The first event to deal with “smoking” holistically: harm reduction from tobacco and novel products, research and policy, the “1st Scientific Summit on Tobacco Harm Reduction” concluded on Saturday June 9, with participation of an enthusiastic audience at Stavros Niarchos Foundation Cultural Center, in Athens, Greece. Co-chairs, professors Demetrios Kouretas and Konstantinos Poulas announced the 2nd Scientific Summit on Tobacco Harm Reduction to be held in Athens on May 31st ‒June 1st, 2019.
In 12 sessions more than 40 scientific papers were presented. The Summit had 140 participants from 14 countries worldwide (Bulgaria, Cyprus, Greece, Italy, Japan, Netherlands, Portugal, Romania, Slovenia, South Africa, Switzerland, Turkey, UK, USA). Research data as well as health policy and regulation issues were discussed at the Summit by scientists and clinicians. Representatives both from tobacco industry and e-cigarette manufacturers also participated in high-level panel discussions.
Undoubtedly, smoking constitutes one of the major public health problems and a significant threat to health and well-being, internationally. In the last decade, the global number of deaths from smoking has tripled from 2.1 million to 6 million. As a result, 13 million Europeans suffer from a chronic condition that is attributable to smoking like increased need for treatment (usually spans over a lifetime), significant impact on the economics of the health system, lost productivity due to morbidity and mortality.
Prevalence of smoking in Greece
Greece has one of the highest smoking prevalence rates among members of the EU and OECD but we see a significant decline compared to the past decade (statistics.gr). In the last 50 yrs almost 420,000 people died from smoking-related diseases in Greece. The latest estimate is that 18.1% of all deaths among individuals aged >35 is due to smoking.
Data from the “Health and Welfare” survey by the National School of Public Health, Athens, presented by Kostas Athanasakis, shows steady decline in the percentage of smokers: measurements in 2006 showed the percentage of smokers in adults at 46.8% whereas latest estimates are around 32.1%. The average number of cigarettes per smoker per day fell from 24 in 2006 to 15.8 in 2017. Also, the direct costs are 1.76 billion (7.9% of total health spending) (conservative estimations) and both direct and indirect is 3.27 billion, i.e. 1.5% of GDP.
Management and smoking reduction strategies
The management and reduction of exposure to major risk factors for health is the key objective of public health. Smoking, due to its high prevalence, remains among the key priorities for intervention. In general, policies for smoking cessation are classified into: regulatory interventions (legislation) and behavioural interventions (incentives for behaviour modification, such as price increases). Price increases (e.g. via taxation) produce measurable results in terms of smoking reduction. Over 100 studies in international literature indicate that an increase of 10% in prices reduces aggregate consumption by 2.5–5%. Effective anti-smoking policies are necessary.
Harm reduction -a holistic policy for the entire public health strategy- may be considered a “second best” option among public health policies against smoking, while smoking cessation remains the key strategy and top priority.
Modifying behaviours against health risks (healthy living), smoking included, should be a key topic in the public health agenda, and harm reduction is a strategy/policy that currently is under consideration of application across a wide array of risk factors.
Agis Tsouros, Keynote Speaker at the Summit, said “It took us 50 years from the moment we were certain of the harmful effects of smoking to ‘act’ and reduce it”. After presenting WHO goals on smoking cessation, he concluded that we all have an obligation to ensure that our children, the children of the world, will grow up in a world free from the effects of smoking.
Michael Toumbis, Pulmonologist, referred to the need for a regulatory framework for products related to health (in particular for tobacco products). He presented the aims of the EU Directive on Tobacco Products and the WHO EMPOWER measures, which are supportive to implementing effective national interventions to reduce the demand for tobacco contained in the Framework Convention on Tobacco Control (FCTC, WHO). He concluded that the current regulatory framework will be adequate, if updated for the new products, and must be fully applied.
Professor Nikos Maniadakis pointed out that while there is some early evidence that some products may be associated with a significant reduction in the exposure of harmful toxicants, existing scientific evidence is far from being sufficient to assess with confidence the differences in individual health risk between newly engineered and existing tobacco products for harm. Also, he pointed out, market surveillance of many different classes of products available is important and should include examination of product chemical characteristics, uptake of toxicants, toxicity, addiction potential, and disease risk and outcomes. This assessment and any claim from producers need to be assessed by independent regulatory bodies capable of examining claims and to determine whether they are valid, Prof. Maniadakis concluded.
The UK and Public Health England have a unique approach to Tobacco control and tobacco harm reduction that was presented to the Summit by Martin Dockrell, Tobacco Control Programme Lead. UK is a leader in tobacco control and one of few countries to have adopted e-cigarette as stop smoking aid. At the same time the UK already has some of the most rigorous regulations on e-cig, and all e-cig sold in the country are tested and have low levels of toxicants. E-Cigarettes are helping smokers to quit, stressed Mr Dockrell.
Michael Fisher referred to the framework on e-vapor products in the US, citing the FDA Commissioner Dr. Scott Gottlieb who said that “We must recognize the potential for innovation to lead to less harmful products, which, under FDA’s oversight, could be part of a solution…”. Mr Fisher also presented Altria’s Reduced Harm Tobacco Products framework which has a rigorous process to develop and evaluate the company e-vapor products to demonstrate harm reduction opportunity.
Research results
On Saturday, research results were presented by the authors who submitted their work to the Summit, on the subjects of Toxicology and aerosol chemistry. George Karles, Altria Client Services, presented data on a new model which allows the estimation of the spatial and temporal variations of the concentration of individual constituents present in the emitted aerosol in vapor and particulate phases separately. Nikolaos Vlachos, University of Patras, discussed the importance of aldehyde emissions and presented data about the relation of these emissions with the resistance temperature and the resistance aging in e-cigarettes. Konstantinos Poulas, University of Patras, presented data about the heavy metal concentrations in e-liquids and their aerosols as well. According to his findings, in liquefied aerosols from most atomizers, the concentrations determined were within acceptable range with the remarkable exception of vapors generated from atomizers that had undergone extensive use where the levels where remarkably increased. Demetrios Kouretas, University of Thessaly, highlighted the importance of assays for assessing the oxidative potential of tobacco particulate matter, and presented a novel assay to assess the genotoxicity caused.
Clinical Development
At “Clinical Development” Session, Dr Patrick Picavet made the first announcement of the “Exposure Response Study” first results. The study assessed the changes across a set of the “8 co-primary clinical risk endpoints” in smokers who switch from smoking cigarettes to using Tobacco Heating System (THS) as compared to those continuing to smoke cigarettes for 6 months. The 8 endpoints were lipid metabolism, clotting, endothelial function, CO acute effect, inflammation, oxidative stress, lung function, and genotoxicity. Five out of 8 endpoints showed statistically significant and favorable changes after switching to THS, leading to the conclusion that full switching is the best option for current adult smokers continuing to use tobacco products.
The effect of switching from smoking to e-cigarette, e-cig safety, etc. are some of the objectives of the SmokeFreeBrain project, which is financed by the EU. Dr Alexis Bailey said that the project provides important novel information on the safety of e-cigarette use and effectiveness for smoking cessation through exploring the biological, and neurobiological mechanisms underlining the effects of e-cigarette use.
Study participants were heavy smokers (smoking of >10 cigarettes/day) willing to give up smoking and switch to nicotine containing e-cigs to help them quit. Results showed subtle reduction in nicotine dependence and smoking craving, decrease in nicotine consumption and subtle improvement in sleep quality and quality of life in general. Despite the fact that participants presented with acute withdrawal symptoms, these were normalised after 28 days of e-cigarette use. Evidence of the study support e-cig use for smoking cessation, concluded Dr Bailey.
Lastly, a Panel Discussion with participation of MDs from Smoking Cessation Centers of Attica hospitals took place, coordinated by Dr Michael Toumbis, highlighting the methods and issues met during the «smoking cessation journey». Τhe Summit closed with a session entitled “Bioethics: Challenges and Obligations” where ethical issues such as informed choices, smokers and non-smokers rights and the ethical issues behind the Harm Reduction approach were discussed.
The Summit was organised by the Department of Biochemistry-Biotechnology, Postgraduate Program “Toxicology” of the University of Thessaly, led by Professor Demetrios Kouretas, and the Laboratory of Molecular Biology and Immunology, Department of Pharmacy of the University of Patras, led by Professor Konstantinos Poulas.
