Reducing the harm from tobacco

There are many products used in NRT, including (from top left) an inhaler and the nicotine capsules that are used with it, a nicotine skin patch and nicotine gum. — Filepic

According to the National Health and Morbidity Survey (NHMS) 2019, more than an estimated 27,200 deaths in Malaysia were related to smoking tobacco.

The NHMS reported that the prevalence of current smokers was 21.3%, i.e. an estimated 4.8 million Malaysians aged 15 years and above were smokers.

Smoking was 30 times higher in males than females.

The highest prevalence was in the 30-34 years age group.

Smoking was more prevalent in those with primary and secondary education, and least with tertiary education.

The prevalence of exposure to secondhand smoke was 31% at home and 27.2% at work.

Dangerous chemicals

All tobacco products, irrespective of type, contain substances harmful to health.

Tobacco smoke comprises thousands of chemicals, of which at least 70 cause cancer.

Some of the chemicals in tobacco smoke include nicotine, hydrogen cyanide, formaldehyde, lead, arsenic, benzene, carbon monoxide, nitrosamines and polycyclic aromatic hydrocarbons.

Most of the substances come from the burning tobacco itself.

There are also radioactive materials in the tobacco leaves used in cigarette and cigar manufacturing.

The amount of these materials depends on the fertilizer and soil used in tobacco farming.

The radioactive materials are released in the tobacco smoke, which is inhaled into the lungs.

Although nicotine is the addictive substance in tobacco, it is the chemicals from the burning tobacco that is the primary cause of harm.

Smoking harms almost every organ in the body and leads to disability and death.

It causes heart disease, stroke, cancer and lung diseases, including chronic obstructive pulmonary disease (COPD), emphysema and chronic bronchitis.

Smoking also increases the risk of tuberculosis, certain eye diseases and diseases of the immune system, including rheumatoid arthritis.

Secondhand smoke causes heart disease, stroke and lung cancer in adults.

Children exposed to secondhand smoke have increased risks of respiratory infections, severe asthma, middle ear disease, sudden infant death syndrome and impaired lung growth.

Tobacco harm reduction

Tobacco harm reduction (THR) refers to a policy, strategy or intervention that aspires to lower the risk of the adverse consequences associated with the continuation of tobacco-smoking.

Such interventions have focused on the utilization of innovative nicotine products, reduced tobacco consumption and pharmaceutical medications.

It is important to remember that uncontrolled use of nicotine is associated with harms like increased risk of cardiovascular, respiratory and gastrointestinal disorders; carcinogenesis (formation of cancer); impaired immune response; and adverse effects on reproductive health.

As such, there should be no encouragement to start on nicotine or its products.Most of the harmful substances in tobacco are caused by its burning during the process of smoking. — AFPMost of the harmful substances in tobacco are caused by its burning during the process of smoking. — AFP

The nicotine in tobacco is very addictive, i.e. once a person starts smoking, there is a compulsion to continue.

Smoking can also lead to further drug abuse and misuse.

Many smokers would like to stop smoking, but it requires multiple persistent attempts as the success rates are small.

Nicotine replacement therapy (NRT) is the administration of low doses of nicotine to replace the nicotine in tobacco.

This is to reduce the desire to consume tobacco, as well as nicotine withdrawal symptoms, in order to ease the transition from cigarette smoking to complete abstinence.

NRT is packaged in many forms, e.g. gum, skin patch, nasal spray, inhaler and sublingual tablets/ lozenges.

The UK Royal College of Physicians (RCP) in its 2016 report stated that NRT is “most effective in helping people to stop smoking when used together with health professional input and support, but much less so when used on its own.“

E-cigarettes are marketed as consumer products, and are more popular than NRT as a substitute and competitor for tobacco cigarettes in many countries.

It appears to be effective when used by smokers as an aid to quitting smoking.

They are being used by confirmed smokers either as alternatives to smoked tobacco in their efforts to reduce harm to themselves or others, or to quit smoking completely.

E-cigarettes are currently not produced to the same standards as that of pharmaceuticals, with varying production standards in the different devices.

They are believed to likely be more hazardous than NRT.

However, it is also believed that the risks to health from long-term usage of e-cigarettes is unlikely to exceed 5% of the harm from smoking tobacco, according to the 2016 UK RCP report.

It is hoped that improvements in technology and production standards can reduce the long-term risks of e-cigarettes.

The Cochrane Review on Electronic Cigarettes for Smoking Cessation found that smokers were likely to stop smoking for at least six months by switching to vaping with nicotine e-liquid, as compared to using NRT, nicotine-free vape or behavioural support.

There are concerns about e-cigarettes increasing tobacco smoking.

They include its appeal to young people to start smoking in the first place, and being used for temporary (versus permanent) abstinence from smoking.

Multipronged approach

Some quarters advocate the use of e-cigarettes, NRT and other non- tobacco nicotine products as a substitute for smoking in many countries.

However, THR interventions have had limited success in reducing tobacco-related exposure, illness or death.

Consequently, there is a need to broaden the range of potentially effective THR strategies.

This was put succinctly in the Federation of Private Medical Practitioners Associations, Malaysia’s (FPMPAM) position statement on Oct 10: “THR is not the sole answer to the public health devastation caused by smoking.

“Rather, it holds the potential to complement evidence-based prevention and cessation interventions.

“We urge all policymakers, regulators, healthcare practitioners and relevant NGOs to examine all dimensions of this issue, consider all the pros and cons, risks and benefits, and to encourage healthy debate before any policy on THR is cast in stone.”

The FPMPAM pointed out that the benchmarks in THR need to include:

  • The initial goal of eliminating smoking tobacco products.
  • The intermediate goal of reducing or eliminating the harms of smoking for individuals who are unable or unwilling to quit, or to adopt the THR approach as an interim measure.
  • The final goal of total abstinence from all forms of nicotine or tobacco-related products.

In short, THR cannot be approached in a simplistic manner.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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