By Professor Tara Rampal MBBS FRCA

& Dr Mahir Yousef FRCSEng, JBS, FMAS, DMAS

What is harm reduction in healthcare?

Harm reduction is a method used in medicine and social care to minimise harm to individuals and/or wider society from hazardous behaviours or practices that cannot be completely avoided or prevented. Harm reduction aims to mitigate the risk of substances and behaviours that detriment humans. Substances can be injected, smoked, swallowed and eaten!. Sometimes by appearing to condone or perpetuate hazardous behaviours that could in theory be prevented, harm-reduction approaches can be controversial, particularly in medicine. To their proponents, however, they represent pragmatic solutions to a range of otherwise intractable causes of avoidable death and disability. 

The impact of harm reduction on public health

The harm reduction method of “Methadone Maintenance Treatment (MMT) is used in the western countries and is widely recognized as one of the most effective ways of reducing risk of overdose, arrest, and transmission of blood-borne viruses like HIV and HCV among people that use opioids.” Harm Reduction Journal https://tinyurl.com/3339tu7c Harm reduction is already in daily medical practice in the middle east. The overeating (abuse) of food (substance) drives obesity and the harm reduction strategy used is the use of xenical drug and bariatric surgery. Long-term cardiovascular outcomes after orlistat therapy in patients with obesity: a nationwide, propensity-score matched cohort study. Orlistat was associated with lower rates of overall major adverse cardiovascular events, new-onset heart failure, renal failure, and mortality. https://tinyurl.com/2s3c8kbh Organisations such as MENAHRA – The Middle East and North Africa Harm Reduction Association exist to advocate best practices in strengthening civil society’s role in delivering harm reduction services, their abstract as shown below.

Smoking cessation

Current approaches to smoking cessation in the Middle East include raising taxes on cigarettes, social media campaigns on the dangers of smoking, Framework Convention on Tobacco Control (FCTC) measures targeting the demand for and supply of tobacco and efforts to eliminate the illicit tobacco trade. For the Individual there is; counselling, Pharmacotherapies, follow up electronic messages to keep patients motivated to quit. The Middle East and UK approach are similar but not the same.  The main difference is that,  the UK, in addition to nicotine replacement therapies, has successfully used e-cigarettes as a tool in harm reduction. Currently patients have to buy their e-cigarettes but have plans to be the first country in the world to prescribe medicinally licensed e-cigarettes to help reduce harm from smoking tobacco cigarettes. E-cigarettes contain nicotine and are not risk-free, but expert reviews from the UK and US have been clear that the regulated e-cigarettes are less harmful than smoking. A medicinally licensed e-cigarette would have to pass even more rigorous safety checks. https://tinyurl.com/2p8bdpb6

Addiction

Smoking is completely preventable, yet, more than half a century after the health harm of smoking first became widely known, almost 1 billion people worldwide still smoke. The primary reason is nicotine addiction, we know that this addiction is  extremely difficult to overcome, many will continue to smoke until they die.  The RCP published a report promoting the principle of harm reduction in nicotine addiction, arguing that, as most of the harm caused by smoking arises not from nicotine but from other components of tobacco smoke, the health and life expectancy of today’s smokers could be radically improved by encouraging as many as possible to switch to a smoke-free source of nicotine. “Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction. London: RCP, 2016” https://www.rcplondon.ac.uk/  In May 2022. The Lancet praised the UK for showing how smoking can become obsolete through approaches that include tobacco harm reduction. https://tinyurl.com/25ctf8f5

Public Health England recently reviewed the challenges of implementing harm reduction with the following conclusions: the greatest obstacle we face is the widespread misconception amongst smokers and health professionals that most of the harm of smoking comes from the nicotine”  This leads to both nicotine replacement therapy (NRT) and e-cigarettes being perceived as harmful as cigarettes.   “While nicotine is the addictive substance, it is relatively harmless. In fact, almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic.” https://tinyurl.com/44s5n349 There is growing evidence on the most effective ways to reduce harm including the publication of data and discussion by the Tobacco Advisory Group and Public Health England’s review of the use of e-cigarettes and heated tobacco products. Harm Reduction is not new; The Royal College of Physicians (RCP) UK, issued a smoking harm reduction report as far back as 1962. Comparing with tobacco harm reduction in Sweden; The availability of ‘snus’ has been estimated to have added around 0.4 percentage point per year to the rate of decline in smoking prevalence. Observational population-level evidence indicates that dual users of both tobacco and e-cigarettes are more likely to try to stop smoking than smokers who do not also use e-cigarettes. “Experience to date suggests that, as predicted in principle in the 2007 report, the availability of e-cigarettes has been beneficial to UK public health,” “all the UK evidence, and almost all the international evidence, on the use of e-cigarettes by children and young people to date indicates that concerns about e-cigarettes helping to recruit a new generation of tobacco smokers through a gateway effect are, at least to date, is unfounded,” “evidence to conclude that any harm from long-term nicotine use will still be negligible compared with the harm of tobacco use.”  https://tinyurl.com/4fp3jb8s

A harm-reduction strategy could be considered to have failed if the net harm were reduced, but the distribution of harm changed in a way that was unjust, e.g. if, as a result of the harm-reduction strategy, some socially or economically vulnerable group became more at risk of harm, or systematically less able to benefit from smoking cessation and prevention strategies. The benefit to existing smokers of switching to e-cigarettes is clear, however, if large numbers of never-smokers were to take up e-cigarette use, they would be exposing themselves to health risks that would otherwise be avoided, and financial costs, which are of particular detriment to poorer smokers, that they would not otherwise incur. At present this does not appear to be happening.”

Barrier to harm reduction

Public Health England have reviewed the challenges of implementing further harm reduction methods in the UK and concluded with, “perhaps the greatest obstacle we face is the widespread misconception amongst smokers and health professionals that most of the harm of smoking comes from the nicotine,” this leads to both nicotine replacement therapy (NRT) and e-cigarettes being perceived as harmful as cigarettes. “While nicotine is the addictive substance, it is relatively harmless. In fact, almost all of the harm from smoking comes from the thousands of other chemicals in tobacco smoke, many of which are toxic.” https://tinyurl.com/44s5n349

E-cigs safety?

Stopping smoking will always be the best option but for those that can’t the medical objective is to minimize harm. E-cigs are used in the tool kit of harm reduction and long-term monitoring is needed. The regulated manufactures do not claim there are no risks to e-cigs but the evidence says they are less risk than combustible cigarettes. Less risk is risk reduction. The risk level and carcinogenic compounds will vary subject to the devise and manufacturer. That’s why it’s critical for tobacco companies to disclose their product details in detailed scientific papers and for researchers to independently verify what the manufacturer says.  Let’s face it, tobacco companies should have their data verified to check their claims. This is where the UK is leading by going down the path of regulation of e-cigarettes for both non prescribed consumer use and doctor prescribed medical use. The risk level of any carcinogenic compounds will vary subject to the format of the devise and manufacturer and where in the world the devise was manufactured as manufacturing regulations vary. It’s a lot like the safety of medications. Paracetamol made by a poor-quality unregulated manufacturer could kill people due to manufacture contamination. Therefore, we have pharmaceutical standards to protect against the varying quality of products and manufacturing standards. This is why people need to choose carefully and speak to their doctor before switching to any non-combustible device. This is also why this CME is helpful as it starts the education process so that healthcare professionals are in the learning process of critical areas such as harm reduction.

Popcorn anyone?

Popcorn lung is technically called Bronchiolitis obliterans which is a respiratory condition that affects the bronchioles of your lungs. In 2002, the Centers for Disease Control and Prevention (CDC) documented cases of lung disease in employees who had worked in a Missouri popcorn factory between the years 1992 and 2000. Investigation showed that those with the worst lung damage had spent considerable time mixing a flavoring chemical called diacetyl with hot oil in large industrial vats. As a result, the major popcorn manufacturers removed diacetyl from their products. Cancer Research UK reviewed popcorn lung and in the article ‘What does the evidence really say about diacetyl and e-cigarettes? In the UK and EU some of the liquids in e-cigarettes used to contain diacetyl. In the EU, diacetyl was banned in e-cigarette liquids under the EU Tobacco Products Directive (TPD) in 2016. So, e-liquids sold in the UK and EU shouldn’t contain diacetyl. As not all pharmaceuticals are manufactured equally, neither are e-cigarettes so it’s prudent to examine if the manufacturers devise contains diacetyl or not. This is another reason for CME education (please view our harm reduction online course)  as poorly manufactured unregulated e-cigarettes could kill you whereas a strictly controlled regulated e-cigarette can be used as a tool in harm reduction for those that cannot or do not want to quit smoking. https://tinyurl.com/339bxx3e

Are all e-cigs a gateway to smoking?

Non-regulated e-cigs from unknown manufacturers with child friendly flavors are bad news. HOWEVER, in March 2022 UCL university, in UK, published that regulated E-cigarettes are not a substantial gateway to smoking for young people. The UCL research found that E-cigarette use in England among young adults between 2007 and 2018 did not appear to be associated with substantial increases or decreases in the prevalence of smoking uptake. Several longitudinal observational studies have previously suggested that e-cigarette use may act as a “gateway” towards later use of cigarettes in adolescents. However, these findings may reflect shared vulnerability in that the same young people who would try e-cigarettes would also more likely later to smoke cigarettes. One way to avoid this self-selection bias is to assess the impact at the population level rather than the individual level, using an approach called time series analysis. Using this method, the current study measured the gateway effect of vaping by looking at the association between prevalence of e-cigarette use among young adults and prevalence of uptake of smoking generally, including among people who have never smoked. The researchers reasoned that if a gateway effect existed, there ought to be associated population-wide changes in the prevalence of smoking uptake when the prevalence of vaping changed. In the new study, published in the journal Addiction, the authors found no statistically significant association between the prevalence of e-cigarette use and ever having smoked regularly (used as an indicator of uptake) among those aged 16 to 24. Lead author Dr Emma Beard (UCL Institute of Epidemiology & Health) said: “These findings suggest that the large gateway effects reported in previous studies can be ruled out, particularly among those aged 18 to 24. However, we cannot rule out a smaller gateway effect and we did not study younger age groups. https://tinyurl.com/3ddfkaub

EVALI

The outbreak of EVALI cases that occurred primarily in the US in 2019. These tragic events were not associated with the use of nicotine-containing cigarettes, but it has led to major confusion about e-cigarettes and some smokers mistakenly believing that e-cigarettes are even more harmful than cigarettes. The investigations on the outbreak conducted by the US Food and Drug Administration (FDA) and the US Centers for Disease Control (CDC) concluded that the outbreak of lung illnesses is strongly linked to the presence of vitamin D acetate, an additive in some vaping products that contain tetrahydrocannabinol (THC). A recent study https://tinyurl.com/bdefzch9 analyzed samples from 51 EVALI cases from 16 states and a comparison group of samples from 99 comparison individuals without EVALI for vitamin E acetate, plant oils, medium chain triglyceride (MCT) oil, coconut oil, petroleum distillates, and diluent terpenes. Both the CDC and the U.S. FDA recommend that people not use THC-containing vaping products, particularly from informal sources such as friends, family, or in-person or online dealers. Both the FDA and the CDC have stressed that consumers should not buy illicit products, particularly those containing THC, or add any substances to legal shop bought liquids. They have also stressed that adult smokers who have switched to e-cigarettes should not go back to cigarettes. This outbreak was linked primarily to unregulated, illicit THC containing products, which should not be confused with regulated nicotine containing products. Once again, e-cigarettes are not without risk and smoking cessation is always the best option for adult smokers. But for those that will not quit, products that are regulated and supported by scientific studies are a better option to continue smoking. https://tinyurl.com/3mp2c948

This article was produced directly from an accredited CME session on harm reduction. CME Medical Education Sponsored by: Philip Morris Management Services (Middle East) Limited