‘Unsmoked’

A HABITUAL smoker for more than 30 years, George (not his real name), 57, went from Marlboros to e-cigarettes and then back again. Unsatisfied with the taste and feel of flavored e-cig juices, he was on this seesaw for several years until he came across Blends, a heated tobacco product (HTP) launched recently in the Philippines.

With breakthrough technology, HTPs impart the thrill of smoking without much of the health hazards. By heating real tobacco rather than burning it, HTPs produce no ash with no smoke and less smell than conventional or traditional cigarettes.

IQOS, the world’s No. 1 tobacco heating system created by Philip Morris International (PMI) as its first smoke-free product, is known to substantially diminish the toxicity of tobacco because it is the act of burning that releases thousands of toxic chemicals.

When tobacco is heated as done with IQOS, 90 to 95 percent of those toxins are not present, according to PMI.

While the highly addictive nicotine is present in both, it is not the primary cause of smoking-related diseases, the world’s largest tobacco company has noted.

“PMFTC, as the market leader in the Philippines, is committed to put the country at the hub of the global smoke-free future. The addition of Bonds by IQOS to our smoke-free portfolio in the Philippines is another significant step towards that goal of a smoke-free future for 14 million Filipino smokers and their loved ones,” said Denis Gorkun, president of PMFTC, PMI’s affiliate in the Philippines.

Bonds by IQOS is the affordable version of the revolutionary product. It was launched locally in November last year. The device has an average selling price of P990, while its accompanying specially designed tobacco sticks called Blends can be bought for P100 per 20-stick pack.

“Bonds by IQOS offers our legal-age consumers access to a compact, low-maintenance and hassle-free smoke-free product—validated by science as a better alternative to cigarettes. With a retail price of P100 per 20-stick pack, Blends is actually sold at a lower price than most of the popular cigarette brands,” Dave Gomez, communications director at PMFTC, told the BusinessMirror in an email interview.

Findings presented at the 2022 London E-Cigarette Summit Evidence proving the viability of smoke-free alternatives as tools to diminish the public health burden from prevalent smoking have been presented in certain fora. The latest findings were presented at the London E-Cigarette Summit on December 9 last year at the Royal College of Physicians, where experts from the scientific and medical communities tackled the science, regulation and public health dimensions of smoking cessation.

Documenting the European experience, the 10th annual e-cigarette convention also identified the important role low-to-middle-income countries (LMICs) could play in achieving global goals.

Filipino summit participant Dr. Lorenzo Mata Jr., president of advocacy group Quit for Good, found the revelations enlightening.

“Dr. Jamie Hartmann-Boyce from the University of Oxford presented a 2022 review of 78 completed studies—representing 22,052 participants across the United Kingdom, the United States and Italy entitled, “Electronic Cigarettes for Smoking Cessation.” The results show that people are more likely to stop smoking for at least six months using nicotine e-cigarettes than using nicotine replacement therapy, and that nicotine e-cigarettes may help more people to stop smoking than no support or behavioral support only.

“I also learned that countries like the UK, which have included tobacco harm reduction as part of their state policy, have witnessed significant reduction in smoking rates,” he told the BusinessMirror at the sidelines of the conference in London.

Also presented was evidence showing biomarkers for dreaded and life-threatening diseases were almost on the same level among e-cigarette users and non-smokers, according to the founder of Quit for Good, which believes that harm reduction provides a tremendous opportunity to prevent the worst outcome of a disease even if it is already beyond cure.

“My most significant takeaway in the E-Cigarette Summit came from Clive Bates, director of Counterfactual Consulting—an advocacy firm focused on sustainability and public health. He said that the ‘strongest evidence of reduced harm is reduced exposure.’ I totally agree because e-cigarettes and HTPs are different from combustible cigarettes since they do not involve burning and do not produce smoke,” Mata said.

He added that evidence presented in the 2022 report of the United Kingdom Office for Health Improvement and Disparities (OHID) reinforced Bates’s theory.  “Citing the 2022 report by the OHID entitled ‘Nicotine Vaping in England: An Evidence Update Including Health Risks and Perceptions,’ Dr. Debbie Robson, a co-author of the OHID annual evidence reviews of e-cigarettes, discussed biomarkers of exposure or medical signs used to measure the effect of a substance on the presence or progress of disease.

“The study revealed that biomarkers of exposure to cancer, respiratory disease and cardiovascular disease are significantly lower in e-cigarette users than in smokers. What is fascinating is the finding that these biomarkers are almost on a par between e-cigarette users and non-smokers.”

Also at the London E-Cigarettes Summit, Prof. Alan R. Boobis, emeritus professor of toxicology at Imperial College London and chair of the UK Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT), an independent advisory panel to British government agencies, revealed COT findings on the absolute and relative risks of e-cigarettes. Considering the public health consequences of cigarette smoking and there being few alternatives attractive to smokers, e-cigarettes or electronic nicotine delivery systems (ENDS) could mitigate some of the harm, he told summit participants.

“ENDS are substantially less harmful than conventional cigarettes, although the difference varies with the health effect. There is little evidence that short- to medium-term use of ENDS causes major harm, but the effects of long-term use are uncertain, though still likely to be less than those of conventional cigarettes. Use of ENDS by non-smokers is potentially associated with adverse health effects to which they would not otherwise have been subject. This information should not be considered in isolation, but in the wider context of the public health consequences of cigarette smoking,” Boobis said.

Asian perspectives

AN Asian perspective came from Dr. Sivakumar Thurairajasingam, associate professor in psychiatry and head of the Clinical School Johor Bahru, Monash University Malaysia. He reported that about 49 percent of current smokers in Malaysia had attempted to quit at least once in the past 12 months, with only a third of them succeeding.

Among those who attempted to quit were current smokers with low nicotine addiction and current smokers aged 45 years old. Being older and married and having tertiary education influenced such attempts.

Disadvantaged groups, including those with a low socioeconomic status, were also vulnerable to the harms of smoking.

Besides having less social support for quitting or a low motivation to quit and a stronger addiction to tobacco, they lack self-determination and tend to skip behavioral support sessions and fail to complete the courses.

Meanwhile, young, higher-educated males have switched to e-cigarettes, 90 percent of whom are current or former cigarette smokers. About 27 percent of the current cigarette smokers use e-cigarettes daily, while 42 percent of those who had quit were daily users.

IQOS launch in PHL and elsewhere

IN the Philippines, the launch of a more affordable version of IQOS bodes well for public health. Market data collected by PMI since the tobacco heating system became available globally allow the company to evaluate the real-world effects on HTPs on the combustible tobacco market.

As of September 30, 2022, there are 70 markets carrying PMI’s smoke-free products. PMI estimates there were approximately 19.5 million total IQOS users, excluding Russia and Ukraine, of which approximately 13.5 million have switched to IQOS and stopped smoking, with the balance in various stages of conversion.

Data also show Japan has the highest prevalence of HTP use, and is the country where these have captured the highest share of the tobacco market. Outside Japan, the country with the second highest market share of consumable HTPs is Lithuania.

“We must recognize that smoke-free products such as e-cigarettes and HTPs are indeed practical and tangible solutions for adults who do not quit smoking cold turkey,” Mata noted. “The clinical application of tobacco harm reduction in as far as e-cigarettes and HTPs are concerned should be augmented to fast track the decline in smoking prevalence.”

In sari-sari stores?

Amid opposition from certain sectors over PMFTC’s plan to use sari-sari stores as a distribution channel for Blends, with parents fearing easy accessibility to their young children, the president of advocacy group Quit for Good cites protections provided by the recently passed Vaporized Nicotine Products Regulation Act or the Vape law.

“At the heart of the Vape law is the state policy to regulate e-cigarettes and HTPs in order to promote a healthy environment, protect its citizens, and reduce the harm caused by smoking. It also provides very stringent rules to ensure that minors cannot access or be attracted to buying these products. Having said this, I believe that the focus now should really be on the full and faithful implementation of the Vape law as soon as possible if we wish to achieve our public health goal of significantly reducing the smoking prevalence in the country, similar to the UK. I humbly call on all the implementing agencies to make every possible effort in hastening the enforcement of the Vape law’s implementing rules to save the lives of the 14 million Filipino smokers,” Mata said.

Important role of LMICs

ACCORDING to Malaysia’s Sivakumar, LMICs can play a big part in achieving global goals because they bear most of the global mortality burden of tobacco use, with 80 percent of the world’s 1 billion smokers living in LMICs (based on 2015 estimates).

The first step is to complement existing tobacco control policies by creating access to a range of non-combustible alternatives to help smokers transition away from combustible tobacco products, he said.

At the same time, policies must be in place to ensure the safety and quality of smoke-free alternatives and their accessibility to adult smokers, while restricting their availability to the youth.

Most important, a risk-proportionate regulatory regime should be applied to enable complementarity with existing interventions designed to reduce the prevalence of combustible tobacco use, Sivakumar recommended.

“Overall, about a fifth of young teenagers [13 to 15 years old] around the world are smokers. High-income countries may lower levels of adolescent tobacco use. LMICs have contrastingly high rates of adolescent smoking, where rates in some countries can reach as high as 46 percent and reflect high rates of all-age smoking. Adult smoking rates generally appear to reflect adolescent smoking rates,” the Malaysian professor noted in his summit presentation.

“With this fear in mind, policymakers in LMICs have made ‘tobacco control’ a priority to mitigate effects of tobacco-related morbidity and mortality, by harnessing cessation interventions techniques from high-income countries. In reality, we are only seeing an increasing number of smokers in LMICs, questioning the effectiveness of the ‘total cessation’ policy. One evident phenomenon is the creation of ‘hidden populations’ of smokers, who continue their smoking habit against regulations and isolate from health providers, in fear of litigation. In driving their agenda, international policies have also neglected special populations, individuals living with mental health problems, where even nicotine replacement has shown modest results,” Sivakumar warned.

Concluding his talk, the professor from Monash University Malaysia reminded policymakers that harm-reduction initiatives ought to respect the rights, health and safety of smokers, without compromising on ‘the right of all people to the highest standard of health,’ in keeping with the World Health Organization’s Framework Convention on Tobacco Control.

Image credits: Maren Winter | Dreamstime.com, e-cigarettesummit.com