Nicotine alternatives and their potential to reduce tobacco induced diseases

Professor Tikki Pangestu, former director, research policy & cooperation, World Health Organization (WHO) has shared his views on how nicotine alternatives could be helpful in reducing tobacco induced harm. Sharing parallels of policy stance in his home country, Indonesia, with other countries who have regulated these alternatives & witnessed a significant fall in the smoking rates. Further, Prof Pangestu called for an open discussion at COP10 to develop an effective tobacco control policy for the world.

The use of alternative tobacco products is becoming increasingly well-known in Indonesia. The country has an estimated 3 million active users of nicotine alternatives. Its use is seen as a potential aid for those wishing to quit smoking and, ultimately, as a way to help tackle the smoking epidemic and prevalence in Indonesia, which has more than 60 million smokers.

Data from the UK shows that since 2017, there have been 50,000 smokers who have stopped smoking after using nicotine alternatives. In fact, a systematic analysis of 78 research studies conducted in Europe found that people were more likely to quit smoking at least six months after using these alternative compared to other methods.

The French health agency also conducted research showing that alternatives helped 700,000 smokers stop smoking between 2010-2017. As there are 12-13 million smokers in France, this means that the success rate of smokers quitting with the use of alternatives reaches 0.7% per year.

If this approach were implemented in Indonesia, which has 60 million smokers, nicotine alternatives could potentially help 420,000 smokers quit smoking every year. They can lead healthier lives and avoid premature death from smoking-related diseases like lung cancer, heart disease, stroke and diabetes.

Despite its obvious potential to address the tobacco epidemic, there are growing concerns about the health effects associated with alternatives. Indonesia and Malaysia allow the use of these alternatives, while other countries such as Singapore and Cambodia have banned them. Interestingly, the Philippines has implemented supportive regulations. According to Tikki Pangestu,  there are two main reasons for these opposing views.

First, there are three common misperceptions about the dangers and risks associated with these alternatives versus their potential benefits. These misconceptions have led to impact even the global tobacco control policy governed by the multilateral agencies. WHO has cast doubts on these alternatives. In the upcoming Conference of the Parties (COP10) in November 2023, the group is expected to propose stringent policy restrictions on nicotine alternatives.

Misconception number one: alternatives are as dangerous as conventional cigarettes. In fact, alternative tobacco products do not produce smoke but vapor. While alternative tobacco products contain addictive nicotine and are therefore not completely risk-free, there is strong evidence based on scientific studies that they have a 90% to 95% lower risk than cigarette smoke.

Recent research from the Indonesia’s Bandung Institute of Technology (ITB) confirms these findings. But there continues to be a denial of this fact. This comes with a blind spot in assessing the risk versus benefit argument, namely the lower health risks of using alternative tobacco products versus conventional cigarettes, which increases the risk of smoking-related diseases.

Then, there is the notion that alternatives can cause severe lung injury. It was linked to lung disease in the US in 2019. However, based on existing analysis, cases were caused by products containing illegally obtained cannabis and significant amounts of vitamin E acetate (VEA). VEA was identified as a possible cause of the disease. After the cause was found, the number of cases decreased.

Misconception number three: nicotine alternatives are seen as a gateway to other tobacco products for young people. In Indonesia and Malaysia, the prevalence of e-cigarettes among teenagers aged 10-19 years is quite high. However, in a study in the United States, the use of nicotine alternative among teenagers since 2014 has succeeded in reducing smoking prevalence up to fourfold in the same period.

Thus, this data shows an inverse relationship between the use of nicotine alternatives and consumption of conventional cigarettes. Hence, the assumption that these alternatives are a gateway to other tobacco products is debatable and depends on the characteristics and population.

As Professor John Britton, Director of the UK Center for Tobacco and Alcohol Studies, states, “Those who cite the precautionary principle as a justification for preventing or banning alternatives ignore the fact that for most users, the counterfactual is premature death from smoking. Smoking kills. But, so does denying smokers the opportunity to quit.”

The future will depend on open dialogue between all stakeholders based on trust, as well as the existence of quality local research to overcome the many misperceptions so that we can move towards a healthier society together as part of Indonesia’s 2045 Vision.

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