Chapter 12
Reducing Harm from Cigarette Smoking
IN THIS CHAPTER
Knowing the difference between tobacco and nicotine
Understanding what happens when you continue to smoke cigarettes
Substituting smokeless tobacco
Turning to e-cigarettes
You already know the health risks associated with smoking. You know that smoking costs you a ton of money as well. You’d like to quit, but maybe you don’t feel like you can face the battle right now. It would be nice if there were a perfect pill that would take away all your cravings or if you’d just wake up one morning as a nonsmoker. But there isn’t a pill and you won’t magically wake up a nonsmoker. You’re simply not ready to give up what has become your best friend — a cigarette.
We want to be clear here: Quitting and complete abstinence from smoking represents your absolutely best bet at long-term good health. No question. But we’re also realists. People vary in their tolerance and ability to fully quit smoking. And sometimes people just aren’t ready or willing to completely stop.
If you’re not ready to completely quit, at least keep the possibility of complete abstinence in your mind as your ultimate goal for the future.
In this chapter, we deal with, “in the meantime.” Harm reduction is a concept in the addiction literature that has gained support over the past few decades. Harm reduction refers to the understanding that some people are going to smoke, vape, or consume tobacco in some form no matter what — at least for a while. Harm reduction approaches aim at reducing the harmful health effects of smoking or vaping until a person is willing to take a run at total abstinence. Harm reduction can improve a cigarette smoker’s quality of life and health.
Here’s a tricky point: If you’re considering harm reduction as an approach instead of quitting, make sure that you’re not kidding yourself. Are you doing it so that you can have an excuse to keep on smoking? There’s a fine line between reducing the harm from smoking and simply making an excuse to keep on smoking.
If you’ve tried quitting numerous times and you consider yourself a failure, you may want to rethink your conclusion. In reality, you’ve reduced harm and produced lots of nonsmoking days that do matter. For example, 30 attempts that average 20 days of nonsmoking means almost two years of nonsmoking! That reduces harm. Keep at it! Of course, the eventual and best goal is quitting, but you already know that.
Distinguishing Between Tobacco and Nicotine
People smoke cigarettes, consume smokeless tobacco in various ways, or vape, primarily to enjoy the effects of a sudden jolt of nicotine. Nicotine is a highly addictive drug.
However, nicotine is not the primary source of increased risk of cancer, chronic obstructive pulmonary disease (COPD), heart disease, and other health maladies (see Chapter 3 for more information about the health risks of tobacco). This distinction is difficult for many people to keep in mind because smoking and nicotine are so frequently and closely associated. People smoke because they’re addicted to nicotine, but they aren’t addicted to the smoke or tar that ultimately makes them sick and kills them.
Rest assured, nicotine does not merit a totally clean bill of health. It is, indeed, a powerfully addictive drug. And it does have some negative health effects, including the following:
- Increased heart rate
- Increased blood pressure
- Increased blood sugar
- Gastrointestinal disorders
- Decreased immune response
- Links to cancer (mostly as a possible tumor promoter)
The severity and pervasiveness of these damaging effects are far less clear and less known than those for tobacco itself. In fact, the relative safety of nicotine is seen in the proliferation of nicotine replacement products available without a prescription. Clearly, the U.S. Food and Drug Administration (FDA) sees nicotine as far less harmful than tobacco. So, if you eliminate all tobacco and substitute pure nicotine, you’ll greatly reduce your health risks from smoking and vaping.
Although nicotine replacement therapy (NRT) is generally not recommended for long-term use, many people continue with it far longer than initially prescribed or recommended. They’re still reducing their health risks over those they would incur if they continued to smoke.
Trying to Reduce the Harm While Continuing to Smoke Cigarettes
Some smokers hoping to reduce harm, without totally giving up cigarettes, try various strategies that don’t necessarily work. Sorry, you can’t have your cake and eat it, too. Although these approaches make intuitive sense, research tells us something different:
- Cutting back the number of cigarettes smoked: Smoking three packs of cigarettes a day is worse than smoking one pack a day. Duh. So, is smoking 15 cigarettes better than a pack and 10 better than 15? And is 5 better than 10? All things being equal, of course. But actually, it isn’t always so equal, as you’ll soon see.
- Smoking with a filter: Filters came onto the smoking scene in the mid 1950s. Tobacco companies touted filters as a safer way to smoke. Unfortunately, their first attempt at filters included asbestos as an ingredient. You’ve probably heard that asbestos is a highly toxic carcinogenic. Later, asbestos was replaced with ostensibly safer ingredients. Today’s cigarette filters do remove some tar and nicotine, and apparently, they slightly reduce the risk of lung cancer.
- Turning to light and ultra-light cigarettes: The makers of these cigarettes claim that they contain decreased levels of tar. The labels have been banned by the government because tobacco company claims regarding safety convey a level of unwarranted protection. Smokers of light and ultra-light cigarettes have been found to be less addicted, but interestingly less likely to quit. That may be because these smokers believe they’re smoking something relatively safe. Not true.
Cutting back, using filters, and smoking light cigarettes are generally ineffective harm-reduction strategies. In part, that’s because smokers who try to reduce their risks by smoking less or smoking ostensibly safer cigarettes end up smoking differently.
Numerous studies have shown that smokers who cut down the number of cigarettes smoked, smoke light cigarettes, or use filters:
- Inhale more deeply
- Hold the smoke longer
- Inhale more often
Guess what these tactics do? They bring the level of nicotine, tar, and numerous carcinogens back up closer to the amount inhaled with regular cigarette smoking. In addition, filters make the smoke less irritating to the throat, which also encourages deeper inhalations.
Many smokers are unaware that they’re compensating for reduced nicotine by smoking differently. Cutting back by reducing the number of cigarettes smoked, often results in not cutting back at all — unless you’re the rare smoker who can cut way back on quantity and not smoke differently. Therefore, these methods are usually a very bad choice for harm reduction. And if you’re one of those extremely rare smokers who can smoke just a few each day, quitting surely seems to be a better option for you with significantly less grief overall.
Some people struggle with decisions about cutting back their smoking or going to a safer cigarette. Check out the nearby sidebar, “Cutting back,” for a story of one woman’s attempt to grapple with harm reduction.
Trying Smokeless Tobacco Products
Most people who try to quit smoking fail — not once or twice but multiple times. Some studies suggest that 30 attempts are not unusual. Most studies have used abstinence from tobacco and nicotine as the only long-term measure of success. But if you ask smokers why they want to quit, most will tell you that it’s because of concerns about health.
So, if improved health is the primary goal of quitting, then reducing harm by using less toxic products makes sense. Smokeless tobacco would be one approach consistent with a harm reduction goal.
While not entirely safe, smokeless tobacco is much less harmful to health than burning tobacco and inhaling the smoke. Unfortunately, little effort has been devoted to studies of harm reduction with smokeless tobacco for those unwilling or unable to cease tobacco use entirely.
One reason for this reluctance is that smokeless tobacco does increase risks of oral cancer and likely the risk of premature death, although those risks appear quite small compared to those caused by regular smoking. The exact comparative risks are unknown because we need more studies to determine that. Of note, the FDA has recently granted permission to a Swedish company to market a smokeless form of chewing tobacco (known as snus) as a safer alternative to smoking combustible cigarettes.
Research indicates that smokeless tobacco has the potential to save lives compared to smoking (see the nearby sidebar, “Smoking rates and snus use in Sweden”). The appeal of this approach has gone up because products are now available that require little or no spitting and are easier to dispose. Users, increasingly including more women, report that some products can be consumed quite discretely, avoiding the considerable stigma once associated with smokeless tobacco.
Another important advantage of using smokeless tobacco products is that they don’t produce smoke. So, they not only reduce harm to the smoker, but also eliminate secondhand and thirdhand smoke for the family, coworkers, and friends in the smoker’s world.
Yet another advantage of smokeless tobacco is that some of the newer products are especially discrete and don’t require spitting and awkward disposal — that allows for less possibility of young children detecting its use in adults and trying to model that behavior. On the other hand, this same discreteness makes the product more appealing to teenagers who are trying to hide their use of smokeless tobacco from their parents.
Smokeless tobacco products sometimes come in enticing flavors and colors, which makes them more desirable to children and pets. Be sure to keep them stored in a safe, unreachable location.
Teens also find enticing flavors attractive. In fact, smokeless tobacco use among teens is growing. Teens are especially susceptible to nicotine addiction, so there’s mounting concern over the issue of flavors and colors that could be used to lure them into the clutches of smokeless tobacco.
Veering to Vaping
The idea of using vaping as a path to smoking cessation is controversial (as is the use of smokeless tobacco). We want to assure you that we’ve done our homework. Some time ago, when we first began to study this issue, we thought that e-cigarettes’ promise as a safer cigarette was a totally unsupportable ploy. We assumed that e-cigarette manufacturers were out to exploit an uninformed public for the purpose of profits.
In our search for the truth, we even visited various vape shops where seemingly sincere personnel did little to assuage our concerns. Nonetheless, we dove into the literature and discovered surprising support for the concept.
One of the benefits of e-cigarettes over NRT is that vaping mimics the act of smoking. Former smokers can enjoy both the act of inhaling with the absorption of nicotine without inhaling so many toxins. Yet, many countries have banned the sale of e-cigarettes.
In part, that’s because numerous people believe that e-cigarettes are as dangerous or more dangerous than smoking tobacco. The basis for this line of thought likely rests upon various associations about vaping and smoking.
For example, nicotine (found in many vaping devices) has been repeatedly associated with the dangers of cigarette smoking for decades. In fact, many people use the terms nicotine and tobacco interchangeably. Indeed, nicotine is the addictive drug that keeps you smoking. But it’s primarily the tar derived from burning tobacco in cigarettes that wreaks havoc on the body.
In addition, smoke is seen as unhealthy. And smoke from burning tobacco is unhealthy. The vapor from e-cigarettes looks like smoke while also being even more voluminous. Therefore, it’s easy to assume that the vapor is highly toxic, even though the data don’t support that idea.
Furthermore, vaping is associated with teenage use. This concern does have validity. Use by adolescents is surging and everything that can be done to keep the nicotine from e-cigarettes out of reach of teens is a good idea. No one wants teens to start a new addictive drug. But again, nicotine by itself, has a fraction of the health risks of tobacco. See Chapters 6 and 7 for more information about the risks of vaping and teen use.
Finally, there’s every reason to be concerned about the vaping-related crisis of serious lung damage, at times leading to death from e-cigarette or vaping product use-associated lung injury (now known as EVALI). Previously healthy vapers have been admitted to intensive care with life-threatening symptoms. The U.S. Centers for Disease Control and Prevention (CDC) is scrambling to determine the cause, although much of the focus has been on vaping products containing tetrahydrocannabinol (THC), especially those purchased on the black market. Particularly suspect are the ingredients (especially vitamin E acetate) used to make the THC liquid the correct consistency for vaping purposes. But as of this writing, the exact cause of EVALI remains elusive. Research continues and scientists believe that more than one cause could be involved.
As discussed in greater detail in Chapter 6, a large part of the current risk associated with vaping can be found in the relative lack of regulations of the industry. You have no clear assurances of what ingredients are contained in the liquid you choose to vape. That’s especially true if you purchase e-cigarettes or vaping devices through the black market. If you do decide to vape, be sure to purchase from a reputable shop. Of course, without clear regulatory guidelines you can’t be sure of what’s reputable. At least check the place out for length of time in business, Better Business Bureau (BBB) ratings, and Internet ratings. There are no guarantees, but do what you can to check.
Combining vaping and smoking
Although many people do continue to smoke and vape at the same time, it’s probably not a great idea to engage in that practice over time. Why do some people do this? Most hope to taper off cigarettes and increase vaping. For some smokers, the tapering works to decrease cigarette consumption. But doing this involves some possible health risk.
Check out the nearby sidebar, “Using e-cigarettes to transition off regular cigarettes,” for the story of a woman who continued vaping and smoking without the guidance of her physician as a means of cutting back on regular cigarettes.
In a nonrandomized, non-controlled study, researchers found that people who smoked and vaped were at greater risk for heart attacks than people who only vaped or only smoked. More research is called for to confirm this finding. The bottom line is that the sooner you quit smoking and eventually quit vaping, the better.
Quitting smoking with vaping
Over time some studies have emerged with the tantalizing promise that e-cigarettes can help smokers quit smoking. In fact, more people in the United States and elsewhere trying to quit, turn to e-cigarettes for help than attempt to quit through NRT. Yet, as of this writing, the FDA has not approved the use of e-cigarettes as a sanctioned approach to smoking cessation.
On the other hand, the United Kingdom has a very different take than the FDA on vaping with e-cigarettes. They acknowledge that vaping is the number-one tool used by smokers to quit. Based on accumulated research, the Royal Academy of Physicians wrote an extensive report with the following conclusions, in which they contend that e-cigarettes:
- Appear to help smokers quit smoking
- Are only about 5 percent as dangerous as regular cigarettes
- Allow former smokers to use nicotine without the risk associated with smoking
- Are preferred by most smokers over NRT, so they’re more likely to try quitting
The Royal Academy of Physicians further concluded that e-cigarettes should be promoted as a substitute for smoking and that most of the harm from smoking can be virtually eliminated.
Because vaping is a relatively new phenomenon, it may be premature for the Royal Academy of Physicians to go as far as they have in promoting the safety of e-cigarettes. Although e-cigarettes certainly appear to be safer than smoking tobacco, only longer-term research will enable us to reach firm conclusions about their precise degree of safety.
Current evidence from the New England Journal of Medicine indicates that abstinence from smoking at one year is twice as likely to occur with e-cigarettes than by using NRT. In addition, short-term health benefits (such as reduced wheezing, coughing, and phlegm) at one year are apparently greater when using e-cigarettes than NRT.
However, among successful smoking quitters at one year, those using e-cigarettes tended to continue vaping. Whereas, quitters who used NRT had pretty much dropped their use of NRT. This finding raises the importance of knowing more about the long-term health effects of continued e-cigarette usage, which is scant at this time.
E-cigarette vapor has traces of toxins, but these appear to be at significantly lower levels than those found in regular cigarettes. Some preliminary research has suggested that e-cigarette vapor produces changes in the circulatory systems of mice, which over a period of years could lead to heart disease. This finding has been replicated in a single study on humans. But we simply don’t know enough about how all this translates into long-term health effects of regular exposure to vapor for people. See Chapter 6 for a more complete discussion of the risks associated with vaping.
So, if you’re interested in trying to quit smoking by using e-cigarettes as either a short-term option on the way to no nicotine or a long-term alternative to cigarettes, be aware that no clear guidelines exist for helping you from the government. That’s because the FDA has yet to approve of e-cigarettes for smoking cessation purposes.
However, it’s common sense, if you’re a heavy smoker, to consider starting at a relatively satisfying amount of nicotine in your vaping devices. Stay at that level for several weeks. Then, if your goal is to become entirely nicotine free, gradually reduce your nicotine levels over a period of time.
Intriguingly, we’ve spent more time in vape shops than we ever thought we would in order to investigate the thoughts and perspectives of customers and employees — an admittedly biased group of folks! In spite of that bias, we noticed a consistent message from a variety of former cigarette smokers. The nearby sidebar, “Quitting by accident,” illustrates that theme.
The story on vaping with e-cigarettes to reduce harm from smoking is not over. More research is needed — especially about long-term effects. Stay tuned. And see Chapter 6 for more extensive information about the risks of vaping.