The doctor’s dilemma: alternative smoking products for adult smokers?

September 25, 2020

“The doctor’s dilemma: Providing guidance on alternative smoking products to adult smokers amid controversy and change” was the subject discussed in a panel discussion on the second day of the Summit, chaired by Dr. Dimitri Richter.

Harm reduction strategy aims to minimize the harms of any risk behavior in all areas, Dr. Peter Harper, Medical Oncologist in UK, said. Tobacco control is a political and scientific discussion. Although scientific evidence show that smoke-free products release much lower levels of chemicals compared to combustible cigarettes, many countries recommend to being treated with the same restrictions to combustible cigarettes. In Sweden, where snus is used, only 5% of population are smokers, compared to median rate 24% in EU, and the country has the lowest tobacco-related mortality in EU. Snus has been accepted and approved by FDA as a modified-risk product, while in EU it is banned. Harm reduction is an extremely important issue, Mr. Harper concluded, since doctors want to provide the best available care to all their patients. Signs are pointing that harm reduction works and can be a useful tool to help smokers quit, even if no long-term data exist.

Harm reduction is a confusing issue both for politics and community, Dr. Efrain Cambronero, Chief of Surgical Oncology in Costa Rica stated, as moral issues emerge. The main dilemma for doctors, he added, is if they should counsel their patients to use the harm reduction products or not. Sure, quitting is the best decision for smokers, Dr. Cambronero said, but we cannot ignore the fact that 30% of lung cancer patients continue to smoke. Above all, we should prevent young people from smoking and help smokers quit, he concluded, but for this group of hardcore smokers who cannot quit despite the risk, there is no dilemma, doctors have to help them at least to reduce the risk.

Professor Manuel Pais Clemente, at Porto University School of Medicine, Portugal, & Vice President of the European Medical Association, stated that during the last 5 decades, all guidelines, policies and regulations for tobacco control were talking about smoking prevention and cessation. But today, there is clinical evidence that we have also other tools to help people reduce the harm from smoking. Doctors must try everything to help their patients, he noted, smokers are people at risk, we cannot deny them our help, no matter what they do to help themselves. Harm reduction came to stay, Professor Pais Clemente added, since there will always be smokers and we need new alternatives to help these people suffer less health consequences.

Dr. Piotr Kuna, Chair, Division of Internal Medicine Asthma and Allergy of Medical University of Lodz, Poland, spoke about airway diseases associated with smoking and smoking-related lung function decline, indicating that loss of lung function is fastest at early stages of COPD. Data regarding smoking and mortality in COPD, he added, show that only 22% of patients quit smoking over a period of 14.5 years. Still, he pointed out, even if a person stops smoking just for a period and then relapses to his bad habit, his lung function will improve. In Poland, he stated, the recommendation for doctors is to follow a kind of protocol, where the advice to stop smoking is the first option and proposal for heat-not-burn products is the last option, saved for those who are not able to stop the hazardous behavior.

In Hungary, harm reduction products are a new concept, Dr. Emil Toldy-Schedel, General Director at St Francis Hospital of Budapest, noted, and therefore medical community still needs to clarify many matters, such as the best way to use them. Numbers of lung cancer/COPD in Hungary are the largest in Europe, he added, therefore it is necessary to collect opinions and discuss for programs to inform people about harm reduction products —both doctors and citizens.

If someone cannot quit smoking, he should be encouraged to use any tool available to reduce the risk for his health, Dr. Michael Toumbis, Pneumonologist and President of the Cyprus Institute of Respiratory Diseases stated. It is true that harm reduction tobacco products are new, and their long-term safety is not yet known, he added, but it is a fact that they release lower levels of chemicals compared to combustible cigarettes. Of course, these products should be used as a tool to help people stop smoking and not as a substitute of combustible cigarettes, Dr. Toumbis mentioned. Unfortunately, harm reduction products are not yet adopted by WHO and FCTC, he concluded, and scientists should work towards this direction.