The Harm Reduction Opportunity
The Role Of Nicotine
The overarching objective of any tobacco policy should be to improve public health by reducing death and disease caused by tobacco use. Tobacco-related diseases are primarily associated with exposure to toxic substances in smoke at levels generated by burning tobacco, not by exposure to nicotine per se. As the U.K. National Institute for Health and Care Excellence stated: “It is primarily the toxins and carcinogens in tobacco smoke – not the nicotine – that cause illness and death.”
Therefore, progress towards the above stated public health objective requires that fewer people use smoked tobacco, even if nicotine use persists through use of alternative products. In fact, allowing consumers to continue using nicotine-containing products, with the nicotine delivered by less harmful means, has the potential to switch greater numbers of smokers away from conventional cigarettes.
For alternative products to benefit public health, three conditions need to be met. First, smokers must find these products satisfying as alternatives to smoking conventional cigarettes. Nicotine plays an essential part in achieving this necessary consumer acceptance. Second, actual reduction in risk promised by these alternative products must be scientifically substantiated — from product development and analysis through clinical evaluations in realistic use conditions. Applied assessment methods should meet recognized scientific standards. Third, the benefits and risks of these products, including those associated with initiation and cessation, must be assessed to determine their overall net impact on public health.
Tobacco harm reduction at the individual and population level, achieved by providing less risky alternative nicotine delivery products, is an important public health strategy, complementary to prevention and cessation efforts. It must appeal to large numbers of smokers without appealing to young people or nonsmokers.
The goal at Philip Morris International is to develop a portfolio of reduced risk products containing nicotine that are satisfying to adult smokers and significantly less harmful than smoking cigarettes – all based on rigorous scientific standards and assessment.
What is nicotine?
Nicotine occurs naturally in tobacco and at significantly lower levels in some other plant varieties.
Nicotine used in pharmaceutical products (nicotine replacement therapies; NRTs) as well as in e-cigarettes is usually extracted from tobacco. It is possible to produce synthetic nicotine, but the process is costly.
When tobacco smoke is inhaled, nicotine is absorbed through the lungs into the bloodstream, and begins to reach the brain within about 10 seconds. There, nicotine binds to special receptor molecules, mimicking the actions of a naturally occurring brain chemical, acetylcholine. In turn, some of these nicotine receptors activate areas of the brain that are involved in producing feelings of pleasure and reward, which may explain the subjective pleasurable effects associated with smoking, but also relates to the desire for nicotine and potential for addiction. Other pathways stimulated by nicotine may contribute to its attention-enhancing and calming effects.
The nicotine takes longer to reach the brain when absorbed through a nicotine patch or nicotine gum.
Nicotine also affects other parts of the body such as the heart and blood vessels.
Nicotine is addictive and not risk-free. Minors, pregnant or breast feeding women, and people with heart disease, severe high blood pressure, or diabetes – should not use tobacco or other nicotine containing products.
How safe is nicotine use?
Experts, including the U.S. Surgeon General and the U.K. Royal College of Physicians, agree that nicotine, while addictive, is not the primary cause of smoking-related diseases. Smoking-related diseases, such as lung cancer, cardiovascular disease, and emphysema, are caused primarily by inhaling harmful compounds formed when tobacco is burned, not by nicotine.
As FDA has stated, “inhalation of nicotine (i.e., nicotine without the production of combustion) is of less risk to a user than the inhalation of nicotine delivered by smoke from combusted tobacco products.” While “inhaled nicotine from a non-combustible product may be as addictive as inhaled nicotine delivered by combusted tobacco products, researchers recognize that the effects from nicotine exposure by inhalation are likely not responsible for the high prevalence of tobacco-related death and disease in this country.”
What are the health risks associated with nicotine?
FDA stated that while nicotine has not been shown to cause the chronic disease associated with tobacco use, there are risks associated with nicotine:
- Nicotine at high enough doses has acute toxicity
- Nicotine adversely affects maternal and fetal health during pregnancy, contributing to multiple adverse outcomes such as preterm delivery and stillbirth
- Nicotine exposure during adolescence may have lasting adverse consequences for brain development
- Nicotine can have detrimental effects on the cardiovascular system and potentially disrupt the central nervous system
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