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Harm reduction in nicotine addiction

Harm reduction in nicotine addiction

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Publicado porBK Ainsworth
A report by the Tobacco Advisory Group of the Royal College of Physicians, October 2007
A report by the Tobacco Advisory Group of the Royal College of Physicians, October 2007

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Published by: BK Ainsworth on Jul 24, 2010
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Two questions arise in considering nicotine sources as substitutes for cigarette
smoking. The first is whether these sources will be satisfying to smokers and
prove to be acceptable substitutes for cigarettes. The second is whether the safety
profiles are acceptable. This latter question is discussed in more detail in later

5Sources of nicotine for human use


chapters, though, on purely theoretical grounds, the absence of other toxins
found in tobacco and particularly in its combustion products suggests strongly
that these products will be far safer.

Several studies have looked at the question of whether nicotine replacements are

useful for the purpose of reducing cigarette use. Some smokers are able to reduce

their cigarette consumption and exposure to carbon monoxide and some other

tobacco smoke toxins by using various nicotine products. Smoking reduction

studies have examined the use of nicotine gum, nicotine patches, nicotine spray and

nicotine oral tablets.3,46

In general, the extent of reduction of levels of biomarkers of

tobacco smoke response is less than the change expected from the magnitude of

change in the self-reporting number of cigarettes smoked per day.47,48

This may be

due to misreporting of cigarette consumption, and/or to compensation by smoking

each cigarette more intensively. The number of smokers who are able to

substantially reduce their smoking tends to decrease over time during clinical trials,

and questions remain as to whether this approach has long-term viability.

The use of smokeless tobacco as a substitute for cigarette smoking has been of

considerable recent interest.49

Smokeless tobacco does not generate combustion

products, which are thought to be responsible for most of the injurious effects of

cigarette smoking. The safety of smokeless tobacco products is discussed elsewhere.

Smokeless tobacco has been suggested as a way to help people quit smoking, and

some smokeless products have been marketed specifically for use when a person

cannot smoke cigarettes. However, the long-term use of smokeless tobacco as an

alternative to cigarette smoking has not yet been experimentally evaluated.

5.6 Conclusions

HA wide variety of nicotine products are available, delivering a range of

nicotine doses. The cigarette is the most widely used product.

HCigarettes deliver high doses of nicotine into the lungs, where it is absorbed

rapidly and transported directly in the systemic circulation to the brain.

HThe nicotine from cigarettes is carried in smoke which contains thousands of

other chemicals, including many that are carcinogenic or otherwise toxic.

HSome of these toxins are present in tobacco before combustion. Most are

combustion products.

HSmokeless tobacco also contains toxins and carcinogens, but delivers high

doses of nicotine without most of the toxic components in smoke.

HMedicinal nicotine products deliver pure nicotine but in relatively low

doses and, particularly for nicotine transdermal patches, very slowly. They
do not deliver other toxic chemicals.


Harm reduction in nicotine addiction

HThe available alternative nicotine products all deliver nicotine more slowly

than cigarettes, and are therefore probably less addictive.

HIt is possible that alternative nicotine products could provide a safer long-

term substitute for cigarette smoking. If so, this could benefit individual
and public health.


1Slade J, Connolly GN, Lymperis D. Eclipse: does it live up to its health claims? Tob Control
2002;11(Suppl 2):64–70.
2Roethig HJ, Kinser RD, Lau RW, Walk RA, Wang N. Short-term exposure evaluation of
adult smokers switching from conventional to first-generation electrically heated
cigarettes during controlled smoking. J Clin Pharmacol2005;45:133–45.
3Hatsukami DK, Lemmonds C, Zhang Y et al. Evaluation of carcinogen exposure in people
who used ‘reduced exposure’ tobacco products. J Natl Cancer Inst2004;96:844–52.
4Breland AB, Acosta MC, Eissenberg T. Tobacco specific nitrosamines and potential
reduced exposure products for smokers: a preliminary evaluation of Advance. Tob Control
5Stepanov I, Jensen J, Hatsukami D, Hecht SS. Tobacco-specific nitrosamines in new
tobacco products. Nicotine Tob Res2006;8:309–13.
6Djordjevic MV. Nicotine dosing characteristics across tobacco products. In: Boyle P, Gray
N, Henningfield J, Seffrin J, Zatonski W (eds), Tobacco and public health: science and
policy. Oxford: Oxford University Press, 2004:181–204.
7Wu W, Ashley DL, Watson CH. Determination of nicotine and other minor alkaloids in
international cigarettes by solid-phase microextraction and gas chromatography/mass
spectrometry. Anal Chem2002;74:4878–84.
8Benowitz NL. Biomarkers of cigarette smoking. In: Shopland DR, Wilkenfeld J,
Henningfield J, Eriksen MP, Modell SD (eds), The FTC cigarette test method for
determining tar, nicotine and carbon monoxide yields for U.S. cigarettes. NCI Smoking and
Tobacco Control Monograph No. 7. Bethesda, MD: US National Institutes of Health,
National Cancer Institute, NIH Publication No. 96-4028, August, 1996:93–111.
9Benowitz NL. Compensatory smoking of low yield cigarettes. In: Shopland DR, Burns
DM, Benowitz NL, Amacher RH (eds). Risks associated with smoking cigarettes with low
machine-measured yields of tar and nicotine. NCI Smoking and Tobacco Control
Monograph No. 13. Bethesda, MD: US National Institutes of Health, National Cancer
Institute, NIH Publication No. 02-5074, October 2001:39–64.
10Henningfield JE, Stapleton JM, Benowitz NL, Grayson RF, London ED. Higher levels of
nicotine in arterial than in venous blood after cigarette smoking. Drug Alcohol Depend
11Gourlay SG, Benowitz NL, Forbes A, McNeil JJ. Determinants of plasma concentrations of
nicotine and cotinine during cigarette smoking and transdermal nicotine treatment. Eur J
Clin Pharmacol1997;51:407–14.
12Hoffman D, Hoffman I. Chemistry and toxicology. In: Shopland DR, Burns DM,
Hoffman D, Cummings KM, Amacher RH (eds), Cigars – health effects and trends. NCI
Smoking and Tobacco Control Monograph No. 9. Bethesda, MD: US National Institutes
of Health, National Cancer Institute, NIH Publication No. 98-4302, October 1998:55–104.

5Sources of nicotine for human use


13Fant RV, Henningfield J. Pharmacology and abuse potential of cigars. In: Shopland DR,
Burns DM, Hoffman D, Cummings KM, Amacher RH (eds), Cigars – health effects and
trends. NCI Smoking and Tobacco Control Monograph No. 9. Bethesda, MD: US National
Institutes of Health, National Cancer Institute, NIH Publication No. 98-4302, October
14Turner JA, Sillett RW, McNicol MW. Effect of cigar smoking on carboxyhaemoglobin and
plasma nicotine concentrations in primary pipe and cigar smokers and ex-cigarette
smokers. Br Med J1977;2:1387–9.
15Wald NJ, Idle M, Boreham J, Bailey A, Van Vunakis H. Urinary nicotine concentrations in
cigarette and pipe smokers. Thorax1984;39:365–8.
16Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T. Tobacco smoking using a waterpipe:
a re-emerging strain in a global epidemic. Tob Control2004;13:327–33.
17Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of
nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther2002;40:249–55.

18Macaron C, Macaron Z, Maalouf MT, Macaron N, Moore A. Urinary cotinine in narguila
or chicha tobacco smokers. J Med Liban1997;45:19–20.
19Behera D, Uppal R, Majumdar S. Urinary levels of nicotine and cotinine in tobacco users.
Indian J Med Res2003;118:129–33.
20Malson JL, Sims K, Murty R, Pickworth WB. Comparison of the nicotine content of
tobacco used in bidis and conventional cigarettes. Tob Control2001;10:181–3.
21Wise MB, Guerin MR. Chemical analysis of the major constituents in clove cigarette
smoke. In: Hoffman D, Harris CC (eds), Banbury Report 23: Mechanisms in tobacco
carcinogenesis. Cold Spring Harbor, New York: Cold Spring Harbor Laboratory, 1986.
22Smokeless Tobacco Database: Massachusetts Department of Health, 2004.
23Determination of nicotine, pH, and moisture content of six U.S. commercial moist snuff
products. Florida, January–February 1999. MMWR Morb Mortal Wkly Rep
24Hatsukami DK, Keenan RM, Anton DJ. Topographical features of smokeless tobacco use.
Psychopharmacology (Berl)1988;96:428–9.
25Benowitz NL, Porchet H, Sheiner L, Jacob P 3rd. Nicotine absorption and cardiovascular
effects with smokeless tobacco use: comparison with cigarettes and nicotine gum. Clin
Pharmacol Ther1988;44:23–8.
26Fant RV, Henningfield JE, Nelson RA, Pickworth WB. Pharmacokinetics and
pharmacodynamics of moist snuff in humans. Tob Control1999;8:387–92.
27Wennmalm A, Benthin G, Granstrom EF et al. Relation between tobacco use and urinary
excretion of thromboxane A2 and prostacyclin metabolites in young men. Circulation
28McNeill A, Bedi R, Islam S, Alkhatib MN, West R. Levels of toxins in oral tobacco
products in the UK. Tob Control2006;15:64–7.
29Benowitz NL, Jacob P 3rd, Savanapridi C. Determinants of nicotine intake while chewing
nicotine Polacrilex gum. Clin Pharmacol Ther1987;41:467–73.
30Benowitz NL. Clinical pharmacology of transdermal nicotine. Eur J Pharm Biopharm
31Molander L, Lunell E, Andersson SB, Kuylenstierna F. Dose released and absolute
bioavailability of nicotine from a nicotine vapor inhaler. Clin Pharmacol Ther1996;59:
32Choi JH, Dresler CM, Norton MR, Strahs KR. Pharmacokinetics of a nicotine Polacrilex
lozenge. Nicotine Tob Res2003;5:635–44.


Harm reduction in nicotine addiction

33Fagerstrom KO, Hughes JR, Rasmussen T, Callas PW. Randomised trial investigating effect
of a novel nicotine delivery device (Eclipse) and a nicotine oral inhaler on smoking
behaviour, nicotine and carbon monoxide exposure, and motivation to quit. Tob Control
34Buchhalter AR, Eissenberg T. Preliminary evaluation of a novel smoking system: effects on
subjective and physiological measures and on smoking behavior. Nicotine Tob Res
35Hoffmann D, Djordjevic MV. Chemical composition and carcinogenicity of smokeless
tobacco. Adv Dent Res1997;11:322–9.
36Benowitz NL, Herrera B, Jacob P 3rd. Mentholated cigarette smoking inhibits nicotine
metabolism. J Pharmacol Exp Ther2004;310:1208–15.
37Henningfield JE, Benowitz NL, Ahijevych K et al. Does menthol enhance the addictiveness
of cigarettes? An agenda for research. Nicotine Tob Res2003;5:9–11.
38Stanfill SB, Ashley DL. Solid phase microextraction of alkenylbenzenes and other flavor-
related compounds from tobacco for analysis by selected ion monitoring gas
chromatography-mass spectrometry. J Chromatogr A1999;858:79–89.
39Pankow JF. A consideration of the role of gas/particle partitioning in the deposition of
nicotine and other tobacco smoke compounds in the respiratory tract. Chem Res Toxicol
40Pankow JF, Tavakoli AD, Luo W, Isabelle LM. Percent free base nicotine in the tobacco
smoke particulate matter of selected commercial and reference cigarettes. Chem Res
41Benowitz NL. Sodium intake from smokeless tobacco. N Engl J Med1988;319:873–4.
42WHO International Agency for Research on Cancer. Volume 83: Tobacco smoke and
involuntary smoking. IARC monograph on the evaluation of carcinogenic risks to humans.
Lyon: IARC, 2004.
43Stepanov I, Hecht SS, Ramakrishnan S, Gupta PC. Tobacco-specific nitrosamines in
smokeless tobacco products marketed in India. Int J Cancer2005;116:16–19.
44Stitzer ML, De Wit H. Abuse liability of nicotine. In: Benowitz NL (ed), Nicotine safety
and toxicity. New York: Oxford University Press, 1998:119–31.
45Hughes JR. Dependence on and abuse of nicotine replacement medications: an update. In:
Benowitz NL (ed), Nicotine safety and toxicity. New York: Oxford University Press,
46Batra A, Klingler K, Landfeldt B et al. Smoking reduction treatment with 4-mg nicotine
gum: a double-blind, randomized, placebo-controlled study. Clin Pharmacol Ther
47Hatsukami DK, Henningfield JE, Kotlyar M. Harm reduction approaches to reducing
tobacco-related mortality. Annu Rev Public Health2004;25:377–95.
48Hecht SS, Murphy SE, Carmella SG et al. Effects of reduced cigarette smoking on the
uptake of a tobacco-specific lung carcinogen. J Natl Cancer Inst2004;96:107–15.
49Savitz DA, Meyer RE, Tanzer JM, Mirvish SS, Lewin F. Public health implications of
smokeless tobacco use as a harm reduction strategy. Am J Public Health2006;96:1934–9.

5Sources of nicotine for human use





Population trends in smoking prevalence in the United Kingdom


Trends in prevalence in other countries


Health risks associated with active smoking


Health risks associated with passive smoking


Effects of smoking cessation



6.1 Introduction

Cigarette smoking is established as a significant cause of death and morbidity. It
is the largest identified avoidable cause of ill-health and premature death.
Despite a vast accumulation of evidence since the first research studies were
published in the 1950s, and public awareness of the adverse health effects, many
people continue to smoke. Furthermore, smoking is emerging as a significant
public health hazard in developing countries where there is potential for a large
number of premature deaths.

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