Tobacco Harm Reduction Emerges as Viable Public Health Strategy

Published September 1, 2005

At the National Conference on Tobacco or Health, held in Chicago in May and attended by more than 5,000 tobacco control advocates and health education officials, an important topic–tobacco harm reduction–was pointedly ignored.

The conference was sponsored by government agencies and not-for-profit advocacy groups, including the American Cancer Society, Centers for Disease Control and Prevention, National Institutes of Health (National Cancer Institute), Robert Woods Johnson Foundation, and American Medical Association.

Harm reduction was not a scheduled topic. Questions raised by conference attendees about making smokeless tobacco alternatives a part of a comprehensive smoking cessation program and the efficacy of smokeless tobacco in addressing environmental tobacco smoke (ETS) went unanswered.

Smokeless Tobacco Less Risky

The discussion of harm reduction in tobacco use largely centers on comparisons between smoking and the use of smokeless tobacco, although issues related to filtered vs. unfiltered cigarettes and low-tar cigarettes are also relevant.

Men who smoke increase their risk of death from lung cancer by more than 22 times and from bronchitis and emphysema by nearly 10 times. Women who smoke increase their risk of dying from lung cancer by nearly 12 times and the risk of dying from bronchitis and emphysema by more than 10 times. Smoking triples the risk of dying from heart disease among middle-aged men and women.

The health effects of smokeless tobacco are also well known and understood among researchers, but not generally among the public. Research consistently shows smokeless tobacco is not “risk free” but confirms it poses substantially less risk to users than smoking does.

Compared to nonsmokers, those who smoke lose on average 6-7 years off their lives. Those who use smokeless tobacco lose approximately .04 years, or about 15 days.

Shift in Policy Possible

The most widely cited risk of smokeless tobacco is oral cancer, although epidemiological studies have shown cigarettes pose a higher risk for oral cancer. There is no lung cancer risk associated with smokeless tobacco, nor is there a risk of heart disease.

According to Dr. Brad Rodu, professor and past chairman of oral pathology at the University of Alabama-Birmingham and currently senior scientist at the university’s Comprehensive Cancer Center, smokeless tobacco is 98 percent safer than smoking.

Research conducted by Rodu and others raises an important public policy question: Might it be good public policy to encourage smokers to switch to smokeless tobacco–or at least not to discourage them from doing so?

Although for many years the prevailing sentiment among public health officials was an emphatic “No,” that is beginning to change. Dr. Neal Benowitz, a professor of medicine at the University of California at San Francisco and director of its cancer center’s Tobacco Control Program, told Los Angeles Times reporter Valerie Reitman for a 2004 article, “If someone can’t quit smoking, there is no question that smokeless is much safer. It doesn’t cause heart or lung disease, and if it does cause cancer, it does so at a much lower rate.”

Joseph Bast, president of The Heartland Institute and a frequent commentator on tobacco-related issues, agrees that harm reduction is an appropriate public health strategy. He advocates eliminating restrictions on advertising comparative health claims.

“As a smoker,” notes Bast, “I want to know about the risks of the products I use. I am not too stupid or addicted to understand comparative health claims and act on them.”

Success in Sweden

Sweden’s experience with smokeless tobacco is a case study in the potential benefits of incorporating a harm reduction strategy into tobacco public policy.

During the past 40 years, a large percentage of Swedish smokers, primarily men, have switched from smoking cigarettes to using a moist snuff product called “snus.”

Over that period, Sweden’s cancer rates for men, including rates of oral cancer, have declined and are the lowest in Europe. By contrast, cancer rates for Swedish women, who did not make the switch from cigarettes to smokeless tobacco in nearly the numbers men did, remain as high as rates for most other European women.

Opponents Insist on Elimination

Not all of the public health community is sold on the appropriateness of harm reduction as a tobacco control strategy. The U.S. Surgeon General’s office, for example, contends that allowing people to know smokeless tobacco is significantly safer than smoking will prevent people from doing what is ultimately the safest thing: quitting tobacco use altogether.

Advocates of “harm elimination” generally support high taxes on all tobacco products and adamantly oppose any advertising that would publicize the significantly reduced risks of smokeless tobacco compared to cigarettes. From their perspective, all tobacco use is bad, and recognizing that some forms of tobacco use are significantly less harmful than others is unacceptable.

Harm reduction advocates, by contrast, support allowing the public to better understand the comparative risks between smoking, smokeless tobacco, and quitting. This would include allowing smokeless tobacco producers and sellers to advertise that their product is 98 percent safer than smoking.

Tax Variance Gaining Acceptance

Another harm reduction strategy often recommended is that in recognition of smokeless tobacco’s lesser risks, taxes to discourage tobacco use should focus on cigarettes, not smokeless tobacco. That approach is gaining some acceptance.

In a February 2005 statement outlining his “Jobs for Kentucky” plan, Kentucky Gov. Ernie Fletcher (R) stated, “The relative taxes on tobacco products … reflect the growing data from scientific studies that although smokeless tobacco poses some risks, those … risks are significantly less than other forms of tobacco products. It … acknowledges that some in the public health community recognize that tobacco harm reduction should be a complementary strategy to … public health policy.

“Taxing tobacco products according to relative risks is a rational tax policy and may well serve the public health goal of reducing smoking-related mortality and morbidity and lowering health care costs associated with tobacco-related disease,” Fletcher stated.

Sean Parnell ([email protected]) is vice president-external affairs for The Heartland Institute.

For more information …

Dozens of articles on tobacco harm reduction and other smoking-related issues are available in The Heartland Institute’s online “Smoker’s Lounge.” Point your Web browser to