Tobacco harm reduction

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Tobacco harm reduction (THR) is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. It is an example of the concept of harm reduction, a strategy for dealing with the use of drugs. Tobacco smoking is widely acknowledged as a leading cause of illness and death, [1] and reducing smoking is vital to public health. [2] [3] [4] [5] [6] [7]

Contents

Tobacco use if not stopped can be the cause of death in 50% of its users, according to the 2021 WHO Report. [7] Tobacco smoking carries serious health risks, [8] including increased risk of developing various types and subtypes of cancers, respiratory diseases, cardiovascular diseases, cerebrovascular diseases, periodontal diseases, teeth decay and loss, and malignant diseases. [2] [3] [4] [5] [6] [7]

Overview

The consumption of tobacco products and its harmful effects affect both smokers and non-smokers, [9] and is a major risk factor for six of the eight leading causes of deaths in the world, including respiratory diseases, cardiovascular diseases, cerebrovascular diseases, periodontal diseases, teeth decay and loss, over 20 different types or subtypes of cancers, strokes, several debilitating health conditions, and malignant diseases. [2] [3] [4] [5] [6] [7] [10] In high income countries, smoking rates have been reduced mostly by reducing the uptake of smoking among younger people rather than improving the rates of quitting among established smokers. It is, however, mostly current smokers who will face disease and death from smoking. [11] [12]

Nicotine itself, however, is addictive but not otherwise very harmful, as shown by the long history of people safely using nicotine replacement therapy products (e.g., nicotine gum, nicotine patch). [13] Nicotine increases heart rate and blood pressure and has a range of local irritant effects but does not cause cancer. [14] None of the three main causes of death from smoking—lung cancer, chronic obstructive pulmonary disease (COPD) (including emphysema and chronic bronchitis), and cardiovascular diseases—is caused primarily by nicotine; the main reason smoking is deadly is the toxic mix of chemicals in smoke produced by the combustion of tobacco. Products that can effectively and acceptably deliver nicotine without smoke have the potential to be less harmful than smoked tobacco. THR measures have been focused on reducing or eliminating the use of combustible tobacco by switching to other nicotine products, including:

  1. Cutting down (either long-term or before quitting smoking)
  2. Temporary abstinence
  3. Switching to non-tobacco nicotine containing products, such as pharmaceutical nicotine replacement therapies or currently (generally) unlicensed products such as electronic cigarettes
  4. Switching to smokeless tobacco products such as Swedish snus
  5. Switching to non-combustible tobacco products

Quitting all tobacco products definitively reduces risk the most. However, quitting is difficult, and even approved smoking cessation methods have a low success rate. [1] In addition, some smokers may be unable or unwilling to achieve abstinence. [15] Harm reduction is likely of substantial benefit to these smokers and public health. [1] [13] Providing reduced-harm alternatives to smokers is likely to result in lower total population risk than pursuing abstinence-only policies. [16]

The strategy is controversial: supporters of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths. [15] [17] Opponents have argued that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation. [18] [19] However, surveys carried from 2013 to 2015 in France [20] and the United Kingdom [21] suggest that on the contrary, the availability of safer alternatives to smoking is associated with decreased smoking prevalence and increased smoking cessation. In Japan, the sales of cigarettes have decreased by 32% since the introduction of heated tobacco products. [22]

History

The concept of tobacco harm reduction dates back to at least 1976, when British professor Michael Russell wrote: "People smoke for nicotine but they die from the tar" [23] and suggested that the ratio of tar to nicotine could be the key to safer smoking. [13] [15] Since then, the harm from smoking has been well-established as being caused almost exclusively by toxins released through the combustion of tobacco. [1] In contrast, non-combustible tobacco products as well as pure nicotine products are considerably less harmful, although they still have the potential for addiction. [13]

Debates on tobacco harm reduction tend to be geographically defined arguments, because of the varying legal, moral, and historical status of tobacco, and the different types of tobacco products and use in different cultures around the world. For instance, cigarette smoking is the dominant form in the United States, while use of cigars, pipes, and smokeless tobacco is limited to a much smaller population. Anti-smoking advocacy efforts and widespread popularization of the negative health effects of smoking over the last few decades have led to restrictions in the sale and use of tobacco products. Despite this, tobacco in all its forms has remained a legal product in most societies. A notable exception is the European Union, where the most dangerous products (cigars and cigarettes) are disproportionately available but smokeless tobacco products, which are far less hazardous, are banned. [24] The exception is Sweden, where there is a long tradition of smokeless tobacco (snus) use among men.

In October 2008, the American Association of Public Health Physicians (AAPHP) became the first medical organization in the United States to officially endorse tobacco harm reduction (THR) as a viable strategy to reduce the death toll related to cigarette smoking. [25] [26] [27] In the United States, the tobacco industry and cigar brands have aggressively targeted African Americans and Non-Hispanic Whites with customized advertising techniques and tobacco-related lifestyle magazines since the 1990s. [8]

"Safer cigarettes"

Cigarette manufacturers have attempted to design safer cigarettes for almost 50 years, but results have been marginal at best. [28] Filters were introduced in the early 1950s, and manufacturers were selling low-yield cigarettes by the late 1960s. [28] Initially it was thought that these innovations were harm reducing. [29] For example, in 1976 investigators at the American Cancer Society published research concluding that light cigarettes were safer. [30] The study authors wrote that "total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked 'low' tar-nicotine cigarettes than for those who smoked 'high' tar-nicotine cigarettes." However, scientific evidence suggests that switching from regular to light or low-tar cigarettes does not reduce the health risks of smoking or lower the smoker's exposure to the nicotine, tar, and carcinogens present in cigarette smoke. [31] Indeed, the WHO recommends that misleading terms, including 'light' and 'mild', should be removed from tobacco product advertising, packaging, and labeling. [32] [33]

Smokeless tobacco

It has been established that use of Swedish and American smokeless tobacco confers only 0.1% to 10% of the risks of smoking, [15] though smokeless products in India and elsewhere in Asia contain higher levels of contaminants and thus confer greater risks. [17] Two respected medical groups believe that smokeless tobacco may play a role in reducing smoking-attributable deaths. In 2007, Britain's Royal College of Physicians concluded "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved." [34]

In the United States, a study based on National Health Interview Survey data found that 73% of smokers who switched to smokeless tobacco as part of their latest quit attempt were successful in quitting smoking. [35] In the same study, smokers who used pharmaceutical nicotine products in their most recent quit attempt had success rates between 0 and 35%. [35]

Snus

Scandinavian snus is a moist form of smokeless tobacco which is usually placed under the upper lip, and is not smoked or swallowed. A 2014 report commissioned by Public Health England on another avenue for tobacco harm reduction, electronic cigarettes, said snus "has a risk profile that includes possible increases in risk of oesophageal and pancreatic cancer, and of fatal (but not non-fatal) myocardial infarction, but not COPD or lung cancer." The report examined the case of snus as "a unique natural experiment in the impact of a socially accepted, non-medical, affordable and easily accessible reduced harm product on the prevalence of tobacco smoking". They concluded that "Although controversial, the Swedish natural experiment demonstrates that despite dual use and primary uptake of the reduced-harm product by young people, availability of reduced-harm alternatives for tobacco smokers can have a beneficial effect. While snus is not likely to become a legal or indeed politically viable option in the UK, this data proves the concept that harm reduction strategies can contribute to significant reductions in smoking prevalence." [36]

Based on the mounting evidence that the health risks of Swedish snus are far lower than those of combustible tobacco products, in August 2014, Swedish Match (a manufacturer) filed a Modified Risk Tobacco Product (MRTP) application with the FDA Center for Tobacco Products (CTP). The MRTP application seeks to modify the warning labels on smokeless tobacco products such that they reflect the evidence of reduced-harm compared to smoking. Among the proposed labeling changes, the MRTP application requests replacing the current warning, "This product is not a safe alternative to cigarettes," with this text: "No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes." [37]

After five years, on October 22, 2019, the FDA granted the first-ever modified risk orders to Swedish Match USA, Inc. for eight snus smokeless tobacco products. [38] The FDA's review determined that the claim proposed by the company in its application is supported by scientific evidence, that consumers understand the claim and appropriately perceive the relative risk of these products compared to cigarettes, and that the modified risk products, as actually used by consumers, will significantly reduce harm and the risk of tobacco-related disease to individual tobacco users and benefit the health of the population as a whole. [39]

In particular, the FDA states, "the available scientific evidence, including long-term epidemiological studies, shows that relative to cigarette smoking, exclusive use of these specific smokeless tobacco products poses lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis." [39]

Electronic cigarettes

E-cigarettes are battery-powered devices that provide nicotine for inhalation in a vapour generated by heating a solution of water, nicotine propylene glycol or vegetable glycerin and typically some flavouring. They were first developed in China in 2003, and first introduced to Europe and the US around 2006. [40]

Effectiveness and safety

When comparing people who use electronic cigarettes with nicotine to no treatment (or "usual treatment") for quitting smoking, a recent systematic review has found that: "there was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT)" [41] When comparing electronic cigarettes with nicotine to electronic cigarettes without nicotine, those with nicotine may be more effective (moderate quality evidence). [41] Research into the long term safety of e-cigarettes for smoking cessation is limited. [41] .However, England's Office for Health Improvement and Disparities have concluded that, in the short and medium term, vaping poses a small fraction of the risks of smoking. And that, while vaping is not risk-free, particularly for people who have never smoked there is significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions. [42] And, in an effort to decrease tobacco related death and disease, e-cigarettes appear to have a potential to be part of the strategy. [43]

Types

There are many brands and models of e-cigarettes available today but they can be broadly grouped into three categories. First generation e-cigarettes are similar in appearance to a conventional cigarette and are typically designed to be for single use. Second generation e-cigarettes are around the size of a large fountain pen, have a battery linked to a permanent vapouriser and a refillable tank for the nicotine solution. Third generation e-cigarettes tend to be larger, with a more powerful battery and two heating elements which allow users to carry the power. [34] Nicotine delivery has typically increased with successive generations of e-cigarette, [44] and it has been suggested that repeated use of second and third generation devices can result in sustained venous blood levels of nicotine which are comparable with those expected in smokers. [45]

Regulation of electronic cigarettes and use around the world

Regulation of e-cigarettes varies around the world. The Institute for Global Tobacco Control (IGTC) has identified 68 countries that have laws regulating e-cigarettes, as at November 2016. [46] Types of regulation include complete prohibition on the sale and marketing of e-cigarettes, prohibition on their use in enclosed public places, minimum age for purchase, an allowance for e-cigarettes to be sold under general consumer product regulations and most recently, in the UK, e-cigarettes may be brought to market as either medicines or consumer products (with those seeking medicines approval undergoing the standard medicines licensing process). The World Health Organization acknowledge that e-cigarettes may play a role in harm reduction strategies, but should be regulated to minimize any potential risks. However, the vast differences in regulatory approaches evident around the world highlights the challenge of developing a global regulatory approach.

E-cigarettes are seen as an attractive alternative by many smokers to cigarettes. [13] While the eventual regulatory status of e-cigarettes in many countries remains uncertain, [13] public health advocates view electronic cigarette as having a valid place within tobacco harm reduction strategy. [47] [ needs update ] In a first step towards the regulation of e-cigarettes, the MHRA granted Marketing Authorisations (licences) for the medicinal products e-Voke 10 mg and 15 mg Electronic Inhaler (PL 40317/0001-2) on 16 November 2015. [48] Public health researchers in the UK estimated that 6,000 premature smoking-related deaths per year would be prevented for every million smokers who switched to e-cigarettes. [47] Since currently approved smoking cessation methods have a 90% failure rate, the use of e-cigarettes as a prominent THR modality is likely to substantially reduce tobacco-related illness in the United States, with the potential to save 4.8 million lives over the next 20 years. [1]

A survey of UK adults found that over two thirds of ex-smokers and over one third of current smokers report that one of the main reasons they use e-cigarettes is to help them stop smoking completely. [49]

Heat-not-burn products

It is unclear whether using heat-not-burn tobacco products instead of traditional cigarettes has a substantial effect on the risk of harm. [50]

Public perceptions

Smokers remain confused about tobacco harm reduction. In a 2004 survey, about 80-100% of participants incorrectly perceived low-yield cigarettes as harm-reducing, while 75-80% mistakenly believed that switching to smokeless tobacco conferred no risk reduction. [51]

Similar confusion exists about electronic cigarettes. In the UK, research commissioned by the anti-smoking charity Action on Smoking and Health found that in 2016, more than three times as many people think e-cigarettes are as harmful or more harmful than smoking than in 2013 (25% vs 7%), the highest proportion since the survey began. [49] They expressed concern that the proportion of adult smokers who thought that e-cigarettes were more or equally harmful than cigarettes was highest in those who had never tried e-cigarettes, and these perceived potential harms was the main reason why they had not tried them. [49]

In 2015 a report commissioned by Public Health England noted, as well as the UK figures above, that in the US belief among responders to a survey that vaping was safer than smoking cigarettes fell from 82% in 2010 to 51% in 2014. [52] The report blamed "misinterpreted research findings", attracting negative media coverage, for the growth in the "inaccurate" belief that e-cigarettes were less harmful than smoking, and concluded that "There is a need to publicise the current best estimate that using EC is around 95% safer than smoking". [53]

In an article published by the Wall Street Journal in 2016 entitled "Are E-Cigarettes a Healthy Way to Quit Smoking?", Dr. Jed E. Rose co-inventor of the nicotine patch said, "Having worked my entire career to develop effective smoking-cessation treatments, I have realized that current approaches are ineffective for the vast majority of smokers. Alternative approaches are urgently needed. The World Health Organization predicts [54] a billion deaths will be attributable to smoking during the 21st century. Electronic cigarettes have an unparalleled potential to reduce the public-health impact of smoking, by allowing smokers to replace the habit and nicotine of smoking without the toxic effects of combustion." [55]

Concerns around tobacco harm reduction strategies

Whilst tobacco harm reduction approaches have the potential to reduce risks to the current adult smoking population, there are hypothesised potential hazards to wider public health. Smoking has become less acceptable over recent years in a number of countries, a result of a number of the Framework Convention on Tobacco Control (FCTC) guidelines to reduce smoking prevalence. The renormalisation of smoking is a concern if e-cigarette use appears to become more appealing, for example through their use in locations where conventional cigarettes are prohibited, advertising and increased e-cigarette use by parents, siblings, peers, celebrities or other influential groups. [56] [57]

Concerns have also been raised that non-tobacco nicotine use may results in uptake of tobacco smoking that would not otherwise have occurred. This 'gateway theory' has been largely applied to the use of e-cigarettes by non-smokers and particularly children. [58] There is no reported evidence, however, that NRT use among young people has ever acted as a gateway to smoking, or that e-cigarette use has resulted in any appreciable increase initiation of smoking among children or adults. The Royal College of Physicians suggest that any association between e-cigarette and conventional cigarette use is likely due to common liability to use these products and the use of e-cigarettes to reduce smoking. [34]

Dual use of tobacco products and non-tobacco nicotine by continuing smokers is another aspect which has raised concern. It is suggested that dual use could inadvertently sustain smoking by making it easier for smokers to temporarily abstain from tobacco use, or encourage smokers to move towards dual use rather than complete cessation in the mistaken belief that this offers significant health gains. Dual use of tobacco and NRT is licensed by the Medicines and Healthcare products Regulatory Authority (MHRA) as a tobacco harm reduction strategy which actually increases the chance of quitting. [59] The Royal College of Physicians reviewed evidence around dual use and smoking cessation and reported that findings were suggestive that e-cigarettes had the potential to offer the same cessation gains, [34] although further research would be helpful to more clearly delineate such an effect.

Much of the opposition to tobacco harm reduction has come from organisations funded by the US Bloomberg Philanthropies including Vital Strategies, the Campaign for Tobacco Free Kids and the UK University of Bath Tobacco Control Group and it is claimed that the USA is the epicentre for all anti tobacco harm reduction globally. [22]

See also

Further reading

Related Research Articles

<span class="mw-page-title-main">Cigarette</span> Small roll of tobacco made to be smoked

A cigarette is a narrow cylinder containing a combustible material, typically tobacco, that is rolled into thin paper for smoking. The cigarette is ignited at one end, causing it to smolder; the resulting smoke is orally inhaled via the opposite end. Cigarette smoking is the most common method of tobacco consumption. The term cigarette, as commonly used, refers to a tobacco cigarette, but the word is sometimes used to refer to other substances, such as a cannabis cigarette or a herbal cigarette. A cigarette is distinguished from a cigar by its usually smaller size, use of processed leaf, different smoking method, and paper wrapping, which is typically white.

<span class="mw-page-title-main">Tobacco smoking</span> Practice of burning tobacco and breathing the resulting smoke

Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed to have begun as early as 5000–3000 BC in Mesoamerica and South America. Tobacco was introduced to Eurasia in the late 17th century by European colonists, where it followed common trade routes. The practice encountered criticism from its first import into the Western world onwards but embedded itself in certain strata of a number of societies before becoming widespread upon the introduction of automated cigarette-rolling apparatus.

<span class="mw-page-title-main">Smoking cessation</span> Process of discontinuing tobacco smoking

Smoking cessation, usually called quitting smoking or stopping smoking, is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is addictive and can cause dependence. As a result, nicotine withdrawal often makes the process of quitting difficult.

<span class="mw-page-title-main">Snus</span> Moist tobacco product placed under the upper lip

Snus is a Swedish tobacco product and non-tobacco nicotine product consumed by placing a pouch of powdered tobacco leaves or powdered non-tobacco plant fibers under the lip for nicotine to be absorbed through the oral mucosa. Whereas the nicotine in tobacco-based snus derives from tobacco leaves, the nicotine in non-tobacco snus can be either naturally or synthetically synthesized.

<span class="mw-page-title-main">Vaporizer (inhalation device)</span> Device to vaporize substances for inhalation

A vaporizer or vaporiser, colloquially known as a vape, is a device used to vaporize substances for inhalation. Plant substances can be used, commonly cannabis, tobacco, or other herbs or blends of essential oil. However, they are most commonly filled with a combination propylene glycol, glycerin, and drugs such as nicotine or tetrahydrocannabinol as a liquid solution.

<span class="mw-page-title-main">Nicotine replacement therapy</span> Treatment for tobacco use disorder

Nicotine replacement therapy (NRT) is a medically approved way to treat people with tobacco use disorder by taking nicotine through means other than tobacco. It is used to help with quitting smoking or stopping chewing tobacco. It increases the chance of quitting tobacco smoking by about 55%. Often it is used along with other behavioral techniques. NRT has also been used to treat ulcerative colitis. Types of NRT include the adhesive patch, chewing gum, lozenges, nose spray, and inhaler. The use of multiple types of NRT at a time may increase effectiveness.

<span class="mw-page-title-main">Chewing tobacco</span> Type of smokeless tobacco product

Chewing tobacco is a type of smokeless tobacco product that is placed between the cheek and lower gum to draw out its flavor. It consists of coarsely chopped aged tobacco that is flavored and often sweetened; it is not ground fine like dipping tobacco. Unwanted juices are spat while chewing.

<span class="mw-page-title-main">Nicotine marketing</span> Marketing technique

Nicotine marketing is the marketing of nicotine-containing products or use. Traditionally, the tobacco industry markets cigarette smoking, but it is increasingly marketing other products, such as electronic cigarettes and heated tobacco products. Products are marketed through social media, stealth marketing, mass media, and sponsorship. Expenditures on nicotine marketing are in the tens of billions a year; in the US alone, spending was over US$1 million per hour in 2016; in 2003, per-capita marketing spending was $290 per adult smoker, or $45 per inhabitant. Nicotine marketing is increasingly regulated; some forms of nicotine advertising are banned in many countries. The World Health Organization recommends a complete tobacco advertising ban.

<span class="mw-page-title-main">Dipping tobacco</span> Finely ground smokeless tobacco product

Dipping tobacco is a type of finely ground or shredded, moistened smokeless tobacco product. It is commonly and idiomatically known as dip. Dipping tobacco is used by placing a pinch, or "dip", of tobacco between the lip and the gum. The act of using it is called dipping. Dipping tobacco is colloquially called chaw, snuff, rub, or fresh leaf among other terms; because of this, it is sometimes confused with other tobacco products—namely dry snuff.

<span class="mw-page-title-main">Health effects of tobacco</span> Circumstances, mechanisms, and factors of tobacco consumption on human health

Tobacco products, especially when smoked or used orally, have serious negative effects on human health. Smoking and smokeless tobacco use is the single greatest cause of preventable death globally. As many as half of people who smoke tobacco or use it orally die from complications related to such use. It has been estimated that each year, in total about 6 million people die from tobacco-related causes, with 600,000 of these occurring in non-smokers due to secondhand smoke. It is further estimated to have caused 100 million deaths in the 20th century.

<span class="mw-page-title-main">Smokeless tobacco</span> Tobacco product used by means other than smoking

Smokeless tobacco is a tobacco product that is used by means other than smoking. Their use involves chewing, sniffing, or placing the product between gum and the cheek or lip. Smokeless tobacco products are produced in various forms, such as chewing tobacco, snuff, snus, and dissolvable tobacco products. Smokeless tobacco is widely used in South Asia and this accounts for about 80% of global consumption. All smokeless tobacco products contain nicotine and are therefore highly addictive. Quitting smokeless tobacco use is as challenging as smoking cessation.

<span class="mw-page-title-main">Nicotine withdrawal</span> Process of withdrawing from nicotine addiction

Nicotine withdrawal is a group of symptoms that occur in the first few weeks after stopping or decreasing use of nicotine. Symptoms include intense cravings for nicotine, anger or irritability, anxiety, depression, impatience, trouble sleeping, restlessness, hunger, weight gain, and difficulty concentrating. Withdrawal symptoms make it harder to quit nicotine products, and most methods for quitting smoking involve reducing nicotine withdrawal. Quit smoking programs can make it easier to quit. Nicotine withdrawal is recognized in both the American Psychiatric Association Diagnostic and Statistical Manual and the WHO International Classification of Diseases.

<span class="mw-page-title-main">Electronic cigarette</span> Device that vaporizes a liquid nicotine solution for inhalation

An electronic cigarette (e-cigarette) or vape is a vaporizer device that simulates tobacco smoking. It consists of an atomizer, a power source such as a battery, and a container such as a cartridge or tank. Instead of smoke, the user inhales vapor. As such, using an e-cigarette is often called "vaping". The atomizer is a heating element that vaporizes a liquid solution called e-liquid, which quickly cools into an aerosol of tiny droplets, vapor and air. The vapor mainly comprises propylene glycol and/or glycerin, usually with nicotine and flavoring. Its exact composition varies, and depends on several things including user behavior.

<span class="mw-page-title-main">Nicotine dependence</span> Chronic disease

Nicotine dependence is a state of dependence upon nicotine. Nicotine dependence is a chronic, relapsing disease defined as a compulsive craving to use the drug, despite social consequences, loss of control over drug intake, and emergence of withdrawal symptoms. Tolerance is another component of drug dependence. Nicotine dependence develops over time as a person continues to use nicotine. The most commonly used tobacco product is cigarettes, but all forms of tobacco use and e-cigarette use can cause dependence. Nicotine dependence is a serious public health problem because it leads to continued tobacco use, which is one of the leading preventable causes of death worldwide, causing more than 8 million deaths per year.

<span class="mw-page-title-main">Flavored tobacco</span> Tobacco product with added flavorings

Flavored tobacco products — tobacco products with added flavorings — include types of cigarettes, cigarillos and cigars, hookahs and hookah tobacco, various types of smokeless tobacco, and more recently electronic cigarettes. Flavored tobacco products are especially popular with youth and have therefore become targets of regulation in several countries.

<span class="mw-page-title-main">Youth smoking</span> Overview article

Smokingamong youth and adolescents is an issue that affects countries worldwide. While the extent to which smoking is viewed as a negative health behavior may vary across different nations, it remains an issue regardless of how it is perceived by different societies. The United States has taken numerous measures, ranging from changes in national policy surrounding youth cigarette access to changes in media campaigns, in attempts to eliminate the use of tobacco products among teenagers. Approximately 90% of smokers begin smoking prior to the age of 18.

The health effects of electronic cigarettes (e-cigarettes) include a range of potential risks such as exposure to toxic chemicals, the possibility of increased likelihood of respiratory and cardiovascular diseases, and concerns about their possible role in cancer development. Upon their introduction, there were marketing claims that they were a safer alternative to traditional tobacco products.

The scientific community in the United States and Europe are primarily concerned with the possible effect of electronic cigarette use on public health. There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco, and serve as a gateway for smoking among youth. The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear. Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco. There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.

A heated tobacco product (HTP) is a tobacco product that heats the tobacco at a lower temperature than conventional cigarettes. These products contain nicotine, which is a highly addictive chemical. The heat generates an aerosol or smoke to be inhaled from the tobacco, which contains nicotine and other chemicals. HTPs may also contain additives not found in tobacco, including flavoring chemicals. HTPs generally heat tobacco to temperatures under 600 °C (1100 °F), a lower temperature than conventional cigarettes.

The chemical constituents of different types of snus vary, and population-level studies suggest that the disease risks vary as well. Using snus is harmful to health, although much less than smoking tobacco.

References

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