World No Tobacco Day: Q&A with Mathieu Morissette and Riccardo Polosa

World No Tobacco Day, which falls on the 31st May, is organized by the World Health Organisation to raise awareness of the devastating effects of tobacco on health and to advocate the implementation of policies aimed at reducing tobacco consumption. To mark the occasion, we discussed on-going research around tobacco consumption and alternatives to smoking with Prof Riccardo Polosa and Prof Mathieu Morissette. If you are interested in reading more on the topic, take a look at this Respiratory Research thematic series on e-cigarettes.

What is your background in relation to research on smoking?

Prof Mathieu Morissette: I have an undergraduate degree in Microbiology and a PhD working on the mechanisms associated with apoptosis and oxidative stress in emphysema from Université Laval in Quebec City. I then completed post-doctoral studies in the laboratory of Martin Stampfli at McMaster University investigating the mechanisms that trigger lung inflammation in response to smoking.

I’m currently associate professor at the Department of Medicine of Université Laval and researcher at the Quebec Heart and Lung Institute. My main research interests are oriented towards non-infectious lung damage, focusing on tobacco smoking but also electronic cigarette.

Prof Riccardo Polosa: I am Full Professor of Internal Medicine and specialist of Respiratory Diseases and Clinical Immunology at the University of Catania as well as the Founder and Clinical Director of the Center for Tobacco Research and Scientific Director of the Center of Excellence for the acceleration of HArm Reduction (CoEHAR) at the same University.

My main research interest is in the area of smoking-related diseases, smoking prevention and cessation, tobacco harm reduction and e-vapour science.

Since 2009, my research team has been involved in studies on the impact of e-cigarettes and we were the first in the world to publish a randomized controlled trial on e-cigarettes (the ECLAT study).

What new research or research areas connected to smoking are you excited about at the moment?

The attractive thing with the ‘smoking/pulmonary lipids hypothesis’ is that it impacts and explains so many aspects of chronic smoking and COPD.

Prof Mathieu Morissette:  My laboratory, as well as others, found that a major aspect of smoking resides in its impact on pulmonary lipid homeostasis and the pulmonary surfactant. The negative effects of smoking on pulmonary surfactant were raised in the 60’s and 70’s, showing that smokers had reduced surfactant levels, but were never really followed up.

Revisiting this concept with the current technology is therefore very interesting. The attractive thing with the ‘smoking/pulmonary lipids hypothesis’ is that it impacts and explains so many aspects of chronic smoking and COPD, including small airway malfunction, lung inflammation, compromised anti-microbial defenses, and links with cardiovascular disease.

The challenge is to approach it from a therapeutic point of view, identifying deregulations that persist after smoking cessation and that could be targeted to alleviate symptoms of COPD or slow disease progression.

Prof Riccardo Polosa: At CoEHAR we have established a large multidisciplinary team that is investigating potential benefit and residual risk of new technologies for cigarette substitution such as e-cigarettes and tobacco heating products. Our multi-pronged scientific program has been focusing on patterns of use, behavioral changes and health effects associated with usage of these new technologies under normal condition.

We will also look at the development of economic models to estimate cost effectiveness and scalability of these products in order to help legislators to take rational decisions about effective and proportionate regulatory regimes for nicotine delivery systems.

Besides these propositions have just started exploring alternative consumer-centric themes for the exploitation of nicotine vaping may have significant value in day-to-day stress management, body weight control, as well as novel indication for therapeutic nicotine (particularly for neurodegenerative disorders).

Which policies, developments, or research findings do you think have achieved the most in improving people’s health in relation to smoking?

Prof Mathieu Morissette: The smoking ban in public buildings and areas certainly helped a great deal. Moreover, the significant research efforts to demonstrate the effects of smoking since the 30’s/40’s have helped raise public awareness. However, there is still a solid core of 15-20% of the population (North America) that still smoke tobacco.

Prof Riccardo Polosa: Fast acceleration in the reduction of smoking prevalence has been shown in all countries where the tobacco harm reduction principle has been integrated with existing tobacco control policies at population level.

Sweden, Norway, Iceland and France – like Japan and South Korea – have dramatically reduced cigarette consumption via product substitution with low risk tobacco cigarette alternatives such as snus, e-cigarettes, and tobacco heating products. In these countries the observed market reduction in smoking prevalence has been obtained without the implementation of new specific tobacco control policies.

In the UK, the public health system has embraced a proactive approach to the e-cigarettes phenomenon. For the first time in the history of antismoking, a media campaign (Stoptober 2017) was designed to include using e-cigarettes as a method to stop smoking. A revolution in communicative terms that could only start just from UK, the only country in the world in which doctors are allowed to promote e-cigarettes for stopping smoking.

I think the integration of two ‘good bullets’ like new nicotine delivery systems and tobacco control policies will make a ‘silverish’ bullet.

Nearly 3 million people are using e-cigarettes in the UK today and more than half have permanently abandoned conventional cigarette smoking. As the number of vapers increases, the smoking rate continues to fall inexorably. The most recent figures have shown that smoking prevalence in the UK is as low as 15% (2017).

These examples indicate that rapid cigarette obsolescence can be attained with a coordinated strategy. I’m not saying these new technologies are the silver bullet, but neither are the tobacco control policies we have now. I think the integration of two ‘good bullets’ like new nicotine delivery systems and tobacco control policies will make a ‘silverish’ bullet.

E-cigarettes have seen a huge increase in popularity in recent years and have proved to be a controversial topic. Where do you stand on them?

Prof Mathieu Morissette: Any mean that helps an individual to stop smoking tobacco is great, and this is generally how the electronic cigarette is perceived, a cessation tool. However, in real life, it is very different. Most E-cigarette users keep smoking tobacco as well; and many E-cigarette users keep vaping for years with no intent to stop.

E-cigarette is definitely not temporary for most people and hasn’t shown to be more effective than the standard smoking cessation tools. Is vaping ‘healthier’ than smoking? Probably. However, there are so many things we do not know about E-cigarette use and all the compounds contained in the E-liquid.

A comparison that is guaranteed to be true is that E-cigarette is worse than breathing air. It is also a great way to become addicted to nicotine, especially kids and teenagers, which is not a good thing at all.

Prof Riccardo Polosa: E-cigarettes are not risk-free, but even the most stubborn critics in the tobacco control movement now acknowledge that they are a much less harmful alternative to tobacco cigarettes.

My long-standing record of engagement with smokers asking for help in their battle against tobacco cigarettes has taught me that antismoking medication and counseling are not good enough and that additional innovative strategies are needed. I’m now convinced that e-cigarettes are a useful acquisition in the antismoking arsenal. This has been proven by a growing number of studies from all over the world.

I believe that full substitution of tobacco cigarettes with these new technologies may well reduce the risk of future tobacco-related diseases, as shown in our research. But to even reverse the harm caused by tobacco smoke, clinical studies need to be investigating long-term health effects in users who have never smoked in their life.

What areas to do you think research will explore next and what policies can you envisage being introduced in the future?

Prof Mathieu Morissette: A ban on tobacco smoking is unlikely to happen. A lower proportion of kids and teenagers start smoking tobacco compared to previous generations but are instead ‘smoking’ other things, increasingly E-cigarettes and cannabis. The long-term effects of these are unclear or simply unknown.

Research still aims at finding therapies for smoking-related or aggravated diseases. Research on biomarkers and susceptibility threats for smoking-related diseases will likely see a ‘Big Bang’ in the coming years due to the increased use of ‘omics’. Such findings could make it possible to identify people highly susceptible to smoking and use it to dissuade them from starting or maintaining the habit. Active prevention is definitely the key.

For the first time we have long-term real world data showing that vaping doesn’t harm the lungs.

Prof Riccardo Polosa: Future research should explore the “unknown unknowns” of E-cigarette aerosol emissions. In particular we should leverage 21st Century Toxicology for more detailed information on biological responses as well as potential harm from flavorings.

Another area of important exploration is that of long-term health effects of vaping. We have recently completed a study looking at the effect of vaping  over the long term in never smokers that found no negative impact on lung function and high-resolution computed tomography after 4-year follow-up.

The study was small and its follow-up incomplete. Larger and longer studies will be important. But for the first time we have long-term real world data showing that vaping doesn’t harm the lungs.

We have started a series of scientific and regulatory initiatives that promote the potential benefits of e-cigarettes with the goal of accelerating the declining trends of smoking prevalence. In the future, WHO should consider integrating the existing tobacco control policies with a pro-vaping strategy in order to accelerate tobacco control progress and that regulation of these products is better focused on standards for safety and quality to safeguards consumers’ best interest. This is already happening in the UK, Iceland and France.

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