In photo – Dr. Rafael R. Castillo , a leading Filipino heart doctor.
MANILA, Philippines — A leading Filipino heart doctor said alternative tobacco products such as vapes and heated tobacco products should be considered as part of smoking cessation intervention programs, and encouraging its regulated use in current smokers may be an effective solution to address the smoking epidemic that kills millions of people globally each year.
In a recent satellite symposium during the annual convention of the Philippine Heart Association, Dr. Rafael R. Castillo, the first Filipino and Southeast Asian to be elected as a trustee of the United Kingdom-based International Society of Hypertension (ISH), said smokers need a viable alternative that can wean them off from cigarette smoking, and help them quit.
He said quitting smoking is still the primary goal. But for recalcitrant smokers or those who can’t quit despite smoking cessation interventions, “the use of electronic nicotine delivery systems or alternative tobacco products may serve as a pragmatic middle ground to reduce harm and eventually make them quit completely,” Dr. Castillo, a past president of the Philippine Heart Association-Philippine College of Cardiology and the Asia Pacific Society of Hypertension, said in a virtual discussion during the 70th anniversary and 52nd annual convention and scientific meeting of PHA.
“With all the heartbreaking failures we had in making recalcitrant smokers kick the habit, we have to face reality. We have to offer recalcitrant smokers alternatives and give them more tools. Smoking addiction is not something that they can easily overcome. We have tried all sorts of smoking cessation interventions—nicotine patches, gums, lozenges etc.— but we are not getting anywhere. We are not really progressing as much as we would like to,” he said.
“While the use of alternative tobacco products does not completely eliminate the harm, they can significantly reduce or mitigate the health risks. Personally, I believe that this is our best bet of all currently available smoking cessation measures to help recalcitrant smokers really kick the smoking problem, not only in our country but worldwide,” said Dr. Castillo.
Dr. Castillo said tobacco harm reduction strategy, or the use of less harmful alternatives to cigarette smoking, may help smokers improve their long-term cardiovascular and other health outcomes.
He noted that the Philippines has the second highest prevalence of smoking in Southeast Asia, next to Indonesia. “While cardiovascular diseases are the leading cause of death in the Southeast Asian region, causing more than 1 in four deaths (3.96 million deaths or 29 percent of all deaths), tobacco is the leading preventable risk factor causing the largest number of deaths in the region—more than 1 in 10 deaths (1.51 million or 11.6 percent of all deaths),” he said.
“It is a serious challenge. It is worse than the Covid pandemic. Smoking is also the number one risk factor for cancer in the Philippines. Smoking is a serial killer that kills so many people,” he said.
Dr. Castillo said addressing the problem requires a pragmatic approach, as the decline in smoking rate has been slow under the current strategy that involves the use of nicotine replacement therapy.
Dr. Jorge A. Sison, who moderated the session, said while smoking prevalence in the Philippines went down to 25 percent last year from 27 percent in the previous years, it remains high.
Dr. Sison, who is also a past president of PHA, said tobacco harm reduction is a promising strategy. “I hope that our government will open its eyes and welcome new addition to our campaign against smoking,” he said.
Dr. Castillo said there is also a need to demystify the misinformation about nicotine. “Nicotine can also be part of the solution to the smoking problem, and it can be part of any intervention that we wish to use to reduce the harm from smoking,” he said.
“Nicotine is not the primary cause of smoking-related diseases. Tobacco smoke contains 7,000 chemicals, of which nicotine is one,” he said. “Smokers commonly misperceive that nicotine is a major carcinogen. Currently available evidence does not indicate that nicotine in itself induces cancer.”
Dr. Castillo said that as nicotine is the substance that causes addiction, it should also play a crucial role in tobacco harm reduction. “Nicotine is the core of the problem, but also the centerpiece of the solution,” he said.
“Complete smoking cessation is still the primary goal. But we have to face the reality that we cannot achieve that. At best after one year of specialist support and drug treatment, successful quit rate is only 20 percent,” he said.
“Our quit rate is not that encouraging. Worldwide, the quit rate is really very low. At best, in countries with very aggressive intervention, it is only 20 percent in a year’s time. It is not good enough. That is why we believe that offering them alternative products which can wean them from smoking conventional cigarettes would be our best bet at the moment,” he said.
Dr. Castillo said that as part of their due diligence to decide whether to allow alternative tobacco products in their smoking patients or not, their research group at the FAME Leaders Academy conducted a systematic review and meta-analysis on the effects of heated tobacco products compared to traditional tobacco cigarettes on heart rate, blood pressure, and other predictors of cardiovascular risks among adult smokers. Their study showed significant differences in some risk factors that may impact favorably on the smokers’ cardiovascular health.
He said HTPs and other alternative tobacco products can be part of tobacco harm reduction which is anchored on the fact that there are some lifestyle practices or bad behaviors that are simply inevitable.
“If that is so, our next objective is to minimize the harm people suffer as a consequence. People make poor lifestyle choices despite suffering negative health effects. Complete smoking cessation is the primary goal, but it is not achievable in the far bigger majority of smokers.
There has to be a pragmatic middle ground. There will still be more than one billion smokers globally by 2025 if the smoking problem is not aggressively addressed,” he said.
Dr. Castillo said e-cigarettes were also found to be more effective than nicotine replacement therapy in making smokers quit, based on a 2019 UK study. “The results concluded that e-cigarettes were more effective for smoking cessation than nicotine replacement therapy, when both products were accompanied by behavioral support,” he said.
Dr. Castillo said that in Japan, cigarette sales fell 34 percent in four years following the introduction of HTPs. He said the same strategy can help the Philippines significantly reduce to a bare minimum the number of cigarette smokers in 15 years.
“We will have about 1.3 billion smokers globally by 2025. So it is time that we reassess how we can better address the smoking pandemic with more effective measures,” he said.