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Harm reduction: can it work?
Jonathan Foulds

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Tobacco harm reduction may be defined as an intervention (policy, advice, treatment etc) designed to reduce the harm to health from tobacco, without requiring complete abstinence from all tobacco constituents (including nicotine) within 6 months.

It is of interest because many smokers are not currently ready or able to quit nicotine, and are currently using the most toxic form of nicotine delivery (cigarette). The tobacco industry is developing and launching numerous alternative products which may be perceived or imply less harm than cigarettes. Previous experience with this industry tactic (the "lights and milds fiasco") was a public health disaster. So called "light" cigarettes turned out to deliver similar quantities of tar and nicotine and be just as harmful as regular cigarettes. There is no reliable evidence that any device that involves combustion and inhalation of smoke is likely to be any less harmful than regular cigarettes. There is also very little reliable evidence that cutting down the number of cigarettes smoked by an individual (eg by 50%) will result in meaningful harm reduction. Switching from smoked tobacco products to nicotine maintenance with a smokeless product (either a tobacco or pharmaceutical product) is one strategy that offers significant reduction in harm to health. The evidence on use of snus by men in Sweden suggests that a large proportion have switched from smoking to smokeless tobacco and had significantly less harm to health as a result.

A regulatory framework should be created that makes it harder to market smoked products and easier to aggressively market markedly less harmful high nicotine delivery smoke-free products for nicotine maintenance.

In the mean time patients should be advised that switching to an alternate tobacco product almost certainly will do no good, and they should be encouraged to use NRT in as high a dose and for as long as it takes to keep them from smoking. Smokers who don't want to quit should be encouraged to use NRT for temporary abstinence and to consider switching long term.

Jonathan Foulds PhD
Director, Tobacco Dependence Program , UMDNJ-School of Public Health
317 George Street, New Brunswick, NJ 08901, USA



Jonathan Foulds PhD is an Associate Professor and Director of the Tobacco Dependence Program at UMDNJ School of Public Health. He trained as a clinical psychologist in the United Kingdom and has spent most of his career developing and evaluating methods to help smokers beat their addiction to tobacco. He has published over 50 papers on tobacco and is Vice President of the Association for the Treatment of Tobacco Use and Dependence (ATTUD).