Nikotinbeutel - Harm reduction bei Tabak

Tobacco Harm Reduction: Nicotine Pouches as Safer Nicotine Products?

Tobacco Harm Reduction: Nicotine Pouches as Safer Nicotine Products?
What exactly does harm reduction mean, and why does this approach seem essential for tobacco as well? You’ll find the answers in the following article. Additionally, you’ll learn how the term "safer nicotine products" can be understood, why nicotine pouches and snus are considered part of this category, and which areas still require significant action on this topic.
Tobacco Harm Reduction: Nicotine Pouches as Safer Nicotine Products?
What exactly does harm reduction mean, and why does this approach seem essential for tobacco as well? You’ll find the answers in the following article. Additionally, you’ll learn how the term "safer nicotine products" can be understood, why nicotine pouches and snus are considered part of this category, and which areas still require significant action on this topic.

What does harm reduction mean?

It is generally known that smoking tobacco poses an increased risk to health. Nevertheless, smoking is still a widespread vice - in Germany, for example, the smoking rate has stubbornly remained at around 30 percent for several years according to the DEBRA study.*1

Smoking rate (tobacco smoking) in Germany - DEBRA study

The German Smoking Behavior Survey (DEBRA study) is a representative, face-to-face survey in which, among other things, the smoking rate (tobacco smoking) in the German population is surveyed. As a year-on-year comparison (2017-2024) shows, the German smoking rate stubbornly remains at around 30 percent. - Graphic: DEBRA/www.debra-study.info

Common strategies used to counteract this are primarily restrictive measures, such as bans on smoking in public places or restaurants, bans on sales to young people and advertising restrictions; however, there are also prohibitive measures, such as increasing the price of cigarettes.

And although such measures seek to curb consumption to a certain extent, cigarettes are still available almost everywhere - a permissive attitude still applies to smoking tobacco. So if you don't want to stop smoking or want to nicotine withdrawal will continue to smoke.

Now the question is pressing: Is there a lack of incentives, is there even a lack of social (affordable) support for smokers who want to quit? Instead of "banning" some things, should perhaps something else or more be "offered"? Of course, there are contact points for smoking cessation in many countries - free counseling services and, albeit somewhat more expensive, nicotine replacement therapies at least start here. Nevertheless, they seem to have (too) little effect in the fight against smoking - and this is precisely where the concept of harm reduction gains importance.

Harm reduction in tobacco consumption - another strategy that is not/only little promoted in most countries - refers to the reduction of health risks by offering consumers safer/less harmful alternative nicotine products and motivating them to engage in less risky behavior - without explicitly advocating bans.*2 This concept can therefore also be understood as a complementary health and social policy strategy to various (already existing) restrictive, prohibitive measures.

Theoretically, classic nicotine replacement therapy products could be included here - but harm reduction itself aims to go beyond this. Specifically, it aims to increase the use of cigarette alternatives such as Nicotine Pouches, e-cigarettes and tobacco heaters*3

Harm reduction in tobacco consumption is therefore not primarily aimed at ending nicotine consumption, but primarily at reducing harm to health. Furthermore, it is not intended to replace other health and social policy strategies against the harmful effects of smoking tobacco. Rather, it is seen as an additional approach to create complementary incentives to reduce smoking rates and thus smoking-related illnesses and deaths.*4

Translation: Harm Reduction German

The Anglicism "harm reduction" can be better understood with the German terms "Schadenbegrenzung" or "harm minimization". In the context of tobacco consumption, a so-called harm reduction strategy i.e. the limitation or minimization of harm caused by tobacco consumption. Since "harm" here refers to individual health and the health of fellow human beings (passive smokers), but can also be understood in the sense of society as a whole - e.g. a burden on the health and social system due to tobacco-related diseases - the term can be defined quite broadly. Respectively, a tobacco harm reduction strategy can have a multidimensional positive effect on at least these three levels.

Does Tobacco Harm Reduction really make sense?

The harm reduction approach for tobacco is becoming increasingly important. This is mainly because current tobacco control measures do not appear to be sufficient. According to a paper by Global State of Tobacco Harm Reduction (May 2022), there are around 1.1 billion smokers worldwide, although this figure has not changed significantly since 2000.*2 Although 80 percent of them live in low- to middle-income countries (LMICs)*2 - even in economically better-off EU member states, smoking rates still appear to be very high as of 2024.*5

If consumers switch to the consumption of less harmful nicotine products in order to successfully minimize harm, one could argue: Doesn't that merely shift an addiction from one source of consumption to another? And yes, that may be difficult to deny - especially if such alternative products also contain nicotine and therefore have a similar addictive potential. But basically, this question misses the essence of harm reduction. If you remember, it is not primarily about stopping nicotine consumption, but about being able to achieve a reduction in harm to health.

The more important question surrounding the meaningfulness of tobacco harm reduction is therefore more likely to be: can it actually minimize (smoking-related) diseases and deaths? And this is where the "Swedish model" is often referred to. As long as Sweden actually has the lowest smoking rate in the EU (at almost 5%, which is usually understood as the threshold for a "smoke-free country"), a low tobacco-related cancer incidence and a low tobacco-related mortality rate, the country with oral tobacco and a low tobacco consumption rate, the country with the lowest smoking rate in the EU (at almost 5%, which is usually understood as the threshold for a "smoke-free country"). Nicotine Pouches but is not tobacco/nicotine free, Tobacco Harm Reduction seems to make sense.

>> Please also read: Tobacco Directive in the new EU Commission: The future for Snus and Nicotine Pouches

Of course, it could again be argued that such a comparison excludes many circumstances and thus threatens to blur the complexity of the facts. However, it is basically clear what a look at Sweden at least suggests: A country can become virtually smoke-free within just a few years and thus displace the most harmful of all nicotine consumption sources if an appropriate tobacco control policy allows a harm reduction strategy to be sufficiently considered.*6 Or to put it more cautiously: Harm reduction can play a functionally essential role in reducing smoking rates. And anyone who sets the latter as a prerequisite for meaningfulness will at least have to admit it: Harm reduction can certainly make sense and holds potential!

Potential for a rapid reduction in tobacco-related diseases

The potential of tobacco harm reduction to rapidly reduce tobacco-related disease and mortality is also underpinned by a report from the UK-based public health agency Knownledge Action Change. As well as incorporating the latest findings and data projections on the global status of tobacco harm reduction, the report found strong evidence of a link between the increasing use of so-called safer nicotine products and a decline in smoking prevalence - in a number of countries worldwide.*7

Tobacco cigarettes are considered the most harmful form of nicotine consumption

The report emphasizes several times that the consumption of
smoking tobacco is considered to be the most harmful form of nicotine
consumption. © Picture: AdobeStock

It could be deduced that successful harm reduction and thus the supply of and legal access to safer nicotine products - such as e-cigarettes, tobacco-free Nicotine Pouches, Snus Swedish-style e-cigarettes, but also tobacco heaters - encourage smokers who want to quit and cannot/will not quit their nicotine consumption to turn their backs on conventional smoking tobacco.*7

Legal and well thought-out access - and this is where we should therefore focus more on - to equally less harmful, or as the report puts it, "safer" nicotine products would therefore appear to have enormous potential to improve the health of countless people who smoke worldwide.

Are Nicotine Pouches and Snus safer nicotine products?

What needs to be clarified now - and here in particular tobacco-free Nicotine Pouches in particular - whether safer nicotine products are actually less harmful. Furthermore, how exactly can "safer" be understood?

As mentioned above, most people know that smoking is bad for your health. What is less well known, however, is that nicotine per se is not the cause of most serious diseases associated with tobacco smoking - primarily cancer.

The German Federal Institute for Risk Assessment published a report on the health assessment of nicotine pouches as early as 2022, which also highlighted the possible carcinogenicity of nicotine - i.e. its potential to cause cancer - based on existing studies and data. The exact wording is as follows:

"The RIVM found no evidence for carcinogenic properties of nicotine in its monograph on nicotine pouches [5]. The review by Sanner & Grimsrud, 2015 concludes that no conclusions can be drawn about possible tumor-inducing effects of long-term treatment with nicotine [33]. [..]"*8

However, so-called tobacco-specific nitrosamines (TSNAs) have been proven to be carcinogenic. And these are present in nicotine pouches at most in very small traces, namely as a result of the extraction process of nicotine from the tobacco leaves*8

This seems to suggest that harm reduction can also be applied to nicotine pouches in the sense mentioned above, and that at least TSNAs can be avoided - if not completely, then to a large extent. And the fact that tobacco smoke, which contains numerous other harmful substances such as tar, is saved anyway during oral, combustion-free consumption, should also support harm reduction.

But does this also make the products less harmful overall? Could they perhaps even be more harmful in other ways due to other ingredients?

The paper by Global State of Tobacco Harm Reduction (May 2022) cited above states this:

"The most dangerous way to consume nicotine is to burn a cigarette and inhale the smoke. Burning tobacco releases tar and gases containing thousands of harmful substances, many of which can cause serious illness and lead to premature death in half of all smokers. Some oral tobacco products also release dangerous toxins during consumption. In contrast, Safer Nicotine Products (SNP) are non-combustible: none of them burn tobacco, and some of them contain no tobacco at all. These include nicotine-containing vapes (e-cigarettes), tobacco-free Nicotine Pouches (white Snus), Snus Swedish-style (an oral tobacco), many smokeless (chewing) tobaccos from the USA and heated tobacco products. "*2

Safe nicotine products are therefore understood to be those whose consumption causes less overall harm to health than smoking - and in addition to tobacco-free nicotine pouches, the paper even includes tobacco snus.

>> You might also be interested at this point: Snus and Nicotine Pouches in focus at the InterTabac 2024

Around 144 million already use safer nicotine products

According to the report published this year by Knownledge Aktion Change, the research commissioned by Global State of Tobacco Harm Reduction 2024 shows that more than two thirds of the world's adult population in around 130 countries already have legal access to at least one form of safer nicotine product.*7

At this point, an estimate of the global number of vapers contained in the report catches the eye. This has risen from 58 million in 2018 to 114 million today, almost doubling. A further 30 million people would use other safer nicotine products*7 According to these estimates, there are now around 144 million such users, which is only a fraction of the 1.1 billion smokers worldwide - assuming this figure has not fallen massively since 2022.

If more than two thirds of the world's adult population have legal access to such products in around 130 countries, and these 130 countries are also the 195 (commonly recognized number*9) worldwide in which the majority of smokers live, then such figures speak for a powerful potential for expansion in terms of harm reduction for tobacco consumption. An important step here will certainly be the stronger implementation of education and information campaigns and the creation of greater awareness of the issue. And this will primarily affect politicians, who will have to assume greater responsibility.

>> A survey by Phillip Morris GmbH also seems to show that there is a knowledge gap not only for possible alternatives, but also for the harmfulness of tobacco smoke in particular among smokers - read more: Users of e-cigarettes and tobacco heaters are increasingly turning to Snus and Nicotine Pouches

In addition, the ratio of two thirds compared to a much larger number for combustible tobacco indicates a need for action when it comes to legal access to products. In Germany, for example, the current situation surrounding Nicotine Pouches is not only confusing, it is even blocking legal local sales in some districts.

Snus in Deutschland - legal?
Might be interesting

Snus and Germany - Will it soon be allowed?

Learn more
Snus in Deutschland - legal?
Might be interesting

Snus and Germany - Will it soon be allowed?

Learn more

Either way, it was mentioned earlier that 80 percent of the world's 1.1 billion smokers live in low- to middle-income countries. Assuming that these figures have changed very little since 2022, the following probably applies: Assuming there is too little legal accessibility to safer nicotine products, even those who would like to become smoke-free but are unable to do so due to a nicotine addiction will find it noticeably difficult without further ado, seemingly deprived of an important chance/opportunity. Because - even if common nicotine replacement products are available for nicotine replacement therapy - these are certainly offered at prices that are probably too expensive for the majority compared to the well thought-out marketing of safer nicotine products.

What is generally implied by the latter is clear: safer nicotine products, if they can be offered more cheaply than conventional nicotine replacement products - with prices similar to those of cigarettes - are affordable for more smokers willing to quit.

In any case, a lot will have to change in terms of legal accessibility and active use if the tobacco harm reduction approach is to be successfully implemented.

Harm reduction for tobacco as an achievement for public health

Harry Shapiro, editor-in-chief and lead author of The Global State of Tobacco Harm Reduction 2024, emphasizes with regard to tobacco harm reduction:

"If fully realized, tobacco harm reduction has the potential to rapidly reduce the global number of smokers. This would deliver one of the greatest public health gains of the 21st century. "*7

This can be understood to the extent that restrictive/prohibitive measures already implemented, which aim to reduce smoking rates, still appear to have too little effect - the reference here is to smoking rates in countries where existing measures are accompanied by a number of active smokers that is still too high.

As smoking tobacco cigarettes seems to be the most harmful form of nicotine consumption (here also especially the country-specific smoking-related morbidity and mortality rates compared to the figures from Sweden are understood), a well thought-out tobacco control policy that allows an effective concept of Tobacco Harm Reduction to be implemented in addition to existing measures already mentioned would significantly help to reduce tobacco-related morbidity and mortality rates. And this would indeed be considered one of the greatest achievements for public health in the 21st century.



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Sources (links last accessed 12/20/2014):

*1 See: https://www.debra-study.info/ 
*2 Cf. also: https://gsthr.org/resources/briefing-papers/what-is-tobacco-harm-reduction/ 
*3 In contrast to conventional nicotine replacement products (chewing gum, patches, etc.), such alternative nicotine products are not medically approved and are often considered to have a higher potential for harm than nicotine replacement products (although definitely lower than smoking tobacco). For this reason, they are not treated in the same way as tobacco in terms of harm reduction. Cf. in this regard: https://www.dkfz.de/de/tabakkontrolle/download/Publikationen/AdWfP/AdWfdP_2021_Harm-Reduction_0.pdf 
*4 On the purely complementary function of harm reduction, which does not conflict with other strategies, see also: https://homepage.univie.ac.at/nicole.lieger/strff/as_harmred.pdf 
*5 Cf. https://de.statista.com/statistik/daten/studie/1099197/umfrage/anteil-der-raucher-in-der-eu-nach-geschlecht/ 
*6 Cf. https://smokefreesweden.org/wp-content/themes/smokefreesweden/assets/pdf/reports/Report%20The%20Swedish%20Experience%20EN.pdf 
*7 Cf. https://gsthr.org/resources/thr-reports/the-global-state-of-tobacco-harm-reduction-2024-a-situation-report/ 
*8 See also: https://www.bfr.bund.de/cm/343/gesundheitliche-bewertung-von-nikotinbeuteln-nikotinpouches.pdf
*9 https://www.t-online.de/leben/alltagswissen/id_100496560/wie-viele-laender-gibt-es-auf-der-welt-.html