By Professor Tara Rampal MBBS FRCA& Dr Mahir Yousef FRCSEng, JBS, FMAS, DMAS

Prof. Tara Rampal and Dr. Mahir Yousef are two experts in the field of smoking cessation and harm reduction. They recently spoke about the potential for e-cigarettes to be used as a harm reduction strategy. This article covers their presentation and discussion.

What is harm reduction in healthcare?

Harm reduction is a method used in medicine and social care to minimise harm to individuals and the wider society from hazardous behaviours or practices that cannot be completely avoided or prevented. Smoking statistics in the Middle East and the challenges of smoking cessation, evidence around harm reduction and smoking, and the obstacles to implementing harm reduction, including youth access were discussed.
Harm reduction is about having options in place so that harm is reduced as much as possible. For example, for many it’s unavoidable to drive a car on a daily basis. Driving is risky behaviour, and road traffic accidents are common, with human error being a strong feature in them. While some accidents are preventable, driving is often an unavoidable risk. Wearing a seatbelt is an example of harm reduction. Similarly on summer days, wearing SPF sunscreen to help prevent the risk of skin cancer. These are strategies which are used in medicine and social policy to minimise the harm to individuals and the wider society from hazardous behaviours that cannot be avoided.
Another example of harm reduction in healthcare is advising exercise and healthy eating in those with obesity, given the correlation and causality to chronic medical conditions. These include coronary artery disease and diabetes which may be precipitated by atherosclerosis. Multiple medical interventions can be used to prevent harm secondary to obesity. Harm reduction in healthcare can be controversial, as it can be seen to perpetuate hazardous behaviour.

Looking at compassionate pragmatism, practical solutions, to try and meet these challenges to avoid death and disability is a possible humane solution to address the challenges presented by risky behaviours. One of the frameworks which has been provided in the Middle East is the MENARA, the Middle Eastern and North African Harm Reduction Association. This organisation provides the framework to reach out to civil society organisations so that their active role within harm reduction can be strengthened.

Smoking statistics in GCC countries

The prevalence of smoking in GCC countries is relatively high, compared to countries, such as Sweden. The smoking prevalence rate there is around 7% for males, and across GCC countries the prevalence is in double figures. The prevalence of smoking in males in Kuwait is 37.9%, and the prevalence amongst males is higher than that in females.

Smoking risks and smoking cessation benefits

Conventional cigarettes are a major cause of preventable death. Conventional cigarettes increase the risk of lung cancer, oesophageal cancer and bladder cancer in both men and women. Other associated conditions include, chronic obstructive pulmonary disease (COPD), coronary heart disease and type 2 diabetes. In pregnancy, smoking can lead to low birth weight and pre-term delivery. It can lead to sudden infant death syndrome if there is smoking in the household. It can exacerbate autoimmune diseases such as lupus and hypothyroidism. The risks associated with cigarette smoking, and education on harms associated with smoking are given through engagement campaigns and at schools.
Stopping smoking prior to surgery has many benefits. These include shorter hospital stays, reduced risks of complications, such as infections, better overall survival rates and fewer readmissions. One of the models which is used within a harm reduction strategy before surgery is prehabilitation, which focuses on optimisation of certain lifestyle behaviours, such as stopping smoking, before an operation. This has a very good success rate and leads to adoption of healthy behaviours.
Despite being aware of the negative consequences, it is still hard to give up smoking. An FDA study found that of the 70% of smokers in the United States who wanted to give up, only 8% were successful. Looking at the UK, going cold turkey without any help or any adjuncts at all, the rate of quitting smoking long-term is 3%.

The quitting success rate from the UCL smoking toolkit study, with the help of nicotine replacement adjuncts and counselling, had a success rate of 23%. Action for Smoking-free New Zealand also found that given the addictiveness of tobacco, there are very low rates of successful quitting. Globally, more than 8 million deaths are caused as a result of smoked tobacco. Yet after one year of quitting smoking cold turkey, the average sustained abstinence rate is around 0.4%. Even clinical forms of nicotine, such as patches, gums, and lozenges have been available for many years and success is still very low.

Approaches to smoking cessation in the Middle East and UK

Approaches in the Middle East are similar to the standardised approaches globally. These approaches involve looking at individual, environment and societal levels, where there is a disincentive on smoking. This can include raising the taxes on cigarettes. Social media and educational campaigns on the dangers of smoking are crucial and very informative, especially for the younger generation. There is also the Framework Convention on Tobacco Control, which looks specifically at the demand and supply of tobacco. Despite the harms, one billion people still continue to smoke. This is because of addictive substances such as nicotine and tobacco. People who smoke are addicted to these substances and when they stop, they get urges, cravings and withdrawal symptoms. The behavioural aspect of smoking, such as going for a break to smoke, can make addictions difficult to overcome. Tools need to tackle nicotine cravings, as well as the behavioural aspects of smoking.
In 2016, the Royal College of Physicians published a report called Nicotine Without Smoke, Tobacco Harm Reduction Strategy. This argued that most of the harm caused by smoking, not from the nicotine, but from other components in cigarettes. The health and life expectancy of smokers could be improved by encouraging smokers to switch to a smoke-free source of nicotine, such as nicotine patches and gums. Smoke-free sources of nicotine are prevalent in Sweden, where there is a very low rate of smoking compared to the rest of Europe. These aid reducing the withdrawal symptoms and address urges. The Middle East and UK have similar approaches, but the UK has successfully used e-cigarettes as a tool for harm reduction.
Public Health England published comprehensive guidance on how to use e-cigarettes. E-cigarettes are currently available for purchase, but there are discussions about bringing in stronger legislation and regulation. This could lead to e-cigarettes being licensed and prescribed medicinally. E-cigarettes contain nicotine, so are not risk-free. They are, however, less harmful than conventional cigarettes. Regulated e-cigarettes can be a very effective tool for helping people to quit smoking. They are not for people who have never smoked, and they should not be used to encourage people to start smoking. E-cigarettes are a harm reduction tool that can be used to replace conventional cigarettes and help people quit smoking.
Administrative and government entities should make concentrated efforts to eliminate illicit tobacco trade and offer expert counselling, pharmacotherapies, and electronic messages to support patients who want to quit smoking. The UK has successfully reduced the rates of smoking. Tobacco taxes, comprehensive smoke-free laws in public places, health warning labels on cigarette packages, decreased advertising and a ban on the sale of tobacco products to minors are measures which have contributed to the reduction in these rates. E-cigarettes have also been an effective tool for smoking cessation. In combination with in-person counselling, e-cigarettes have been shown to be twice as effective as other nicotine replacement products. For effective harm reduction, there needs to be correct education and strong guidance to healthcare professionals to be able to have effective smoking cessation discussions with patients who wish to quit smoking. In New Zealand, there has been a dramatic reduction over the last decade or so in those who conventionally smoke daily, and this is linked to increasing e-cigarette use. This provides a less harmful alternative to manage nicotine addiction, although it may lead people to have dual-usage. E-cigarette use for smoking cessation has a significant impact on chronic disease prevention. Evidence to date suggests that the availability of e-cigarettes in the UK has been beneficial to population health.
Harm reduction strategies are a way to reduce the negative health and social consequences of tobacco use. They can be considered a failure if they appear to reduce net harm, however actually redistribute harm to different groups of people. There is a clear benefit for the use of e-cigarettes in existing smokers. However, there is also concern that e-cigarettes could lead to an increase in smoking among never smokers, particularly among economically or socially vulnerable groups. The data currently available does not suggest that this is happening, but it is important to monitor the situation long-term. The Public Health Charity, which was set up by the Royal College of Physicians, and Action on Smoking and Health (ASH) are looking at this.

E-cigarettes and youth 

It is illegal to sell tobacco products to anyone under the age of 18 and a large majority of 11–17-year-olds have never tried or are unaware of e-cigarettes. However, the trend of people who are trying vaping is increasing. This is a crucial area where there needs to be effective education and continual monitoring of rates. Young people who used e-cigarettes, who haven’t smoked before, reported mainly as something to try as their main reason for their use. Legislation around this needs to focus on safeguarding younger members of society.
There currently isn’t longitudinal data on the impact of nicotine on younger children, under the age of 18 years, over a long period of time. Awareness of e-cigarettes is relatively high and regular use remains low, but should be something that is monitored over a long period of time. E-cigarette use can be promoted on social media. For young people who receive a lot of information on social media, there needs to be a good framework and guidance on what can and cannot be promoted. Sample studies from Switzerland and Japan, between 2017 and 2018, show a low percentage of people both in junior high school and high school that use e-cigarettes on a regular basis, between 0.7 to 1.7%. Smoking of conventional cigarettes is 0.6 to 1.5%, and in high school, the use of conventional cigarettes monthly or daily seems to be higher than those of e-cigarettes as well. The ASH Youth Survey released in February 2022 showed that the number of year 10 students who smoke daily decreased in 2021, however daily vaping increased. The government has recently introduced vaping regulations to protect teenagers by banning vaping advertising and sponsorship and sales to young people, this has also been done in New Zealand to protect young people.

In summary, smoking is the biggest avoidable cause of death, disability and social inequality in health in the UK. Nicotine products without the harmful components of tobacco smoke can prevent most of the harm from smoking. In the interest of public health, it may be important to promote the use of e-cigarettes, nicotine replacement therapy, other non-tobacco and nicotine products to help people quit smoking. At the same time, there’s a strong need for regulation to reduce direct and indirect adverse effects of e-cigarette use, and this should be monitored. The majority of e-cigarettes are used by smokers who are trying to reduce harm to themselves and others from smoking or to aid smoking cessation. Prof. Tara Rampal runs harm reduction clinics, where there is an individualised approach to those who wish to stop smoking, given the different habits, behaviours and cultural background that people have. Given the addictive nature of nicotine, in smokers who have used cigarettes for a long time or a short time, the clinics provide personalised programmes and harm reduction strategies to aid smoking cessation. The evidence-based effectiveness of counselling with nicotine replacement therapy is used for all patients in Prof. Rampal’s clinics. “Regulations and licensing is a crucial step in order to get confidence from the public that this has been licensed, and that all has to be backed scientifically by data, and again, a huge education campaign” states Prof. Rampal. “We have to be very aware that we are not suggesting to anyone that e-cigarettes are completely without any harm and that they should take it up if they’re not smoking.” Prof. Rampal acknowledges that these conversations with people who wish to quit smoking can be challenging, and given the addictive nature of smoking, a supportive approach that isn’t stigmatising is required to help those who wish to quit. Smoking cessation monitoring can be challenging because data is self-reported. However, “there is also carbon monoxide monitoring, which can be done in the clinics as well, especially if they’re preparing for something like a major operation”. Prof Rampal uses this in her clinics, “you can show patients the levels of carbon monoxide in their breath, and then they can also have those levels measured once they move on to e-cigarettes and see the dramatic fall for themselves that motivates them further.”

Dr Mahir Yousef has witnessed dual-use being a significant problem in his practice in the Middle East. During this conversation, he discussed the regulation of e-cigarettes and the possibility for them to be written as a prescription. This may encounter barriers with un-regulated products being sold. “When taxes were raised on cigarettes and on nicotine products in the Middle East, it didn’t actually reduce the number of smokers, it just opened the black market in a very bad way, so that any cigarettes from anywhere were smoked” states Dr Yousef. “We know that for a fact that we can’t actually control what people do as a measure to our prohibition or demanding them not to smoke, that’s the last thing we want.” The effects will be seen in longitudinal data. Prof. Rampal states “I think those take 20-30 years to come across. So on a population level, we are still very much at the nascent stage.”