Seeing past the smoke

With an estimated 1,100 million regular smokers in the world today and one related death every 10 seconds, tobacco is among the world’s most used and dangerous drugs. Ann McNeill and Jamie Bridge suggest how harm reduction philosophy could replace the usual global ‘quit or die’ response.

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In recent years, there have been many successful interventions and campaigns around the world to reduce or prevent tobacco consumption. In the UK, price increases, marketing bans, sales restrictions, warnings on packaging, nationwide smoking cessation campaigns, and education in schools have helped to gradually reduce the prevalence of cigarette consumption. It is anticipated that new smokefree legislation across the UK will have an additional impact.

However, there is still a significant population in every country who are either unable or unwilling to stop smoking, and they are often people from the most deprived areas or groups. In many countries in the developing world, where the epidemic is still at an early stage, the toll of tobacco-related mortality and morbidity will be unprecedented in years to come. If current patterns continue, an estimated 10 million people will die every year as a result of their habit by 2020. Something has to be done to reduce the harms faced by those who continue smoking – we cannot simply disregard and condemn them.

To address this issue, the International Harm Reduction Association (IHRA) made a strategic decision to broaden its scope from illicit drugs to all psychoactive substances, including tobacco and alcohol. Harm reduction is an approach widely applied to illicit drug use, which explicitly accepts the continued use of substances and aims to reduce associated harms. For illicit drugs, this can involve providing sterile injecting equipment, safe substitute treatments, outreach and peer support, or advice on how to use drugs as safely as possible. For tobacco, however, this approach has so far received little attention.

The premise behind the tobacco harm reduction approach is that most tobacco use is underpinned by dependence on nicotine. However, it is not the nicotine that causes most of the harm, but rather some of the other 4,000 constituents of cigarette smoke, of which 60 are known carcinogens. Drawing an analogy with illicit drug use, the cigarette is the equivalent of the “dirty syringe”. Consideration therefore needs to be given to separating the drug from the delivery system.

Cigarettes are the most dominant global tobacco product – highly engineered and sophisticated devices designed to deliver nicotine efficiently to the human body. They are also the most dangerous and eventually kill about half of those who regularly use them. Although there will never be a truly “safe” cigarette, it may theoretically be possible to design one that is less harmful.

Cigarettes are virtually unregulated in that little attention is paid to what goes into them, or what comes out. One exception to this (highlighted in the IHRA collection – see box) is “reduced tar” cigarettes, which are deceptively marketed in many countries as “mild” or “light”. Cigarette manufacturers often comply with tar reducing legislation by making cosmetic changes to their products, such as adding more ventilation holes to the filters. Many smokers turn to these brands rather than quitting but then alter the way they smoke in order to compensate for the reduction in nicotine. They take more and deeper puffs, smoke right down to the butt, or cover the holes on the filters. While these cigarettes pass the standard machine operated regulatory tests, they fail to account for such behavioural changes, and it is widely accepted that these products have had limited (if any) positive health impacts.

In the spirit of harm reduction, the tobacco industry and tobacco regulators are negligent if they do not do all within their powers to make cigarettes less harmful. This may include designing cigarettes less likely to cause accidental fires and regulating or changing harmful ingredients added for taste or smoothness.

One alternative to cigarettes is smokeless tobacco, which is currently used around the world in a range of forms – from the high-risk smokeless products used across South Asia, through the fermented and mediumrisk products in the USA and Canada, to the much lower-risk products used in Sweden. There is a growing recognition that the latter product in particular, which is generally known as ‘snus’, is significantly less harmful than smoking (but not harmless). There are also products that heat, rather than burn, tobacco – such as Eclipse, which is marketed in the USA as a safer alternative to conventional cigarettes. The role of these products as part of a tobacco harm reduction strategy has enjoyed much debate within the tobacco control community.

Some tobacco control experts argue that smokers need to be informed about the different options available to them and the associated levels of risk in order to make informed consumer choices. However, Sweden is currently the only European country that allows the supply of snus, thanks to special dispensation from the European Union, which has outlawed smokeless tobacco in the rest of the continent. Significantly, Sweden currently has the lowest rates of lung cancer and cigarette mortality in Europe and is the only European nation to achieve the World Health Organization’s target for reduced per capita cigarette use.

On the flipside, some experts argue that the availability of less harmful tobacco products will simply maintain people’s tobacco use when they otherwise would have quit.

There’s also harm reducing alternatives to tobacco itself, such as the increasingly diverse range of nicotine replacement therapies (NRTs). These include such products as nicotine gum, patches, nasal spray, inhalators, tablets and lozenges, and are widely available for purchase and prescription. They have no known long-term adverse health effects and are therefore potential substitutes for cigarettes that address the nicotine dependency underlying most tobacco use.

In a harm reduction regime, NRTs can play a key in reducing the levels of death and disease attributed to smoking. They can be used alongside existing efforts to help people stop smoking, and reduce harm to nonsmokers from passive smoking. However, NRTs are relatively expensive, largely unavailable to smokers in the developing world and much more tightly regulated than cigarettes.

Many public health and tobacco policy experts argue that a single, combined regulatory framework is needed for all tobacco and nicotine products. Having such a policy in place would create a level playing field where cleaner nicotine products could replace cigarettes as the dominant form of nicotine delivery.

As with harm reduction interventions for any psychoactive substance, the key factors are information, choice, coverage and accessibility. None of the products or interventions mentioned in this article is designed to stand alone – they should all be seen as part of a collective approach that sits alongside cessation, prevention and exposure reduction strategies (in the same way that harm reduction for illicit drug use can sit alongside demand and supply reduction approaches). If smokers cannot be convinced to quit, they could at least be encouraged to reduce the risks they face (and the risks others face) with the help of products such as long-term and regulated smokeless tobacco products.

• Ann McNeill is a Professor in Health Policy and Promotion at the University of Nottingham; Jamie Bridge is the Communications and Project Development Officer for the International Harm Reduction Association. This article was first published in the April 2007 edition of Drink and Drug News (www.drinkanddrugs.net). Reprinted with permission.