This post is a follow up to the recent post titled “ Are E-Cigarettes Safe?” and to further respond to comments on the KevinMD site when he reposted the article to a broader audience. The most interesting criticisms involved a discussion of harm reduction. The argument is that not everyone is able to or is going to quit smoking, and taking a black-and-white, “quit or die” approach to tobacco use may be overlooking other ways to reduce the harm of tobacco use.
Harm reduction in other addictions is much more widely accepted. Condom use for “safer sex” is widely practiced and accepted as an alternative not as safe as abstinence, but far safer than unprotected sex. Needle exchanges and methadone clinics are in most cities in the U.S., and reduced risk of HIV and heroin overdose deaths have been well documented. An interesting article on harm reduction in tobacco use by Lundberg, Ross and Whelan makes a strong argument that Tobacco Harm Reduction is an overlooked and viable alternative.
The data is overwhelming and convincing that smoking cigarettes causes a host of health problems including many cancers, cardiovascular disease and lung disease. We also know that smoking cigarettes and use of oral tobacco are extremely addicting and that quitting tobacco use is difficult. None of the FDA approved smoking cessation aides have success rates that even approach 50%.
Given these facts:
- Smoking tobacco and use of traditional chewing tobacco is very harmful to a person’s health
- We have very poor success rates at helping people quit tobacco use. The benefits of currently available smoking cessation aides are small at best.
- The dangers of use of alternative nicotine products like e-cigarettes and “ Sweedish snus” is almost certainly far less dangerous than smoking traditional cigarettes or traditional oral tobacco.
Is the concept of “Tobacco Harm Reduction” an appropriate alternative?
Conversely is it unreasonable to stick to the traditional government and health establishment mantra that “there is no safe tobacco product?”
Tobacco harm reduction, a compromise where a less harmful tobacco or nicotine product could be substituted for a higher risk product, without abstaining from tobacco/nicotine use altogether is an unpopular concept in theU.S. InEuropeit is much more widely accepted. In Sweeden snus (a form of tobacco that is steam pasteurized, moist and that contains far less nitrosamine compounds produced from traditional heat-drying, packaged in tea-bag like filters that users place under their lip) is a commonly used tobacco option for smokers to use to stop smoking, and lung cancer in Sweedish men is lower than in the rest of the European union where snus use is much less common. (1) Fairly extensive investigation has so far failed to show an increased cancer risk with Sweedish snus.
Might use of far less dangerous tobacco products than cigarettes and “chew’ be considered for those who want to quit smoking but cannot. An estimated 30% of smokers try to quit each year with about a 10% success rate. Maybe if some of those who cannot quit switched to a less harmful tobacco product like Sweedish snus, or e-cigarettes as a source of nicotine without the high concentrations of tar and other carcinogens in tobacco smoke the incidence of cancers and chronic lung disease related to smoking would drop. I certainly will continue to strongly encourage my patients to quit tobacco use. Unquestionably this is the safest and best solution, but for those unable or unwilling to quit my question is whether a tobacco harm reduction approach might be an potential alternative?
I’d love to hear comments from readers on this concept.
I was a heavy smoker for 30 years and have tried to stop smoking more times than I can remember. Without going into details, I started to use Swedish Snus 9 months ago and have been smoke-free since then. To say that I am thrilled with this outcome would be an understatement.
I know that using Snus is probably not ideal but it is probably magnitudes better for me that to continue smoking. And that is good enough for me.
Susan: I agree that quitting is by far the best approach. I also acknowledge that all “snus” is not equal, and that assuming that U.S. tobacco producers will produce a “snus” that has the same apparently very low carcinogenic properties of Sweedish snus is inappropriate. I just struggle with some tobacco users who simply fail over and over to quit, and wonder if harm reduction measures for these individuals is better than continued failure at cessation attempts. Thanks for you thoughts. DrP.
I appreciate the concept of reducing harm but suggesting a person addicted to one harmful product substitute the use of another harmful product instead is not helping – it’s enabling. You cannot compare the exchange of heroin needles for sterile ones in order to prevent HIV and the use of methadone clinics or even condoms to prevent the spread of STI’s with encouraging a patient to substitute one tobacco product for another. It’s apples and oranges and how successful are methadone clinics with getting addicts completely off addictive drugs anyway? You mentioned that thus far there hasn’t been any increase in cancer – but is that all cancers including oral, esophageal, gastric, etc that may be affected by using something like snus?
What are the chances that the tobacco companies would maintain the purity and processing that Swedish companies currently use in producing snus? Probably little to none – they’ve already made changes in how it’s processed per Wikipedia which potentially changes (?)how it’s aborbed?
“Conversely is it unreasonable to stick to the traditional government and health establishment mantra that “there is no safe tobacco product?” No, I don’t think so. By suggesting a patient use tobacco alternatives you are watering down the message that tobacco causes cancer and that it is unsafe; and that is a disservice to patients. Be truthful and straight forward but don’t support their poor choices. And BTW, I smoked for 15 years before I quit – cold turkey. It was very difficult but important, for me and for my family. And my doctor did not hold back on telling me to flat out quit.