45 years ago, when he had just turned 30 and was working in a department that looked after people trying to quit smoking, clinical psychologist Karl Olov Fagerström developed what is known as the Fagerström test – a short questionnaire consisting of eight Questions to assess a smoker’s nicotine addiction. Four decades later, the test is still in use, just with two fewer questions.
“The test provides a rough estimate of a given smoker’s likelihood of successfully quitting,” explains Fagerström, who originally designed the test for individual use as it allowed him to diagnose his patients and provide treatment based on magnitude to personalize their disorder.
At the age of 76, Karl Fagerstrom has become one of the world’s most authoritative voices on smoking and a headliner at every convention he attends. He continues to travel the world sharing his knowledge and experiences. A founding member of the Society for Research on Nicotine & Tobacco (SRNT), Fagerström was in Seville, Spain in early June, where he attended the 25th Congress on Dual Disorders – an event attended by more than 1,500 experts on mental health and addictions in the spanish town. During the congress, he spoke to EL PAÍS about the therapeutic options available to people with tobacco use disorders who want to quit smoking or reduce the harm caused by smoking.
Ask. Although nicotine is demonized around the world, they argue that in the long run it poses no greater risk than other commonly consumed substances.
Answer. Yes, pure nicotine has the same health benefits as caffeine and is less harmful than alcohol.
Q So should nicotine be separated from tobacco in clinical terms?
TO. Yes, since pure nicotine is significantly less harmful than lighting tobacco and inhaling all the products of combustion, there are good reasons to refrain from burning. Coffee would also be very harmful if subjected to a combustion process. The health risk of tobacco comes primarily from the approximately 70 non-nicotine carcinogenic substances and substances such as carbon monoxide, which cause cardiovascular diseases. The effects of tobacco on the respiratory tract, such as B. COPD, could be largely avoided if the combustion process could be avoided.
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Q In any case, nicotine is not addictive. In Spain, according to a survey from 2022, 34% of women and 44% of men have used tobacco in the last 12 months. In view of these figures, is a tobacco-free society conceivable?
TO. Yes, I think a tobacco-free society is a realistic goal, but we are unlikely to achieve a nicotine-free society. In medicine, too, the principle applies that where one cannot heal, the damage should be reduced. Where people who want to quit cannot, they should be offered less harmful alternatives. Those who do not want to quit smoking should be discouraged from smoking and supported in switching to less harmful alternatives. We are talking about products that deliver nicotine with or without tobacco, but whose use does not cause combustion, which is really harmful.
Q Does harm reduction explain the data from Sweden, where according to Eurobarometer smoking prevalence was 4% in 2021?
TO. The usual anti-smoking measures have been introduced in most countries and some are better than in Sweden, so it is very likely that the snus [tobacco marketed in bags for oral consumption] You played a big part. The most common smoking cessation product used by Swedish men is snus. In fact, using snus as a cessation aid has also proven to be more effective than other aids, including nicotine replacement therapy (patches, gum, etc.) and medications like Champix [the brand name for varenicline]. According to the World Health Organization, this has resulted in Swedish men having the lowest rates of smoking-related deaths and illnesses in the world. And that’s eye-opening data, because Swedish men use tobacco just as much as men from other countries in the European Union, but as you said, very few smoke, just 5%.
Q Can e-cigarettes also be considered as harm reduction measures?
TO. Yes, as long as adult use represents a greater public health benefit than primary adolescent use. Ultimately, we assume that there is a risk with electronic cigarettes: that young non-smokers, attracted by the taste, will start using them. To realize the potential of e-cigarettes as a harm reduction tool, a sensitive regulatory regime must be in place. For example, nicotine-containing products could be regulated in the same way that alcohol is regulated in the Scandinavian countries.
Q The UK Health System (NHS) recently announced that one million smokers will be given a free e-cigarette starter kit to encourage them to quit smoking.
TO. I think it’s a great way to encourage smokers to try e-cigarettes, which would later help smokers quit smoking and potentially help e-cigarette users quit nicotine as well . It has also been found that addiction to e-cigarettes is lower than that of regular cigarettes.
Q However, the Spanish Society for Medical Oncology (SEOM) warned on May 31, World No Tobacco Day, that new forms of tobacco use, including e-cigarettes and electronic cigarettes, are just as harmful as tobacco.
TO. No, lo creo. Of course, we don’t yet have long-term epidemiological studies showing that e-cigarettes are less harmful, but we do know that they contain fewer toxic substances than regular cigarettes and also that users’ exposure to these toxic substances is significantly lower. This is one of the reasons why the US Food and Drug Administration (FDA) gave them market approval [the first three electronic nicotine delivery systems were approved in October 2021]. Does this mean electronic cigarettes are a healthy product? Definitely not. Their long-term consumption can be addictive and also harmful to health. For me, the biggest concern with e-cigarette ingredients is the flavorings, many of which are not approved for inhalation. I think if one could use safe flavors there would be an obvious harm reduction. Traditional cigarettes are killing people around the world every second. This is unlikely with e-cigarettes.
Q The vast majority of people with a mental disorder also suffer from a tobacco use disorder called dual pathology. According to data from the US and UK, almost half of the cigarettes sold are bought by people with mental disorders.
TO. Harm reduction is all the more important for mentally ill people because they smoke more frequently and also smoke more cigarettes per day, inhale more deeply and respond much less well to smoking cessation strategies. Partly for this reason, this population group dies between 15 and 20 years earlier than the general population, with the effects of smoking being the main cause of these deaths. In the particular case of schizophrenics, nicotine may even have therapeutic effects, reinforcing the notion of harm reduction.
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