Tobacco harm reduction in Afghanistan: a recipe for improving smokers' health

Tobacco Harm Reduction (THR) offers a promising approach to addressing the significant burden of smoking in Afghanistan. Over three million Afghans smoke daily, making it a leading cause of preventable deaths in the country. While the previous Afghan government implemented various tobacco cessation policies and strategies, these measures were only partially effective in reducing the number of smokers or smoking-related deaths. In 2021, community-based initiatives in Kabul and Herat started advocating for Tobacco Harm Reduction (THR) as a novel, realistic, and practical approach proven to promote smoking abstinence and minimize tobacco harm. However, implementing THR strategies in Afghanistan faces numerous challenges, including a lack of governmental support, funding issues, unfavorable market conditions, the high cost-effectiveness of THR products, and misconceptions about these products. To effectively promote THR in Afghanistan and overcome these challenges, it will be necessary to implement THR policies that support THR products for smokers, regulate the market for these products, produce them locally with healthcare professional oversight, conduct more engaging advocacy campaigns, and secure domestic sponsors.

Snus and Snuff Use in Switzerland Among Young Men: Are There Beneficial Effects on Smoking?

Introduction

There are few recent longitudinal studies on smokeless tobacco (SLT) products and smoking outside the United States or European Nordic countries. The present longitudinal study tests whether Swedish-type snus and nasal snuff use decreases smoking incidence and prevalence in a central European country.

Methods

The sample consisted of 5198 Swiss men (around 20 years of age). Retention rate was 91.5% over 15 months. Regression models, adjusting for a variety of psychosocial, smoking-related, and other risk factors, assessed whether no, low (less than weekly), and high (weekly or more) use baseline groups showed changes or maintenance in snus and snuff use related to smoking initiation, cessation, and reduction.

Results

Among baseline nonsmokers, snus initiators (OR = 1.90, p = .003) and low baseline maintainers (OR = 4.51, p < .001) were more likely to start smoking (reference: persistent nonusers of snus). Among baseline smokers, initiators (OR = 2.79, p < .001) and low baseline maintainers (OR = 2.71, p = .005) more often continued smoking, whereas snus quitters less frequently continued smoking (OR = 0.57, p = .009). High baseline maintainers were non-significantly less likely to continue smoking (OR = 0.71, p = .315). Among continuing smokers, only snus quitters significantly reduced the number of cigarettes smoked per day (b = -1.61, p = .002) compared with persistent nonusers of snus. Results were similar for snuff.

Conclusions

SLT use did not have any significant beneficial effects on young men in Switzerland but significantly increased the likelihood of smoking initiation and continuation, independent of whether the substance is legally sold (snuff) or not (snus). This does not exclude that there may be beneficial effects at older ages.

Implications

Our research provides evidence that SLT use has no benefits for cigarette smoking initiation, cessation, or reduction among young men in a central European country, where SLT is not highly promoted or receives tax incentives. This is true for both legally sold nasal snuff and Swedish-type snus that cannot be legally sold. Results indicate that without incentives for using it, among young people shifts from smoking to SLT use are questionable and confirms the need for country-specific studies before the global public health community engages in promoting SLT.

Adolescents' First Tobacco Product: Results from a Nationally Representative Survey

Objectives

To inform targeted prevention efforts, it is important to understand which tobacco products are used first and associations by demographic characteristics.

Methods

We conducted a nationally-representative random digit-dial telephone survey of 1125 adolescents ages 13-17. Adolescents reported the first tobacco product they tried, and we analyzed associations with demographic variables.

Results

Two-hundred nineteen (18.6%) adolescents reported ever using a tobacco product. The most common first product tried was cigarettes (35.4%), followed by electronic nicotine delivery systems (24.3%), smokeless tobacco (17.7%), cigars (11.4%), and waterpipe (11.2%). Weighted multivariable logistic regression analyses showed girls were 2.7 times more likely than boys to report cigarettes as their first product, Hispanic/Latinos were 5.0 times more likely than non-Hispanic/Latinos to report cigarettes, and those whose mothers had at least a 4-year college degree were 6.1 times more likely to report waterpipe compared to those whose mothers had less than a 4-year college degree.

Conclusions

Nearly one in 5 adolescents had tried a tobacco product. Although cigarettes were the most frequently reported product, most youth initiated with a non-cigarette tobacco product, and demographic differences were found. These findings point towards potential regulatory policies, including targeted campaigns, which might deter adolescents from initiating tobacco use.

Young or adult users of multiple tobacco/nicotine products urgently need to be informed of meaningful differences in product risks

Previously, it has been argued that health information efforts need to inform the public about meaningful differential risks from tobacco/nicotine products. The fact of multiple product use by the same individual further supports this need. When the majority of youth, for example, who use smokeless tobacco are also current tobacco smokers, it makes little sense to mount a smokeless prevention campaign that fails to include clear messages about the much greater risks from smoking. In April 2016, The Food & Drug Administration (FDA) announced a $36 million campaign for youth that "smokeless doesn't mean harmless." Research shows the public (a) already knows that smokeless tobacco is not harmless, but are (b) also largely unaware that cigarettes are much more harmful than smokeless. Though not harmless, smokeless tobacco has been estimated to be over 90% less harmful than cigarettes. 'Gateway' fears are made moot by current use of multiple tobacco/nicotine products. When multi-tobacco product use is commonplace among users, usable information on significant differences in risk is crucial for both adult and younger users. The FDA and like campaigns and health information websites should follow established ethical principles and accepted communication methods to inform the public of less-harmful tobacco/nicotine products as well as the greater harms of smoking, in keeping with the Surgeon-General's advice that reductions in smoking in particular will bring about the greatest public health advances.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Appropriate and inappropriate methods for investigating the "gateway" hypothesis, with a review of the evidence linking prior snus use to later cigarette smoking

Background

The “gateway hypothesis” usually refers to the possibility that the taking up of habit A, which is considered harmless (or less harmful), may lead to the subsequent taking up of another habit, B, which is considered harmful (or more harmful).

Methods

Possible approaches to designing and analysing studies to test the hypothesis are discussed. Evidence relating to the use of snus (A) as a gateway for smoking (B) is then evaluated in detail.

Results—design and analysis considerations

The importance of having appropriate data available on the sequence of use of A and B and on other potential confounding factors that may lead to the taking up of B is emphasised. Where randomised trials are impractical, the preferred designs include the prospective cohort study in which ever use of A and of B is recorded at regular intervals, and the cross-sectional survey in which time of starting to use A and B is recorded. Both approaches allow time-stratified analytical methods to be used, in which, in each time period, risk of initiating B among never users of B at the start of the interval is compared according to prior use of A. Adjustment in analysis for the potential confounding factors is essential.

Results—review of evidence

Of 11 studies of possible relevance conducted in Sweden, Finland or Norway, only one seriously addresses potential confounding by those other factors involved in the initiation of smoking. Furthermore, 5 of the 11 studies are of a design that does not allow proper testing of the gateway hypothesis for various reasons, and the analysis is unsatisfactory, sometimes seriously, in all the remaining six.

Conclusions

While better analyses could be attempted for some of the six studies identified as having appropriate design, the issues of confounding remain, and more studies are clearly needed. To obtain a rapid answer, a properly designed cross-sectional survey is recommended.

Which nicotine products are gateways to regular use? First-tried tobacco and current use in college students

BACKGROUND

The potential for emerging tobacco products (ETPs) to be gateway products for further tobacco use among youth is of significant concern.

PURPOSE

To examine use of various nicotine-containing products on a tobacco-free college campus and whether the first product tried predicts subsequent tobacco use.

METHODS

Undergraduate students (N=1,304) at a large university completed an online survey of past/current use of cigarettes; smokeless tobacco (SLT); hookah; ETPs (dissolvables, snus, and electronic cigarettes); and nicotine replacement therapy (NRT). Data were collected from September 2012 to May 2013 and analyses were conducted from June to September 2013. Students were classified as single, dual, or poly tobacco users.

RESULTS

The sample consisted of 79.5% non-users, 13.8% single, 4.4% dual, and 1.5% poly users. Overall, 49.4% of participants reported trying a tobacco product. Hookah was the most tried product (38%), but cigarettes were most often the first product ever tried (51%). First product tried did not predict current tobacco use and non-use, but individuals who first tried SLT or cigarettes (rather than hookah or ETPs) were more likely to be poly tobacco users. Current tobacco users who first tried ETPs or hookah were largely non-daily users of hookah; current tobacco users who first tried cigarettes or SLT were largely non-daily or daily users of cigarettes/SLT.

CONCLUSIONS

Hookah and ETPs are increasingly becoming the first tobacco product ever tried by youth; however, uptake of ETPs is poor, unlike cigarettes and SLT, and does not appear to lead to significant daily/non-daily use of cigarettes and SLT.

Tobacco harm reduction: the need for new products that can compete with cigarettes

Over the last 50 years, the concept of tobacco harm reduction has been well established. It is now understood that nicotine itself is not very harmful and nicotine replacement therapy products have been widely used as an aid to quit, reduce to quit or temporarily abstain from smoking for many years. The popularity of the unlicensed electronic cigarette has increased despite an unknown risk profile and sinus use in Sweden provides strong evidence in support of a harm reduction strategy. The regulatory environment around harm reduction has changed in the UK and is continuing to evolve across the globe. The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. The significant positive impact on public health that could be gained from encouraging people to switch from cigarettes to licensed medicinal nicotine products cannot be ignored.

Smoking and snus use onset: exploring the influence of snus debut age on the risk for smoking uptake with cross-sectional survey data

INTRODUCTION

Snus use has become increasingly prevalent among young people in Norway, while smoking has declined. Little is known about the transitions between snus and other tobacco products, particularly among younger users. A major concern involves the association between snus initiation and future smoking uptake.

METHODS

A total of 409 lifetime snus users who had started with snus before cigarettes or were never-smokers were selected from a national sample of participants in annually repeated cross-sectional surveys (2005-2011) of Norwegian men and women aged 15-74 years. About 30% of them were lifetime smokers, 84% were men, and the mean age was 29.4 years. Logistic regression was applied to investigate the association between age of snus uptake and the risk for becoming a smoker later on.

RESULTS

Respondents who started using snus before the age of 16 years had an odds ratio of 3.1 (confidence interval = 1.98-4.76) of being lifetime smokers compared with those who initiated snus later. The prevalence of current smoking among early snus initiators (22.9%) was comparable to that found among never-snus-users (29.6%). Among late snus initiators, current smoking prevalence was 5.9%.

CONCLUSION

In this study, snus debut age was an important factor for the association between snus use and smoking.

The chemical composition of smokeless tobacco: a survey of products sold in the United States in 2006 and 2007

Selected toxicant concentrations and other chemical measures have been determined for 43 U.S. smokeless tobacco products sold in 2006 and 2007. Products evaluated included moist snuff, dry snuff, loose leaf, plug, dissolvable and snus tobacco brands. Reference products available for scientific research purposes and eleven Swedish products were also evaluated and compared to the commercial products studied. Chemical endpoints determined included benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N-Nitrosodimethylamine (NDMA), nitrite, cadmium, lead, arsenic, nickel, chromium, chloride, water, pH and nicotine. Different toxicant profiles were observed for the products studied, with snus tobacco brands generally containing relatively low concentrations of B[a]P and tobacco specific nitrosamines (TSNAs) compared to other moist snuffs. Smokeless tobacco reference product toxicant profiles were similar to corresponding commercial products, with the exception of the TSNA content of the dry snuff reference material. TSNA concentrations observed for all commercial products were lower than historically reported values, likely reflecting changes in product shelf life, tobacco curing practices and, possibly, product blend formulations during the last 20-30 years. The survey results summarized provide a temporal point of comparison with future data anticipated from FDA "harmful and potentially harmful constituents in tobacco products" reporting.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."