.”  In addition, “ASH supports regulation to ensure the safety and reliability of e-cigarettes but, in the absence of harm to bystanders, does not consider it appropriate to include e-cigarettes under smokefree regulations.” 

I encourage you to read the 9-page report, which is available here.  I’ll highlight some important points, many of which I have made previously (PubMed Links to the original ASH references are provided where possible).

Nicotine Substitution

“In 1976 Professor Michael Russell wrote: ‘People smoke for nicotine but they die from the tar.’ (reference 6).  Indeed, the harm from smoking is caused almost exclusively by toxins present in tobacco released through combustion.  By contrast, pure nicotine products, although addictive, are considerably less harmful.  Electronic cigarettes consequently represent a safer alternative to cigarettes for smokers who are unable or unwilling to stop using nicotine.”

Propylene Glycol

“There is little evidence of harmful effects from repeated exposure to propylene glycol, the chemical in which nicotine is suspended (references 12 , and 13) One study concludes that e-cigarettes have a low toxicity profile, are well tolerated, and are associated with only mild adverse effects. (reference 14).” 

I should add that the investigators in ASH reference 12 also found that propylene glycol vapor killed bacteria and viruses that were suspended in the air of enclosed spaces (here and here), another potentially positive aspect of this agent.

Second-hand Vapor Risks

“Although e-cigarettes do not produce smoke, users exhale a smoke-like vapour which consists largely of water.  Any health risks of secondhand exposure to propylene glycol vapour are likely to be limited to irritation of the throat.  One study exposed animals to propylene glycol for 12 to 18 months at doses 50 to 700 times the level the animal could absorb through inhalation. Compared to animals living in normal room atmosphere, no localised or generalised irritation was found and kidney, liver, spleen and bone marrow were all found to be normal (reference 12).

“The fact that e-cigarettes look similar to conventional cigarettes has been said to risk confusion as to their use in public places, such as on public transport.  However, given that the most distinctive feature of cigarette smoking is the smell of the smoke, which travels rapidly, and that this is absent from e-cigarette use, it is not clear how any such confusion would be sustained.”

In other words, ASH does not buy into indoor e-cigarette bans because these products don’t expose bystanders to toxic agents, and e-cigarette vapor is instantly distinguished from the smoke of combusted cigarettes.    

While ASH has over many years aggressively opposed the tobacco industry, it notes on its website that it “works to eliminate the harm caused by tobacco.  We do not attack smokers or condemn smoking.”  In this case, ASH has honored this sentiment, objectively evaluating e-cigarettes and establishing a credible position.