Tobacco products are used by an estimated 1.3 billion individuals globally, with more than 80% living in low- and middle-income (LMIC) countries. Due to its addictive nature, it is hard to curb its spending behavior [1, 2]. The tobacco epidemic is one of the world's most serious public health threats, killing more than 8 million people each year. More than 7 million deaths are directly related to tobacco use, whereas around 1.2 million are related to nonsmokers exposed to second-hand smoke . Tobacco use is the major avoidable cause of disease, disability, and death. Tobacco smoking can result in lung cancer, chronic bronchitis, and emphysema. It is also responsible for an increased risk of heart disease, stroke, neurological disorders, reproductive complications, premature skin aging, osteoporosis, psychiatric disorders, leukemia, cataracts, type 2 diabetes, and pneumonia .
In response, over the last two decades, a significant global effort has been directed toward reducing the tobacco epidemic, specifically, since the World Health Organization adopted the Framework Convention on Tobacco Control in 2003 . This was the world's first public health treaty, promoting smoke-free legislation and organizing the implementation of a national tobacco control program based on MPOWER policies. To recognize the impact of tobacco smoking, in 2015, the 2030 Agenda for Sustainable Development included stronger tobacco control as a global development goal .
Nicotine is the addictive component of tobacco with brief to no cardiovascular effects which poses no risk of respiratory disorders such as chronic obstructive pulmonary disease or cancer . This correlates to the modern smoking cessation strategy known as Tobacco Harm Reduction (THR), which tries to reduce the health risks associated with tobacco use by encouraging the use of alternative nicotine products such as e-cigarettes, snus, etc . ST products, NRT, and e-cigarettes would result in reduced or no exposure to carcinogens and other harmful substances while still supplying nicotine . THR is a public health strategy that aims to reduce the health risks associated with tobacco use in individuals and society. Tobacco smoking is recognized as a primary cause of illness and death , and smoking cessation is critical to public health . However, smoking/tobacco abstinence is challenging, and even approved smoking cessation therapies have a low success rate . Even so, some smokers may be unable or reluctant to quit smoking .
Nicotine is like opioids, alcohol, and cocaine in terms of drug dependence, which often reinforces relapse after tobacco abstinence, rendering most attempts at smoking cessation unsuccessful. According to a 2006 national Institute of Health (NIH) consensus conference on tobacco use, 70% of smokers want to quit, and 40% make a serious attempt at it each year in the US, but fewer than 5% succeed in any given year . Therefore, providing low-harm alternatives to smokers results in a lower total population risk than adopting abstinence-focused programs . These low-harm alternatives include modern Smokeless Tobacco (ST), E-cigarette products, and Nicotine Replacement Therapy (NRT), such as nasal snuff, chewable tobacco, oral snuff, and nicotine medications, e.g., nicotine gums and patches.
Compared to smoking cigarettes, using ST is relatively safer and associated with fewer health risks. Numerous epidemiological studies and meta-analyses confirm that using ST is associated with minimal risk of cancer, myocardial infarction, and stroke . E-cigarette use mimics cigarette handling routines and cues of smoking, a psychological craving unrelated to nicotine, leading to a more viable smoking cessation without any withdrawal symptoms. THR has the potential to lead to one of the greatest public health breakthroughs in human history by considerably decreasing the forecasted one billion cigarette-caused deaths this century .
Numerous governmental surveys and one clinical trial conducted in the US suggest that a significant number of smokers have quit smoking by substituting ST products for cigarettes and that ST products are efficient in helping smokers become smoke-free. Due to their different tobacco consumption (i.e., Swedish snus), Swedish men have had the lowest rates of smoking-related cancers of the lung, larynx, mouth, and bladder in Europe over the last 50 years, as well as the lowest percentage of male deaths related to smoking of all developed countries. Over 60% of nicotine consumption among Swedish men is from snus. The Swedish tobacco experience proves ST to be safer than smoking tobacco .
E-cigarettes are both used as tobacco substitutes for long-term abstinence and as a smoking cessation aid. It is a unique harm reduction innovation because according to some vapers, e-cigarettes are preferred, over time, to tobacco smoking and have surpassed tobacco smoking in popularity making them much more than just a smoking substitute. Furthermore, scientific evidence indicates that e-cigarettes are 95% less harmful than tobacco smoking. Hence, vaping (e-cigarettes) has become quite popular as a smoking quitting tool and a harm reduction approach among the United Kingdom medical and public health bodies .
Overall, effective tobacco harm reduction requires the availability of scientifically substantiated less harmful products, such as ST and e-cigarettes, to the public. Consumers should have access to science-backed information, i.e., the relative harmfulness of each tobacco product, to make informed choices. This commentary aims to provide an overview of Afghanistan's tobacco control and THR state and offers recommendations for the effective implementation of THR policies.