#399 The Lancet: Adding harm reduction to tobacco control.

“There is no good reason why a switch from tobacco products to less harmful nicotine delivery systems should not be encouraged.” So stated a 1991 Lancet Editorial, yet 16 years later cigarettes continue to dominate the nicotine-delivery system market, despite their clear health risks. LISTEN

Adding harm reduction to tobacco control

Editorial

The Lancet 2007; 370:1189

“There is no good reason why a switch from tobacco products to less harmful nicotine delivery systems should not be encouraged.” So stated a 1991 Lancet Editorial, yet 16 years later cigarettes continue to dominate the nicotine-delivery system market, despite their clear health risks. Most smokers want to quit but continue to smoke because they are addicted to nicotine, and cigarettes deliver high doses of the drug rapidly to the brain. But the adverse health effects come mostly from nitrosamines and other carcinogens in the tar and carbon monoxide and nitrogen oxides in the smoke. Half of all smokers will die prematurely if they continue smoking. With 1·6 billion smokers expected worldwide by 2025, all opportunities to reduce the harm caused by tobacco smoking must be seized.

Current tobacco control policies as outlined in the WHO Framework Convention on Tobacco Control (including price and tax increases, and prevention of smoking in public and work places) have typically achieved reductions in smoking prevalence of at best 1% per year in countries where cigarette smoking is common. Given the limitations of tobacco control, argue John Britton and Richard Edwards in a Viewpoint published online on Oct 5, radical reform of nicotine and tobacco product regulation is needed. Based on a report published by the UK's Royal College of Physicians (RCP), Britton and Edwards apply harm-reduction principles to smoking and conclude that a wide range of nicotine products, including medicinal nicotine (currently marketed as nicotine-replacement therapy) and low-nitrosamine smokeless tobacco products, such as snus, should be developed, regulated rationally in relation to each other, and made available in inverse proportion to their hazards. They argue that as smoked tobacco (cigarettes, cigars, pipes) causes far more disease than most forms of smokeless tobacco, which in turn are more hazardous than medicinal nicotine, efforts should be channelled into developing low-risk products capable of delivering nicotine as efficiently as cigarettes, while subjecting smoked tobacco products to increasing restrictions. Stopping smoking and cessation of nicotine product use is the ultimate goal, but for those who cannot quit, or who want to reduce the harm related to smoking, less hazardous methods of obtaining nicotine should be available.

However, Martin McKee and Anna Gilmore argue in our Correspondence section that snus has not been proven to be an effective aid to quitting smoking and that the risks of dual snus and cigarette use have to be considered. They are correct. Controlled trials are needed to confirm the Swedish observational studies that suggest snus helps quitting. Moreover, widening access to snus could increase the profits of tobacco manufacturers who are now busily marketing snus as a harm-reduction product. British American Tobacco, for example, has introduced Lucky Strike snus into Sweden and South Africa. Meanwhile, Marlboro snus and Camel snus are being marketed by Philip Morris USA and R J Reynolds, respectively. In McKee and Gilmore's view, permitting such snus branding might encourage continuing nicotine addiction which could mitigate the effects of smoke-free legislation. Allowing tobacco companies to get yet another wedge in the tobacco market is a serious concern. But so long as there are progressively increased restrictions on smoked tobacco, effective and familiar branding of harm-reduction products may help smokers to switch.

No tobacco product has been shown to be totally risk-free. Observational data suggest, for example, that snus is associated with an excess risk of pancreatic cancer, but not oral or lung cancer, in Swedish male construction workers who were followed up for 20 years. The generalisability of such data remains to be tested in other populations, and long-term follow-up of users of nicotine and smokeless tobacco products is needed to identify all possible risks. Of relevance here too is the likelihood that medicinal nicotine and low-toxicity smokeless tobacco will be far less hazardous to non-users than smoked tobacco. Quantifying this relative benefit would be useful.

Britton, Edwards, and the other members of the RCP's Tobacco Advisory Group advocate a courageous approach to nicotine addiction. Greater availability of medicinal nicotine, and perhaps even of low-toxicity smokeless products, along with increasing restrictions on smoked tobacco, is likely to reduce tobacco-related mortality and morbidity. Given the known hazards of smoked tobacco, and the numbers of people who smoke, innovative thinking is needed. We support tobacco harm reduction alongside rigorously applied tobacco control policies.

Comments

[swedsnus]

It is true that tobacco like other products such as alcohol, sugar, chocklate, butter, biff and so on are not risk free! Why do some people talking very negative against snus? Is politics or just for fun to punish snus consumers?

[Snuff]

There's also a historic tobacco alternative that is once again growing in popularity - nasal snuff.

Snuff users are on the increase not only in the UK, but World wide. I think partly due to the recent 'smoking in enclosed premises' legislation that came into force over the last year or so.

I do however think it's ridiculous that smokers can't be given the facts on changing over to snuff and/or snus by the governments within the EU.

Fortunately 'Smokeless New Zealand' has a great website, on which they discuss viable 'less harmful' tobacco user alternatives to cigarette smoking with the people of New Zealand
http://www.smokeless.org.nz/

It's almost as if the big pharmaceuticals have taken over from cigarette companies with them having the 'ear' of governments in monopolising NRT products.

Let's face it, many people quit NRT products because they become addicted to them and they wind up being as expensive as smoking cigarettes...

Why not give them a less harmful alternative NRT that is also cheaper.

[Phil]

I'm making the transition from smokes to snus. Feel free to check out my blog about it.

[video surveillance]

Nicotine adicts have the problem that, there's not a different way to get it from another form than cigarrettes.. it is harmful and risks are for everyone around that person.

[Fire Detection]

I think smoking should be band from everywhere because is harmful and al what it do is just sick people is crazy how people still gettingsick and dyieng from this just unbeleiveble.