TCS Daily


Is Harm Reduction Possible?

By Michael Kunze - January 1, 2005 12:00 AM

Editor's note: The following remarks were delivered at the Risk: Regulation and Reality Conference by Dr. Michael Kunze, Professor of Public Health, University of Vienna (Austria). The conference was co-hosted by Tech Central Station and was held on October 7, 2004 in Toronto, ON.

Dr. Michael Kunze: Thank you, Chairman, you must speak at my funeral, it was so beautiful. But, I mean, listening to the Chairman and the other two speakers, I find out why I was invited. Because I'm German speaking, and the German language has a beautiful word for all that risk fear, it's angst. German angst. Germans always have angst. Angst that the Russians may come. Well, they didn't come by military forces, now they come into Vienna and the rest of the German speaking country and spend a hell of a lot of money. Then they had angst that the Chinese will come, and they didn't come, but they will come and buy all Europe if they continue like that. Now the Germans have angst that the American troops will leave Germany because they are needed somewhere else I understand. But, you made a mistake, I am not German, I am Austrian, and the Austrians don't care. They don't have angst. They drive like hell. They drink like hell. They eat a lot. And, well, they have a good time, usually. But, I will address today two huge problems and a little, a third one, huge problems on my table and kept me this morning busy on the phone. As you can imagine, for me it's now, I can't figure out how late it is. So I started very early being on the phone, two huge problems, which have nothing in common and everything in common. It's the flu problem; you addressed it already, and the tobacco problem. The flu problem is the one, which is of immediate threat. There is no other disease, which might kill so many people in a short period of time. And the tobacco problem is the greatest medium to long-term health problem. Both are linked in the public health measures. And, of course, the third one, which is obesity. Obesity in Austria is a growing epidemic. In some parts of, Eastern part of Austria, in the state of Burgenland, we have almost as many obese people as in the United States of America.

A few words on the flu crisis the United States of America is going to experience. I understand that Canada has a different situation when it comes to the flu vaccine, but news broke yesterday, or the day before yesterday already, that America will fall short of 50 million doses of flu vaccine. This is a real problem. This is a real problem and I don't know how they will overcome it. I was on the phone, and I'm sure Austria got the flu supply, so I feel somewhat relieved. I told my people, get everybody vaccinated as soon as possible otherwise they will ship it to the U.S. Really, that's a real crisis, which America, United States of America is now facing, and 50 million flu shots are lost due to manufacturing problems. This means many, many people will die, ethical problems, not to mention the pandemic situation. This is something different - Pandemic. And when I was invited to Toronto of course I recall the problems you had the other year, but the influence of pandemic will be something that SARS will make us smile about. It's SARS by 1,000 times more important, but then from an economic point of view, there is also an advantage to some companies. For example, I have no shares in Roche, but Roche will benefit a lot because they have the new Tamiflu available, and this will be big business, I guess for them.

Now, I go back to real stuff, which I have prepared for you, but I couldn't resist in going into details a little on this real crisis. You told me F5? It's one, two, three, four, and five. Nothing happens. This is a hidden stress test, how Austrians perform after a nine hour flight in the morning. Okay, here we are. I told you I'm a public health person, so we have many, many things on our table and I don't know what tomorrow will bring except German angst and flu and tobacco. We deal with tobacco, with hypertension, with AIDS, with accidents and many more, and, of course, flu also on an international basis. By the way, again, enterprise. I'm a medical doctor and I don't understand, of course, what money is all about and budget and enterprise, but the flu crisis the United States of America is now going to face shows us that we need new production, not only facilities, but production technology. And there is a new one available, by the way, developed in Austria because you have to get rid of the classical egg derived production procedures and go to the cell lines. But, anyway, so there is always business opportunity if there is a crisis.

Okay, Canada, I'm very proud to be here because Canada is much better than Austria when it comes to tobacco control. What I gathered from my papers and from the available publication is you have a growing population, yesterday a migration officer asked me whether I wanted to stay, and I said, no, I go home tomorrow. He said, would you like to stay? I said, no, I want to go home. I want to come back. So it's a growing population. [Laughter] You have already decreased per capita consumption of cigarettes, very successful, very tough tobacco control measures. And, and this is the proof in the pudding, even positive tobacco related mortality trends, which is especially true for males, so it pays off, so to speak, what you're doing for tobacco control. But, and this is very important to recognize, successful tobacco control may result in higher dependence among the remaining smokers. It might be necessary to have additional strategies for those because the low dependent people, they stop by their own, and infrastructures and restaurants and imposed, and all this kind of stuff, and price policy. But the rest of the population is very, very addicted and needs different strategies. This is the hypothesis.

I checked whether the Canadians have recognized what we did in Vienna so far and I checked the National Clearinghouse in Tobacco and Health System, and believe it or not, they found 11 results with a name Kunze in them. Very proud. Even Canada knows my group and me. And, as you heard from our Chair, I have the privilege of serving on several committees in the European Union and at the WHO, so I may represent Austria, as tiny as it is, in the international scene as well.

The basic political document more or less is the international convention on tobacco control. Canada is also part of it, and many, many other countries. For the first time there is a global alliance, political alliance, to do something about the [indiscernible] tobacco epidemic or the, it's not tobacco epidemic, it's tobacco related mortality, morbidity epidemic, which is the problem.

One of our projects, one of our daughter institutes is the Nicotine Institute of Vienna, designed purely for diagnosing and treating tobacco addicts. Tobacco smoking is an addiction. It is in the international classification of diseases. It has a position. It's a disease. Not in everybody, but in many of the tobacco consumers. They need medical care. We know how it works, the nicotine dependence, how it develops, what mechanisms we have, what differences have, neurophysiologic, we all know that you have one reference for my group here and we know what we can do about it. There is a specific treatment, evidence-based, it's very important nowadays, everything has to be evidence-based. And the newest bible, just to do some marketing, Peter Boyle and others are the editors of Tobacco and Public Health Science and Policy, Oxford University Press, and here in the chapter on tobacco dependence, treatment of tobacco dependence, a voice given to us.

I don't go into details, don't be afraid, but we can say today, even extreme forms of tobacco dependence can be treated. We can help everybody, so to speak. But, we have also admitted nobody can cure tobacco dependence. We can control it. Nobody in the world can cure a dependence that it's gone forever, like somebody has an angina from streptococcal infection, and you give penicillin, then you say, I'm a healer. We all want to be healers. Medical people can't heal very much. Broken legs, streptococcal angina, you cannot heal diabetes, you cannot heal hypertension, most of the things you cannot cure, but you can control it. We need for that, more and better services on the self help level, on the primary health care level, hospitals specialized, clinics like ours. We see hundreds and hundreds and hundreds of patients.

But the real question for us in the future will be from a political point of view is will there be a tobacco-free world? Will there be a nicotine-free world? I doubt whether a nicotine-free world would be a good thing to envisage. Nicotine is an unbelievably good psychoactive drug. It's the best psychoactive drug, much better than alcohol, because it has no acute side effects. Before giving a lecture like this, and you are scared and here and there, I mean, I could go to the toilet and have a cigarette and get stress level down. If I have a couple of whiskeys, I mean, I might feel better, but you will have a different impression, I guess. [Laughter]

So, I mean, tobacco-free world, I would rather phrase we are going to a smoke tobacco-free world because the problem starts when we burn tobacco to set nicotine-free. Nicotine itself is not carcinogenic. It's addictive. But it doesn't produce myocardial infarction. It doesn't produce lung cancer. But burning is the problem. And a nicotine-free world, I don't think this is a real vision. Then everybody comes and says, primary prevention, we should start in schools and with the children and then we solve the problem.

So far we have a time lag, that's the real problem. If we would have the best program for kids, the results would be in 10, 20, 30 years, and we have problems right now with the addicted people. And, of course, there is the vaccination issue. We are playing with the idea of vaccinating people against nicotine. It's not a lecture to go into details, but it's a fascinating idea. Also in relapse prevention, we immunize people after they have stopped smoking and then the nicotine molecule meets the antibody in the bloodstream and it's blocked and cannot cross into the brains and so the relapsing smoker wouldn't feel anything from the psychoactive properties and would give up. So it might be an idea at some stage, but it's far out, far out.

So we need primary prevention on the one hand and treatment of tobacco dependence. I guess we all agree on that. Do we need something else? Question mark. I would say, yes. Harm reduction. And now I'm entering the mine field, I know it's now getting dangerous, but I go home tonight and what should happen to me?

Harm reduction, a big political debate, a big fight in the smoking control community, not everybody buys that idea, but, we do it in automobiles, you mentioned it, we have many safety features in automobiles. And, going to the medical word, harm reduction, if a systolic blood pressure of 220, which is high, dramatically high, would be brought down to 160, nobody would say, this is optimal, this is good, but everybody would say, that's a step in the right direction. If you have a cholesterol count of 420 and you bring it down to 280, nobody would say, that's perfect, but everybody would say, this is success. And if you measure in a smoker, we measure carbon monoxide, CO, in the expired air, from 72 and bring it down to 31, this is not good, but it's a step in the right direction. In this room, for example, we have CO most probably between 2 and 3 if we measure all the non-smokers here. But we would say this is a reduced harm. We do it everywhere. In the medical world, harm reduction is an absolute established principle. But in tobacco, there are a lot of ethical and political issues, also in this country, I guess, and, for sure, in the European Union.

Of course, light cigarettes, this was a failure. Light cigarettes are no way out of the current problem. We thought it for a long, long time that reducing nicotine, and reducing tar would help. But then we found out that people tried to compensate. They inhaled deeper and we have the problem and even new problems. So the light cigarette is a dead end of that development because you burn tobacco. As soon as you burn, you have the problem of benzopyrenes and the cancer risk and carbon monoxide and atherosclerosis. So this is a dead end. Light cigarettes we forget, and we mustn't call them light anyway. That's forbidden.

We played around with the idea for a long time, harm reduction, the possibility of nicotine replacement back in 1997, just to show you that we have been in that field for quite some time, and then European Respiratory Journal, in '98, always focusing on nicotine replacement, on the lozenge, on the patch, on the inhaler, on the nasal spray, the sublingual tablet, and whatever we have here, so the medication field, the pharmaceutical field. But it's very interesting that the pharmaceutical field and the other field are coming closer and closer and closer. We had the nicotine replacement therapy on prescription. Then it went over the counter. Now in some countries it is going general sales. And from the other end we get new products, tobacco derived products. We call them alternative nicotine delivery systems, or ANDS. Alternative nicotine delivery systems, there are many new ones. Nicotine replacement therapy, very much established, and the other, cigarette replacement products, tobacco derived or not tobacco derived. By the way, all the nicotine comes from tobacco, also the nicotine replacement products.

And then another input is comparative lung cancer epidemiology. What do I mean by that? If you have a look at MAPS [ph.] where the figures for lung cancer are plotted, you get a remarkable picture, which leads you, perhaps, a step forward. This is male lung cancer. The redder it gets, the more lung cancer the people have. You don't have to be a university professor to find out something is going on in Scandinavia, especially Sweden. It's so different, and oral cancer the same, so to speak, they don't have oral cancer either. This is very important in Sweden, because they use a lot of oral tobacco products, they get the nicotine from oral tobacco products but they don't have more oral cancer. And then we just compared Austria and Sweden and you see the red line, the Austrian males, the green line, and the Swedish males, that is a tremendous difference. And the ladies, the Austrian and the Swedish ladies, have similar rates. The explanation, which we brought up, and caused a lot of troubles, was it must be the different forms of nicotine intake. Austrian males and Swedish males consume the same amount of nicotine. But this is not always told, but Austrian males take the nicotine out of cigarettes and Swedish males take the nicotine out of oral tobacco, called Snus, in 23 percent of the male population, and only 16 percent are smoking.

So, 39 percent of the Swedish males are consuming nicotine on a daily basis and they get much less lung cancer. In Swedish males and Swedish females and Austrian females, they don't use Snus and they have the similar lung cancer figures. We thought this is very convincing and we published it and got beaten over the head by some people, had debates. They said, the difference in male lung cancer, Austria, German, Sweden, Finland is that they can be explained by different forms of nicotine intake.

Again, some figures, mortality lung cancer, just have a look at it. EU, Germany, Finland, Austria, Sweden, half of the EU, in males, EU, Germany, Finland, Austria, Sweden, high up, or in the same range, again, what I showed you in the other graph. A couple of years ago we already published a concept, which says, prevention of lung cancer by long-term use of alternative nicotine resistance. At that stage we were focusing on nicotine replacement therapy because we have to do something with lung cancer. It's a man-made epidemic without any successes in medical terms. Whatever we do, the results are more than poor, but it's big, big business. At some stage I will dare to write a book when I'm really old and nothing can happen to me anymore, a lung cancer business because of big business. Snus and alternative, first comparison, and so forth, you see, we are entering the mind field even more, but then came the rescue. United States Calvary came to the rescue, Professor Brad Rodu and Professor Philip Cole [ph.] published in the European Journal of Epidemiology, the Burden of Mortality from Smoking comparing Sweden with other countries in the European Union. I mean, the Americans had to do it and we could have done it ourselves. But, it's good, always, to have it.

Almost 500,000 smoking attributable deaths occur annually among men in the European Union, about 200,000 would be avoided if it would have the Swedish situation. Only 1,100 deaths would be avoided if, in women, because, as you heard, they have a different form, they use cigarettes. And then they calculated what all the countries would benefit from. I won't go into details, except for Austria, smoking-attributable death, so we lose every year. They say 11,000 attributed to smoking, if it would have Swedish situation, we would have another 6,000. So that's quite something.

And you have to understand and acknowledge that we have the phenomenon of nicotine dependence because nicotine is a psychoactive drug. Smokers don't smoke because they are stupid, because they don't have a strong will to give up, because they like the psychoactive activity and mankind has always tried to modify mood by whatever measures, singing the National Anthem or going to war or whatever, or drinking, and so forth. The Austrians do both, I mean, we lost our anthem to the Germans, we now have a new one, which, it's not so nice, but we drink and we smoke and we drive automobiles. And this nicotine indirectly leads to tar exposure if you burn tobacco and increases lung cancer risk and if you, this is the whole cake, is a sample of Austrian smokers, and you have high dependent ones, low dependent ones, medium dependent ones, you can measure it very easily. The lung cancer patients are recruited, or recruit better to speak themselves out of the high dependent ones because they are high dependent, there wasn't a lot of nicotine, and they inhale really deeply and get the carcinogens.

No smoker smokes in order to get carcinogens or carbon monoxide. Our political message is that we must not leave them alone. We have to offer something to those who cannot or don't want to stop smoking. Here comes the ethical question. Do heavy dependent smokers have a right to get nicotine in a less harmful way? The answer for me, is, of course, yes, but many other people don't feel like that. Can it be done by a nicotine replacement therapy? Can it be done by something else? By Snus or other oral tobacco? We know Snus because in the European community this is the much more debated product category. But you all know in the European Union we have a directive and, as the Chairman has already mentioned, Snus is banned outside Sweden. So if one of my patients cannot stop smoking, and I know this guy will fall ill, I'm somewhat in trouble if I say I try to get you some Snus and if nicotine replacement doesn't really work.

So it's a fantastic situation. Of course there are people asking for more regulations in the European Union, more regulations even, but not only for one category, but for the whole nicotine containing thing. I know that something is going on in the U.S. also in a very peculiar direction, perhaps, but this is only what I gather.

So, it's the future of nicotine consumption, which we will have to discuss very soon. It's also a human and consumer rights issue. Do those people who cannot stop smoking or do not want to stop smoking get nicotine in the least harmful way? And we, of course, believe yes. But there's a huge political dimension attention to it, and, my final comment is, primary intervention of tobacco consumption is beautiful if it can do that, but it's a vision, which comes too late for the already dependent smokers. And, for all of you, whether you are a smoker or not smoker, get your flu vaccination soon, as long as stock is available. Thank you. [Applause]

James Glassman: Thank you. Thank you, Dr. Kunze for that excellent presentation. I actually have one question. I understand that in Canada there is, on labels for a snuff, something to this effect. I saw this last night on the Internet. I may not have the quote right, but, it says that this product is not a healthy alternative, maybe it says safe alternative, I'm not sure of the word, to cigarette smoking. Do you think such warning labels should be on snuff?

Dr. Michael Kunze: Yes, from a scientific point of view, it's not the safe alternative because nicotine is addictive. The wording is leading people back to cigarettes, isn't it? So the wording, I don't have a better wording, spontaneously, but this wording, I would say, carries the problem of misleading consumers. It is not the best solution. The best solution would be to give up cigarettes, but if you cannot give up those cigarettes this is an option for you until you are prepared to give up cigarettes or something like that.

James Glassman: Questions? Any questions from the floor?

Male Audience Member: The flu vaccine, do you really recommend that?

Dr. Michael Kunze: Yes, definitely, for everybody. The ethical problem they will now face is that they only vaccinate the risk groups, whatever risk group might be. We can then talk over coffee break in detail. Flu vaccination is good and everybody should be vaccinated, not only the high-risk groups. This is a misconception. But, more, perhaps, later.

James Glassman: Just, what is Snus, or, can you tell me what the difference is among smokeless tobacco and is there any special dangers if smokeless tobacco is taken in different ways?

Dr. Michael Kunze: Well, I'm always referring to Snus because it's the Swedish form. This comes in a loose form or in pouches, like small tea bags. There is a specially prepared tobacco in it and some ingredients. I mean, and you don't chew it, actually, you just put it in your mouth and the nicotine is then going into your blood stream through the mucosa. It is less harmful, in a way, especially if you observe certain standards. It is, of course, not safe and healthy, I mean, it doesn't improve your health, but for those people who cannot or don't want to stop smoking, it is an alternative, different way. But you shouldn't swallow it, of course. Swallowing it would not be nice because you would get hiccups, but nothing else.

James Glassman: What about chewing, is there a difference, though, from a health point of view, from chewing tobacco, as people do in the United States and Canada, I believe, and snuff, which is inhaled through the nose?

Dr. Michael Kunze: Well, it depends not only of the route of administration but also from the product. What we need, and I don't know what standards you have now imposed, we need safety standards in production and the Swedish product, at least, I don't know about the Canadian products, in Sweden they are kept in the refrigerator, which is also important to keep them not having bacteria growing and then nitrosamines are built and all this kind of stuff. But this nose tobacco issue, I mean, it's a Bavarian habit, by the way, it comes from Bavaria, many other parts. We don't have any indication that is really a problem for the people who consume it.

James Glassman: So the key is, burning is what causes the carcinogens?

Dr. Michael Kunze: Absolutely.

James Glassman: We have several other questions.

Female Audience Member: I have the conception that with chewing tobacco it increases nose cancer and tongue cancer. Would that be the same thing [inaudible]?

Dr. Michael Kunze: Yes, I mean, of course if you go to the textbook then you see the dreadful pictures from India, Sri Lanka, and so forth, and, of course, it is based on the products they use and the composition of the product. But, as I showed you, this comparative epidemiology, I mean, it's just, my American teacher, Professor Ernest Wynder always told me, epidemiology is done by eye-balling, and you saw it, Sweden has very low lung cancer and very low oral cancer. Completely different if you go to Sudan, if you go to Sri Lanka, to India, Pakistan, and so forth. They have different products and they have increased oral cancer, definitely.

Male Audience Member: [Inaudible] from a public health standpoint if you could address, I think public policy makers have this sort of irrational fear of physical risk. [Inaudible]? There are a lot of things that we are [inaudible] that aren't necessarily things we need to ban. I wonder if this is [inaudible].

Dr. Michael Kunze: Absolutely. Some people followed the concept we want, at some stage, a drug free world, or we get rid of all substances, which affect the mood of people. I just quote Commissioner Byrne, the EU Commissioner for Health: nutrition is the next tobacco. Regulate it. It's also your issue. Regulate it. And then how about coffee? How about coffee? There is a coffee addiction. I mean, you could even regulate that. We could regulate everything. But workaholics need regulation. [Laughter]

James Glassman: Well, the truth is, as you said, cigarette smoking, which, frankly, I've never done, but I've certainly lived with people who have, really does have very beneficial psychological effects. You understand the attraction of cigarette smoking, as well as coffee drinking, and I think as Radley points out, this is not, probably not, and I don't think anybody has ever done the research, but if we somehow could separate the health effects, or the physical health effects, we'd find that these kinds of behaviors are actually good for society.

Dr. Michael Kunze: I mean, it's all nicotine. That's the point. The cigarette is the most deadly way to set nicotine free. It's a very efficient way. But this is the problem, because you burn it. I mean, nicotine itself is a unique drug because if you're anxious you can reduce your stress, if you feel tired then you increase your awareness. So, I mean, it's beautiful, in a sense, but it's addictive. And then I come to your point again, I mean, should we ban all addictive substances?

James Glassman: We'll take one more, and, actually, you're doing the right thing, which is you are standing at the microphone. I should have told everyone to do this, but, excellent. Excellent behavior here.

Female Audience Member: I am well trained.

James Glassman: You are well trained. Go ahead.

Female Audience Member: I have one question and then I'm going to need to go have a cigarette. [Laughter]. To what does your research attribute the low statistics of smoking with women versus smoking with men?

Dr. Michael Kunze: You mean the difference why they smoke and the others give it up?

Female Audience Member: The amount, the mortality.

Dr. Michael Kunze: The mortality in males, you mean, is higher than in females, but in females it's going up, and in males it's going down. The explanation is, among, might be other effects, as genetic and so forth, but the male cigarette consumption, especially in the past, and those people who die now started smoking 30 years ago, was much higher than among females. So the amount of carcinogens the average male smoker got was much higher than the average female smoker.

Female Audience Member: Do you suppose there's also going to be a negative perception or concept for Snus? Is that how you say it?

Dr. Michael Kunze: No, the only explanation at present we have, the Swedish ladies don't use Snus in a greater percentage.

Female Audience Member: It's not perceived as an alternative?

Dr. Michael Kunze: It's not chic yet. It is a male habit, still. But it will change most probably.

Female Audience Member: Thank you. On that I am going to have a cigarette. [Laughter]

James Glassman: Oh, okay, one more question.

Female Audience Member: question about Snus, I want to know, do you have to spit constantly when you are using Snus? Doesn't that introduce a whole other set of safety issues?

Dr. Michael Kunze: I have a sample with me. We could try one out. I don't know whether we have to go out of the building. We can do it here. No, they don't spit.

James Glassman: You're thinking of baseball.

Female Audience Member: Chewing tobacco.

James Glassman: You're thinking of chewing tobacco. Thank you, again, Dr. Kunze. [Applause] We're going to take a break right now and we'll come back and hear from Dr. David Gratzer [ph.] on disease without borders, Sallie Baliunas and Tim Patterson on climate change and Radley Balko, who asked a very perceptive question on obesity and personal freedom. We will back, what, about 20 after 10. Thank you.

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