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The Polish Society of Civilization Diseases has prepared recommendations for people who smoke. For nicotine addicts, a harm reduction strategy is recommended. What is it about?
How many Europeans smoke?
Tobacco addiction is a disease and, like any disease, it should be treated according to the latest medical knowledge. According to Eurobarometer surveys published in 2017, more than a quarter (26%) of Europeans over the age of 15 smoke various types of tobacco products, and 33% people aged 25-39 are smokers. [1] Another 20 percent. of those interviewed say they smoked in the past but have stopped now. In 2006-2017, there was a XNUMX% decrease in the percentage of smokers. However, there are worrying trends for individual age groups. It has been observed that among Europeans aged 15-24, compared to 2006, they admit to smoking by 4%. more respondents (increase from 25% to 29%).
The impact of smoking on health and life expectancy
The most frequently quoted estimates say that each year over 700 Europeans are dying from smoking-related diseasesand the life expectancy of smokers is on average ten years shorter than that of non-smokers [2]. The latest Global Burden of Diseases, Injuries, and Risk Factors Study report from 2020, aimed at analyzing the impact of exposure to risk factors on human health, showed that smoking is the most important cause of death in men and the sixth most significant in women worldwide . [3] Nicotinism causes 8,7 million deaths globally, which is about 15% of the total number of people suffering from smoking. all deaths in 2019.
Both active and passive exposure to cigarette smoke predispose to the development of atherosclerosis and the occurrence of cardiovascular events such as heart attack and stroke. Nicotine addiction also contributes to an increased risk of lung diseases, numerous cancers and other civilization diseases. It has been shown that the most important aspects affected by cigarette smoke include: impairment of vasomotor functions, initiation of an inflammatory reaction, unfavorable modification of the lipid profile, dysfunction of platelets, changes in coagulation factors, disturbances in fibrinolysis and damage to DNA of cells.
Current nicotinism treatment recommendations
Total cessation of tobacco use should be recommended to all smokers. Intervention regarding smoking is the responsibility and the responsibility of all healthcare professionals. It is important that smokers are treated as addiction patients, and the assistance provided to them includes not only education about the harmful effects of smoking and the benefits of quitting, but also information about pharmacological and non-pharmacological methods of quitting smoking. Even small (less than a few minutes) medical intervention has been shown to increase the chances of quitting smoking. [4] The currently recommended minimum brief intervention required requires the consideration of several components known as “five P”:
- Ask the patient about smoking.
- Advise the patient to stop smoking and inform them about the dangers of tobacco and the benefits of stopping smoking.
- Conduct a Quit Readiness Assessment.
- Help the patient to stop smoking, provide support, conduct pharmacotherapy, engage the nurse from the practice and the patient’s family to help.
- Plan and carry out check-up visits, telephone consultations, monitor the effects of therapy, and, if necessary, refer them to more intensive specialist treatment. [5]
Various types of smoking cessation interventions have now been proven effective. They rely heavily on psychological-behavioral interventions and pharmacological reduction of nicotine withdrawal symptoms. [6] The choice of the type of therapy to be administered is influenced by many factors. These are among others:
- patient preferences,
- effectiveness and tolerance of a given form of treatment,
- regional availability of various types of therapy,
- cost of therapy.
Regarding pharmacological methods, the most commonly used substances include preparations such as:
- cytisine (partial nicotinic receptor agonist) – an alkaloid, the effect of which is to selectively bind to nicotinic receptors with 7 times greater affinity for the receptor than nicotine, with the simultaneous ability to stimulate dopamine secretion. It helps to relieve symptoms occurring in the period after stopping nicotine. The largest study conducted so far comparing the effectiveness of cytotine with nicotine replacement therapy showed that after 1 month, continuous abstinence from smoking occurred in 40% of respondents. participants receiving cytisine and was nearly 10 percent. higher than in patients receiving nicotine replacement therapy. [7, 8]
- nicotine replacement therapy (NRT) – preparations available in the form of transdermal patches (patches), oral forms (gum, lozenges, sublingual tablets, inhaler), and in some countries as a nasal spray.
- wareniklina (partial nicotinic receptor agonist) – the effectiveness of the drug in supporting smoking cessation is due to the partial agonist effect of varenicline on the α4β2 nicotinic receptor – its binding to this receptor causes an effect sufficient to reduce the symptoms of nicotine craving and withdrawal symptoms. The medicine appeared to be effective in comparison with the high dose NRT. [9]
- bupropion – a selective catecholamine (noradrenaline and dopamine) reuptake inhibitor. A drug that was initially used in the treatment of major depressive episodes and for which later studies have shown significant efficacy in supporting smoking cessation. [9]
Despite the effectiveness of smoking cessation proven in clinical trials, the methods described above are not available or known to most addicts. And even after proper implementation of the treatment, it is long-term effective in an average of 25%. smokers. [6] In Western Europe, even 80 percent. smokers do not try and do not want to quit. This is due to many factors, the most important of which seem to be: lack of appropriate knowledge, subjective belief that it is impossible to quit addiction, difficult accessibility and high costs of therapy.
A strategy to reduce the risk of quitting smoking
Taking into account the above barriers to quitting smoking and the relatively high percentage of people who continue to smoke, it seems important to have an alternative approach to the problem, which will be addressed to people who, for various reasons, do not want to or cannot stop smoking altogether. The strategy in question is to reduce the harm associated with the use of nicotine products. It was prepared by the Polish Society of Civilization Diseases (PTChC).
The scheme in question recommends that, in the event of failure of other forms of treatment aimed at stopping smoking completely, patients should be encouraged to give up smoking traditional cigarettes, pipes, cigarillos or cigars in favor of using products such as heat-not-burn (HnB), i.e. systems for heating tobacco without burning it. Such systems are less hazardous to health and are not associated with such adverse health effects as traditional cigarettes. It is also important that these products are non-smoking products that initiate nicotine addiction. As shown by the results of research carried out in Poland, 0,2 percent. adolescents identify these types of products as initiation products. [10]
It is estimated that the complete replacement of traditional cigarettes with other nicotine products within 10 years would reduce the number of premature deaths in the United States alone by 1,6 million to 6,6 million, which could translate into a total of 20,8 million to 86,7 million. 11 million fewer life years lost. [12] A recent publication, independent of the tobacco industry influences, from reputable research centers (e.g. the Netherlands Food and Consumer Product Safety Authority) showed that, compared to traditional tobacco smoking, the use of HnB products significantly reduces exposure to eight the main carcinogens in tobacco smoke. [10] The study estimated that the combined exposure to these substances was 25 to XNUMX times lower when using HnB instead of cigarettes. Which, according to researchers, is associated with a significant increase in the life expectancy of smokers and a reduction in the risk of cancer development.
Moreover, it should be emphasized that the transition from traditional cigarettes to HnB products can be a bridge to permanent smoking cessation. A randomized UK study found that tobacco preparations other than conventional cigarettes are twice as effective as NRT in maintaining long-term abstinence from smoking (18% versus 9%) [13]. In heavy smokers, replacing a traditional cigarette with HnB is associated with immediate relief of withdrawal symptoms and a high level of subjective satisfaction. [14]
Approach to HnB products as a substitute for cigarettes to reduce smoking-related harm harm reduction) has been included in the official positions of public institutions for some time. According to the Dutch National Institute for Public Health and the Environment (RIVM), “it seems reasonable to conclude that using HnB products instead of cigarettes will significantly increase life expectancy in the subgroup of smokers who will die of cancer”. [15]
In turn, German specialists indicate that: «The best thing smokers can do for their health is to stop smoking immediately. If this is not possible, the recommended solution is to completely switch to non-smoking alternatives (e-cigarettes, tobacco warmers, tobacco-free nicotine products). An important aspect to note is that the change must be complete without continuing smoking at the same time (dual use). » [16]
The US Food & Drug Administration (FDA) also referred to the use of HnB products. [17] In its position paper, the FDA authorized the designation of Philip Morris International’s IQOS product as a risk-modified tobacco product (modified risk tobacco products, MRTP), emphasizing that the product’s controlled heating of tobacco without burning significantly reduces the production of harmful and potentially harmful compounds compared to cigarette smoke. The agency also stressed that the complete transition from burning cigarettes to the IQOS tobacco heating system significantly reduces the body’s exposure to the 15 harmful and potentially harmful chemicals compared to cigarette smoke. The aerosol emitted by IQOS has been shown to contain significantly lower levels of potential carcinogens and toxic substances that can damage the respiratory or reproductive systems.
In conclusion, physicians and other health care professionals should conduct interventions aimed at stopping smoking for all smokers. Despite all currently available treatments, it may not be possible for some patients to quit smoking. The solution that can reduce the negative effects of smoking in people who cannot quit smoking are standardized and tested tobacco heating products that reduce exposure to harmful compounds generated during the tobacco combustion process. The use of the indicated products should now be treated as one of the less harmful alternatives to traditional cigarettes, and at the same time a bridge between pharmacotherapy and complete abstinence. All patients who are heavy smoking should receive adequate information on this.
Recommendations for legal regulations
The distinction in fiscal legislation between conventional cigarettes and medically tested novel products (HnB) and other reduced risk tested nicotine products should be maintained, and an increase in excise duty on conventional cigarettes should be considered. The above is in line with the direction indicated by the International Agency for Research on Cancer in the report published in 2019 [18]
The procedures for placing nicotine-containing alternatives on the market should also include an assessment of the risk reduction potential for lower exposure of the consumer to harmful compounds compared to cigarette smoke. If the complete banning of tobacco products is not possible, appropriate labeling of alternative products tested by public research centers with such potential is in the interest of public health. The indicated solutions may be an effective step towards the complete elimination of traditional cigarettes from the market.
Recommendations for smoking patients
The optimal procedure for a smoker is to completely break the habit. If this is not possible, the recommended solution is to switch completely to non-smoking alternatives (tested tobacco heating systems, tested no-tobacco nicotine products).
An important aspect to note is that the change must be complete without continuing smoking at the same time (dual use). Dual use may be acceptable for a short transitional period, but must end as soon as possible in favor of a total shift, as smoking several cigarettes a day is known to still carry serious health risks (there is an exponential relationship between cigarette consumption and risk).
Smokers should choose for themselves the types of products that are appropriate to reduce the risk of smoking (nicotine inhalers, heating systems, gums, nicotine sprays or patches) and ideally be able to switch to them completely as soon as possible.
The position of the Polish Society of Civilization Diseases: Harm reduction strategy as a modern approach to the management of patients addicted to nicotine
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