Harm reduction: can it work?
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
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).