Tobacco Harm Reduction

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A great introduction to the concepts of THR is this video by Professor Gerry Stimson, an expert in harm reduction generally, as well as tobacco harm reduction.


Ending Tobacco Smoking In Britain: Radical strategies for prevention and harm reduction in nicotine addiction

Royal College of Physicians

A report by the Tobacco Advisory Group of the Royal College of Physicians, September 2008

“People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm.

Harm reduction is therefore feasible in tobacco smoking by providing smokers with nicotine from a source that does not involve inhaling tobacco smoke.

Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction.

Use of smoke-free nicotine by smokers would also reduce involuntary exposure of others, particularly children, to tobacco smoke.”


Harm Reduction in Nicotine Addiction: Helping People Who Can't Quit

Royal College of Physicians

A report by the Tobacco Advisory Group of the Royal College of Physicians, October 2007

“This RCP report makes the case for harm reduction strategies to protect smokers. The report demonstrates that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved. The report also argues that the regulatory systems that currently govern nicotine products in most countries, including the UK, actively discourage the development, marketing and promotion of significantly safer nicotine products to smokers.”

“Public health ethicists have argued that it is not enough to speculate that there is some chance of adverse effects to society if an individual is allowed to exercise rights, it is necessary to show that there is clear and convincing evidence that the risk to society is substantial. In judging whether public health interests should override individual health interests, one needs to evaluate both the ‘proportionality’ and the ‘probability’ of the problems for public health.”

“Although stopping tobacco use is the ideal outcome for individual and public health, this is often difficult to achieve. Making a wider range of safer products available would be a harm reduction approach to tobacco control.

Harm reduction approaches in public health are sometimes criticised for condoning the activity they are trying to make safer. The Royal College of Physicians takes no position on the morality of smoking. However, since smoking is dangerous to health, and is hard to give up, the College wants to see a range of effective methods to help smokers quit or to reduce the harm they sustain.

The present status quo, in which cigarettes are freely available, medicinal nicotine products are available but under regulations that restrict availability and effectiveness, and some smokeless tobacco products are prohibited, denies smokers the right to choose safer nicotine products.

Balancing the nicotine market, so that all nicotine products are equally available and comparably priced, would provide smokers with choice but would not encourage change from high risk to lower risk products.”


Tobacco Harm Reduction: How rational Public Policy could transform a pandemic

Sweanor, D., et al.

Published in the International Journal of Drug Policy, 2007

"Nicotine, at the dosage levels smokers seek, is a relatively innocuous drug commonly delivered by a highly harmful device, cigarette smoke. An intensifying pandemic of disease caused or exacerbated by smoking demands more effective policy responses than the current one: demanding that nicotine users abstain. A pragmatic response to the smoking problem is blocked by moralistic campaigns masquerading as public health, by divisions within the community of opponents to present policy, and by the public-health professions antipathy to any tobacco-control endeavours other than smoking cessation. Yet, numerous alternative systems for nicotine delivery exist, many of them far safer than smoking. A pragmatic, public-health approach to tobacco control would recognize a continuum of risk and encourage nicotine users to move themselves down the risk spectrum by choosing safer alternatives to smoking – without demanding abstinence."


Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments

Phillips, C.V.

Published in Harm Reduction Journal, 2009

"Harm reduction is particularly compelling for the use of nicotine because so many people have such a strong propensity for using it. Nicotine is a very beneficial drug for many people, providing alertness, focus, pleasure, and relief from a variety of psychological symptoms and pathologies. A substantial fraction of the population gets these benefits by smoking even though the health costs are so high, which means that demanding they quit entirely entails great welfare costs and is not likely to work.”

“Hiding THR from smokers, waiting for them to decide to quit entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.”


The Case for Harm Reduction for Control of Tobacco-related Illness and Death

Nitzkin, J.L., & Rodu, B.

Published by AAHP, 2008

“In practical terms, enhancement of current policies based on the premise that all tobacco products are equally risky will yield only small and barely measurable reductions in tobacco-related illness and death. Addition of a harm reduction component, however, could yield a 50% to 80% reduction in tobacco-related illness and death over the first ten years, and a likely reduction of up to 90% within 20 years. These projections are based on the expectation that a significant number of smokers will continue to smoke and the knowledge that risk of death from lung cancer continues for decades after the smoker has stopped smoking.” <pdf></pdf>

American Cancer Society/U.S. Centers for Disease Control study confirms the value of tobacco harm reduction: Switching from smoking to smokeless tobacco is almost as good as quitting entirely

Phillips, C.V.

Published by, 2007

“For those smokers who are unwilling or unable to quit using nicotine, switching to smokeless tobacco provides most of the benefits of quitting nicotine entirely. The study used the same data that the U.S. government uses to estimate the health effects of smoking. It found that Americans who had switched from smoking to smokeless tobacco before 1982 had only slightly higher risk of death than former smokers who had quit tobacco entirely; if there was any risk from using smokeless tobacco at all, it was much lower than from continuing to smoke.”[1]

Tobacco smoking, harm reduction, and nicotine product regulation

Britton, J. & Edwards, R.

Published in The Lancet, 2008

“In the 50 years since the health risks of smoking first became widely recognized, the political and public health responses to smoking at national and international levels have been grossly inadequate.”

“A logical harm reduction approach for the millions of smokers who are unlikely to achieve complete abstinence…is to promote the substitution of tobacco smoking with an alternative, less hazardous means of obtaining nicotine.”

“We believe that the absence of effective harm reduction strategies for smokers is perverse, unjust, and acts against the rights and best interests of smokers and the public health.”

“The regulatory framework should therefore apply the levers of affordability, promotion, and availability in direct inverse relation to the hazard of the product, thus creating the most favourable market environment for the least hazardous products while also strongly discouraging use of smoked tobacco.”[2]

Electronic cigarettes are the tobacco harm reduction phenomenon of the year – but will they survive?

Bergen, P.L. & Heffernan, C.E.

Published in Yearbook, 2010

“those regulators are generally incapable of considering the lifestyle advantages of a product (e-cigarettes help people not just to quit smoking, but also to keep enjoying much of what they liked about smoking), especially when it competes with the cessation products made by their major constituents in the pharmaceutical industry.”

“E-cigarettes have already been banned in many countries and are likely to be banned in more. But none of the bans seem to be based on demanding better quality control, and few seem to be tied to any health claims at all. Rather, they seem more to result from “not invented here” syndrome. Perhaps this is too cynical, but it seems that had these products been invented by white Western anti-smoking activists (see, e.g., Niconovum) and given over to the control of wealthy Western institutions (physicians and pharmaceutical companies, or perhaps even tobacco companies), they probably would have been embraced as a miracle and rushed through for approval. But because they were created by a Chinese engineer and supported by a grass roots education and distribution network, they trigger most every imaginable institutionalized kneejerk.”

“Many smokers are finding this almost certainly low-risk alternative one of the most satisfying and, to varying degrees, available. In mimicking the essential attractions of traditional smoking, they provide a welcome change from failed attempts to become nicotine-abstinent, or successful quitting that leaves people with dramatically lowered welfare. It overcomes shortfalls of pharmaceutical nicotine products which are not optimized for long-term use and do not even work very well for transitioning to abstinence (Chapman & MacKenzie 2010).

As with any alternative to smoking that exists outside dominant institutions and does not focus on purifying everyone completely, e-cigarettes face a great challenge. All the powerful institutions involved with tobacco policy (government agencies, major NGOs, competing companies) seem to oppose their existence, caring little about their public health benefits. These products seem to bother anti-tobacco extremists, who have been quite successful in their tactics of demonizing and misleading people about nicotine, even more than low-risk inter-oral products. Presumably they fear that clean modern products that prompts learning and a devoted following is a threat to their propaganda. It tends to make nicotine consumption seem less like the “moral” or “values” issue they wish to make it, and it becomes a rational consumption decision by adults. However, unlike with smokeless tobacco in most places, it is conceivable that educated nicotine users who want to engage in THR might be physically prevented from getting this low risk alternative.” <pdf></pdf>

The fluid concept of smoking addiction

Peele, S.

Published in, Yearbook 2010

n the 1957 WHO report Addiction Producing Drugs, addiction was ascribed to psychologically debilitated people, and is thus highly pejorative. The image of the drug (heroin) addict was of an uncontrolled sociopath. That this did not describe most smokers also contributed to the SGR64’s determination that smoking was not addictive: “It [calling smoking habituation] does, however, carry an implication concerning the basic nature of the user and this distinction should be a clear one. It is generally accepted among psychiatrists that addiction to potent drugs is based upon serious personality defects from underlying psychologic or psychiatric disorders which may become manifest in other ways if the drugs are removed. [Yet e]ven the most energetic and emotional campaigner against smoking and nicotine would find little support for the view that all those who use tobacco, coffee, tea and cocoa are in need of mental care...." (pp. 351-352).

Indeed, SGR64 concludes, “Medical perspective requires recognition of significant beneficial effects of smoking primarily in the area of mental health” (p. 356).”

“People give up tobacco more or less as their needs dictate they should or must, like all harmful habits. All of this shows, of course, that addiction is politically and social defined, despite repeated but mistaken claims to have identified a purely biological, asocial basis for defining and recognizing addiction.”[3]

Smokeless tobacco: the epidemiology and politics of harm

Phillips, C.V. & Heavner, K.K.

Published in Biomarkers, 2009

“The health burden from tobacco smoking results almost entirely from inhalation of the components of smoke, although this is not widely known. The primary benefit of smoking is nicotine delivery, but nicotine can be obtained without combustion. Thus there is potential for tobacco harm reduction (THR), the substitution of lower-risk nicotine products for smoking. Epidemiological evidence suggests that smokeless tobacco causes about one one-hundredth the health risk of smoking. Despite the practice of harm reduction being widely accepted in public health, however, THR has faced fierce opposition from anti-tobacco activists. These activists have effectively misled the public about what aspect of smoking cigarettes causes the harm, convincing them that nicotine and tobacco themselves are harmful, ignoring the smoke. In the interests of promoting public health and rescuing science from politics, experts on inhalation hazards and health could play an important role in educating the public and policy makers about THR.” [4]

Public comment regarding tobacco harm reduction to the U.S. Food & Drug Administration from

Phillips, C.V., Bergen, P.L., Heavner, K.K., & Nissen, C.M.

Published in, Yearbook 2010

“In summary, regulating tobacco calls for recognizing that nicotine is a popular drug that it is a “lifestyle” consumption decision and/or self-treatment for many conditions that are not formally diagnosed, making it different from carefully controlled medical treatments for specific diseases. Demand will likely never be eliminated, and trying to eliminate it will take the FDA far beyond its mission and competencies. Like the products that FDA is experienced at regulating, the market will be dominated by major corporations; this should be recognized and turned into an asset rather than futilely resisted. Because this popular drug is caught up in so much politics, attempts at social engineering often overwhelm the good science. However, good science and honest provision of information will improve people’s health efficiently and without causing a net reduction in overall welfare.”[5]

You might as well smoke; the misleading and harmful public message about smokeless tobacco

Phillips, C.V., Wang, C., & Guenzel, B.

Published in BMC Public Health, 2005

Results We found that when any substantive information about the risk from ST is given, the risk is almost universally conflated with the risk from cigarettes. Accurate comparative risk information was quite rare, provided by only a handful of websites, all appearing low in our search results (i.e., of low popularity and thus unlikely to be found by someone searching for information). About 1/3 of the websites, including various authoritative entities, explicitly claimed that ST is as bad as or worse than cigarettes. Most of the other sites made statements that imply the risks are comparable. Conclusion Through these websites, and presumably other information provided by the same government, advocacy, and educational organizations, ST users are told, in effect, that they might as well switch to smoking if they like it a bit more. Smokers and policy makers are told there is no potential for harm reduction. These messages are clearly false and likely harmful, representing violations of ethical standards.”[6]

Tobacco harm reduction: an alternative cessation strategy for inveterate smokers

Rodu, B. & Godshall, W.T.

Published in Harm Reduction Journal, 2006

“Many smokers are unable – or at least unwilling – to achieve cessation through complete nicotine and tobacco abstinence; they continue smoking despite the very real and obvious adverse health consequences. Conventional smoking cessation policies and programs generally present smokers with two unpleasant alternatives: quit, or die. A third approach to smoking cessation, tobacco harm reduction, involves the use of alternative sources of nicotine, including modern smokeless tobacco products. A substantial body of research, much of it produced over the past decade, establishes the scientific and medical foundation for tobacco harm reduction using smokeless tobacco products.”

“Tobacco harm reduction empowers smokers to gain control over the consequences of their nicotine addiction. At its simplest it is nonintrusive and solely educational, and therefore has a strong moral rationale. The strategy is cost-effective and accessible today to almost all smokers. But its implementation will require rethinking of conventional tobacco control policies and their premises.”[7]

Public Health Implications of Smokeless Tobacco Use as a Harm Reduction Strategy

Savitz, D.A., et al Published in the American Journal of Public Health, Health Policy and Ethics, 2005

“Despite much success in eliminating tobacco use, we need more, not fewer, tools in the multifaceted effort to address this public health issue. Motivated current smokers who are unable to quit should be a specific target audience for harm reduction strategies.”[8]

A tobacco-free society or tobacco harm reduction? Which objective is best for the remaining smokers in Scandinavia?

Lund, K.E. Published in Norwegian Institute for Alcohol and Drug Research, Oslo 2009

“Cigarette smoking is ideal for a harm reduction strategy, because the substance that causes addiction – nicotine – is not the cause of the health risk. People smoke because of nicotine, but die from tobacco smoke. Much less hazardous nicotine products are available.”

“To get people to understand the necessity for a measure that appears to involve changing the expressed aim of tobacco policy – a tobacco-free society – is a challenging task. The task is no easier when the traditional measures for reducing smoking have been successful. Why should we change direction?

However, harm reduction does not involve a change in direction for preventive work. Harm reduction should be regarded as an additional component to the measures that have already been shown to be effective. On the way to the final aim of a tobacco-free society, harm reduction could be a pragmatic and temporary measure that could clearly save many lives.”


The implicit ethical claims made in anti-tobacco harm reduction rhetoric – a brief overview

Nissen, C.M., et al

Published in Yearbook, 2010

“Using tobacco/nicotine has benefits (for many people) and costs; if the costs are lowered a lot and the benefits are lowered only a little bit (which is the case for many people who substitute other products for smoking), then net benefits increase and more people will get positive net benefits from using such a product. In other words, if the health risk is low enough, and the psychological benefits (pleasure, relaxation, relief from distress, etc.) are high enough, people will rationally choose to use ST or e-cigs.”

“It should be obvious that allowing people in positions of influence to turn their own minority opinions into declared social ethics is a rather scary way to make social policy.”

“This analysis suggests that attacks on THR are not based on defensible ethics. They are presented in ways that apparently appear credible to some observers, but seem to be based on undefended ethical positions that, if accepted, would equally condemn a wide variety of other public health activities and a large portion of activities that people choose to engage in. We present this as a challenge and invitation for anti-THR activists to better defend their arguments as stemming from ethical principles that others would accept. If they continue to fail to do so in light of explicit challenges like this one, then those arguments must be judged to be not only unpersuasive, but also inherently unethical to put forward.” [9]

An analog visual comparison of best, current and worst case scenarios in (tobacco) harm reduction; numeracy-aiding tools to get the message across

Bergen, P.L. & Heffernan, C.E.

Published in Yearbook, 2010

Figure 2: Cancer risk from a lifetime of smoking compared to a lifetime of smokeless tobacco use.

Visula comparison 1.jpg

Figure 2 limits the analysis to cancer, the risk that most people associate with smoking and ST use, though actually a minority of the estimated risk in both cases. This version of the graphic also illustrates an alternative presentation, comparing the present real case with how much worse it would be if no one engaged in the reduced harm option. When compared to behaviors where harm reduction is the norm, this illustration could be useful.”

“Figures 4 and 5 illustrate comparisons of the huge potential of THR, and its current lack of success, to other harm reduction arenas where the current case is much closer to the best case, though the reduction in risk is limited. This first figure illustrates what is probably the most widely-employed, understood, and appreciated harm reduction strategy. The quite dangerous activity that is being in a car has been made immensely safer though the use of seatbelts. Indeed, most of the potential benefits have been achieved, though even the best case scenario would not come close to THR’s 99% reduction in risk. In a less typical comparison, limits on impulsive access to firearms result in many suicide attempts failing that otherwise would have succeeded.”

Visual comparison 2.jpg

Visual comparison 3.jpg

“Thus, these graphs illustrate the oft-repeated point about THR, that the current political situation is very strange. (They would do so more effectively if they were scaled by total population risk, but that is not practical in the present medium. We will experiment with such presentations.)

While many harm reduction interventions, even those that involve controversial subpopulations, are embraced, the harm reduction intervention that appears to offer the greatest potential improvement, in absolute and relative terms, is violently opposed.”[10]

Survey of smokers’ reasons for not switching to safer sources of nicotine and their willingness to do so in the future

Heavner, K., et al

Published in Harm Reduction Journal, 2009

"One of the barriers to smoking cessation via product switching is misinformation about Smokeless Tobacco (ST) and pharmaceutical nicotine products. Most (67%) people in a telephone survey in the US and 59.8% of a sample of nurses mistakenly believed that nicotine is the main cause of tobacco-related cancers. Surveys of smokers and college students in North America found that fewer than 15% realize that ST is less harmful than smoking. In addition, a study found that most (75%) male US military recruits believe that switching from smoking to ST does not reduce tobacco users' risk. Many smokers have similar misconceptions about the health risks from using pharmaceutical nicotine products... If efforts to actively convince smokers that there is no opportunity for harm reduction were to end, we would expect to see the change begin. If the resources that are currently devoted to misleading smokers about harm reduction were instead targeted at informing them that they have satisfying choices that are almost as good for their health as quitting entirely, a very large change could happen quite rapidly."[11]

Should the Health Community Promote Smokeless Tobacco (Snus) as a Harm Reduction Measure?

Gartner, C.D., Hall, W.D., Chapman, S., & Freeman, B.

Published in PLoS Medicine, 2007

“Background to the debate: The tobacco control community is divided on whether or not to inform the public that using oral, smokeless tobacco (Swedish snus) is less hazardous to health than smoking tobacco. Proponents of "harm reduction” point to the Swedish experience. Snus seems to be widely used as an alternative to cigarettes in Sweden, say these proponents, contributing to the low overall prevalence of smoking and smoking-related disease. Harm reduction proponents thus argue that the health community should actively inform inveterate cigarette smokers of the benefits of switching to snus. However, critics of harm reduction say that snus has its own risks, that no form of tobacco should ever be promoted, and that Sweden's experience is likely to be specific to that culture and not transferable to other settings. Critics also remain deeply suspicious that the tobacco industry will use snus marketing as a "gateway” to promote cigarettes. In the interests of promoting debate, the authors (who are collaborators on a research project on the future of tobacco control) have agreed to outline the strongest arguments for and against promoting Swedish snus as a form of harm reduction.”[12]

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