Research & Commentary: Tobacco Harm Reduction

Published February 2, 2012

Nearly 50 million American adults—more than a fifth of the nation’s adult population—smoke cigarettes. After vigorous efforts aimed at reducing that figure, the percentage of Americans who smoke has fallen by almost half in the past four decades. In recent years, however, the number of people quitting cigarettes has begun to level off, and many newly approved therapies intended to encourage quitting have proven largely ineffective—none works in more than about 8 percent of cases.

Consequently, some doctors and scientists suggest a “harm reduction” strategy in which smokers give up cigarettes and instead use tobacco or nicotine in different forms such as “e-cigarettes” or smokeless tobacco. In 2008 the American Association of Public Health Physicians endorsed tobacco harm reduction as a last resort for chronic tobacco users unable to quit altogether.

Opponents of this strategy say it doesn’t go far enough; they insist the goal of smoking cessation efforts should be the end of all nicotine use, regardless of source.

Brad Rodu, a professor of medicine at the University of Louisville and senior fellow of The Heartland Institute, disagrees with this premise. Writing in the Cincinnati Inquirer, he noted, “Nicotine, like caffeine, is addictive but otherwise relatively harmless. Nicotine’s benefits include improved concentration, enhanced performance of some tasks, and elevated mood. Tobacco smoke, however, containing thousands of toxic agents, is a dangerous nicotine delivery system, conferring risks for cancer, cardiovascular disease and emphysema. Eliminate the smoke, and you eliminate virtually all the risks.”

The following articles examine tobacco harm reduction from multiple perspectives.

Program Urges Smokers Switch to Smokeless Tobacco
Writing in USA Today, Michael Felberbaum documents the efforts of the James Graham Brown Cancer Center and the University of Louisville to promote the use of smokeless tobacco in tobacco harm reduction as part of their “Switch and Quit” program.

Tobacco Harm Reduction Emerges as Viable Public Health Strategy
Sean Parnell writes in the Heartlander digital magazine about the emergence of tobacco harm reduction and nicotine replacement products on the market and their potential value in tobacco cessation. Parnell discusses recent shifts in tobacco policy toward harm reduction and the success such efforts have had in Sweden.

Tobacco Harm Reduction: An Alternative Cessation Strategy for Inveterate Smokers
This report by Brad Rodu and William T. Godshall describes traditional and modern smokeless tobacco products and the prevalence of their use in the United States and Sweden. The report also documents evidence that smokeless tobacco has served as an effective substitute for cigarettes among Swedish men, who consequently have among the lowest smoking-related mortality rates in the developed world. The authors also identify misinformation being spread about smokeless tobacco products.

Assessment of Swedish Snus for Tobacco Harm Reduction: An Epidemiological Modeling Study
The authors of this assessment examine the potential population-health effects of snus in Australia. They use multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to use of snus.

Opposition to Marketing of “Reduced Risk” Tobacco Products
In a letter to Congress, a coalition of health care groups, including the American Public Health Association, urges controls over the marketing of “reduced-risk” tobacco products. The authors worry advertisements could lead smokers to believe these products are a safe alternative to quitting.

Public Health Physicians’ Group Endorses Harm Reduction as Alternative to Smoking
Jillian Melchior writes in the Heartlander digital magazine about the American Association of Public Health Physicians’ endorsement of tobacco harm reduction, in which smokers substitute other forms of tobacco and nicotine for cigarettes, cigars, and pipes instead of quitting outright, as a last resort for chronic tobacco users. The endorsement, made public at the end of 2008, is notable as the first time a U.S. medical organization has endorsed tobacco harm reduction as a viable strategy for reducing deaths due to tobacco use. The article also includes comments from opponents, who argue the focus should remain on total cessation of tobacco use.

Tobacco and Tobacco Products at a Crossroads in the 21st Century
Tobacco and health policy consultant Scott D. Ballin outlines the issues he believes must be considered in the debate and dialogue if harm reduction is to move forward.

Concerns Voiced by the Public Health Experts about Electronic Cigarettes
Opponents of electronic cigarettes, including several public health groups, voice their concerns in this News & Events piece from the Food and Drug Administration.

Clearing the Smoke: The Science Base for Tobacco Harm Reduction
Committees from the Institute of Medicine report on their in-depth studies of the reliability of tobacco harm reduction as a public health policy. Tobacco harm reduction is considered viable as a public health policy but will require careful implementation and regulation of the use and marketing of these products. Further research into these products is also needed, the committees reported.