Abstract
Background: Smoking and its health and societal burden are widely addressed with prevention and smoking cessation strategies that have a solid evidence base. Tobacco harm reduction, on the other hand, is a less researched approach that may have huge potential among smokers in the real world. Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products (HTP) might reduce smoking-related health risks, but the evidence on how smokers perceive or use these alternative nicotine products for tobacco harm reduction is only emerging.Aims: This thesis aimed to explore the potential of alternative nicotine products to reduce tobacco-related harm among smokers. Specific aims were:
1.To compare the relative health risk profile of HTP with smoking and/or using other alternative nicotine products.
2.To assess smokers’ interest in trying different alternative nicotine products.
3.To explore smokers’ transitions between smoking, use of alternative nicotine products and quitting smoking.
4.To investigate perceptions and experiences of tobacco harm reduction among smokers who want but cannot stop smoking.
Methods: Four studies were conducted: a systematic literature review of studies on new HTP (31 publications up to November 2017), a secondary analysis of a cross-sectional online survey data (2019) of smokers from Great Britain (N = 1777), a secondary analysis of a longitudinal online cohort survey data (2016-2017) of past-year smokers from the United Kingdom (N = 2857) and a qualitative study of smokers who want but cannot stop smoking (N = 20, interviewed in 2018-2019).
Results: Regarding aim 1, the review showed that HTP expose users and bystanders to lower but not negligible levels of tobacco-related toxicants compared with tobacco smoking. The majority of reviewed studies were affiliated with the tobacco industry. Regarding aim 2, a quarter of adult smokers in Great Britain—particularly those less dependent and less motivated to stop smoking—have never tried alternative nicotine products. Younger and less dependent smokers with low motivation to stop smoking were more likely to have ever tried e-cigarettes only, while older and more dependent smokers with higher motivation to stop smoking were more likely to have ever tried NRT or NRT and e-cigarettes. Regarding aim 3, over a 16-month period, smokers were relatively stable in their tobacco and nicotine use patterns and most of them continued smoking without attempting to stop or reduce the harmfulness of their tobacco use. Smokers who were using NRT or e-cigarettes concurrently had higher probabilities of changing their tobacco and nicotine use pattern and moving away from smoking. Regarding aim 4, smokers who had recently failed to stop smoking were ambivalent towards using smoking cessation support, NRT or e-cigarettes. Many of them considered alternative nicotine products unnecessary because the alternatives were less satisfying than smoking, did not help to stop smoking and posed a risk of continued nicotine addiction.
Conclusions: The reviewed evidence suggested that new HTP might reduce tobacco harm similarly to NRT and e-cigarettes if smokers were to completely replace smoking with these products. Many smokers would prefer to continue or completely stop smoking rather than replace smoking with less harmful but less gratifying alternative nicotine products. Smokers who are less dependent and less motivated to stop smoking might be particularly reluctant to try alternative nicotine products and should be offered alternative support for changing their tobacco use. In contrast, smokers who concurrently use NRT or e-cigarettes are more likely to reduce tobacco harm in the longer term than smokers who do not use these alternative products. Smokers’ characteristics seem to be associated with their preferences for alternative nicotine products and consequently with longer-term changes in smoking. The currently offered tobacco harm reduction options cannot serve most of the smokers who are unwilling or unable to stop smoking—they might require different support to address the harm from their continued smoking.
| Date of Award | 1 May 2021 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Leonie Brose (Supervisor) & Ann McNeill (Supervisor) |