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  1. Health Effects of Tobacco Use

The Relative Risks of Tobacco Products

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Significant progress has been made in reducing cigarette smoking in the United States through comprehensive, population-level strategies. However, more than 30 million U.S. adults still smoke cigarettes, and smoking remains the leading cause of premature disease and death nationwide.

FDA’s Center for Tobacco Products (CTP) is committed to protecting the health of all people in the United States through a comprehensive approach to reduce the burden of tobacco use. This includes timely and evidence-based public health education that complements the agency’s regulatory actions.

In addition to preventing youth initiation and promoting cessation among people who use tobacco products, CTP is working to educate adults who smoke about the relative risks of tobacco products.

What Is Meant by “Relative Risks” of Tobacco Products?

No tobacco product is safe. However, the health risks for different tobacco products exist on a spectrum, which is sometimes referred to as a “continuum of risk.” Combusted, or smoked, tobacco products - such as cigarettes - are the most harmful type of tobacco product. Non-combusted products - such as e-cigarettes and other smokeless tobacco products - generally have lower health risks than cigarettes and other combustible tobacco products.

Before introducing a new tobacco product to the U.S. market, a company must submit a marketing application to the FDA and receive authorization. New tobacco product applications are evaluated by FDA scientists who determine if the application shows the new tobacco product meets the applicable statutory standards. Tobacco products that may be legally marketed in the United States are listed in FDA’s Searchable Tobacco Products Database.

Additionally, to market a tobacco product as a modified risk tobacco product (MRTP), an MRTP application must be submitted to the FDA. An order permitting the sale of an MRTP refers to specific products, not an entire class of tobacco products. An MRTP application generally must demonstrate that the product will significantly reduce harm and the risk of tobacco-related disease to individual tobacco users and benefit the health of the population as a whole.

Are E-Cigarettes a Lower-Risk Alternative to Cigarettes?

While e-cigarettes can generally be a lower-risk alternative for adults who smoke cigarettes, the use of e-cigarettes is not risk-free. These products deliver harmful chemicals and contain nicotine, which is highly addictive. Moreover, given the harmful chemicals found in e-cigarettes, further high-quality research on both short- and long-term health outcomes is needed.

Given that there is no safe tobacco product, youth and adults who do not use tobacco products should not start using e-cigarettes.

For adults who smoke, switching completely from cigarettes to e-cigarettes may reduce exposure to many harmful chemicals present in cigarettes. However, it is important that they switch completely from cigarettes to e-cigarettes to get the full health benefit. Long periods of dual use of cigarettes and e-cigarettes can result in harms to health similar to, or in addition to, the harms from exclusive use of cigarettes.

To date, FDA has authorized 23 e-cigarette products and devices. These products have undergone rigorous scientific review, including toxicologic assessments, and have been found by FDA to meet the statutory public health standard.

What Options Are Available to Adults Who Smoke Cigarettes and Are Looking to Quit?

For adults who currently smoke cigarettes, fully quitting the use of all forms of tobacco products would most benefit their health. Evidence-based, FDA-approved medications - including nicotine replacement therapy (NRT), bupropion, and varenicline - have been proven to be safe and effective. These approved medications, along with behavioral counseling, should be the first line of therapeutic treatment for adults seeking to quit smoking. Behavioral counseling and medication are independently effective and combining them increases the likelihood of cessation.

As part of its efforts to encourage quitting among adults, CTP has developed cessation education materials for a wide range of audiences. CTP also partners with the National Cancer Institute’s smokefree.gov, which provides quitting support to people who use tobacco products.

For adults who smoke who choose to use e-cigarettes, it is important that they switch completely from cigarettes to e-cigarettes to get the full health benefit. Since there is no safe tobacco product, eventual abstinence from all tobacco products should be the end goal.

Why Is It Important for Adults Who Smoke to Understand the Relative Risks of Tobacco Products?

Many people who use tobacco products have misperceptions about nicotine and the risks of various tobacco products. Despite science that shows that e-cigarettes generally have lower levels of harmful ingredients than cigarettes, many adults believe that e-cigarettes are just as harmful or more harmful than cigarettes.

Research has found that some adults who perceive e-cigarettes to be as or more harmful than cigarettes are less likely to switch from cigarette smoking to exclusive e-cigarette use.

What Is CTP Doing to Educate Adults Who Smoke About the Relative Risks of Tobacco Products?

The concept of relative risk is complex, and it is important to ensure efforts to educate adults who smoke on this topic are evidence-based and likely to achieve desired outcomes, while also minimizing impact on unintended audiences, including youth.

CTP is continuing to build scientific knowledge through research to inform the development of educational strategies and approaches, including potential messaging. A priority of this research is identifying effective ways to reach intended audiences while minimizing the impact of any potential consequences on unintended audiences.

Studies are planned on messages related to the relative risks of tobacco products that include participation by adults who smoke, as well as research among health care providers in primary care settings who may play a key role in the delivery of potential messaging. For example, on August 2, 2023, the National Institutes of Health, in coordination with FDA, published a Notice of Funding Opportunity for “Public Health Communication Messaging about the Continuum of Risk for Tobacco Products.”

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