Tobacco harm reduction

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Tobacco harm reduction describes actions taken to lower the health risks associated with using nicotine, especially as delivered through combustible tobacco, including but not necessitating complete abstention. These measures have been argued to include:

  1. Cutting down before quitting smoking
  2. Smoking Less
  3. Temporary Abstinence
  4. Switching to non-tobacco nicotine containing products, such as medically licensed nicotine replacement therapies or currently unlicensed products such as electronic cigarettes
  5. Switching to Swedish or American smokeless tobacco products
  6. Switching to organic or additive-free tobacco products.

It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence.[1] Harm reduction may be of substantial benefit to these individuals.


Given the varying legal, moral and historical status of tobacco, and the different types of tobacco and tobacco use in different cultures around the world, debates on tobacco harm reduction tend to be geographically defined arguments. For instance, inhalant cigarette smoking is the dominant form in the United States, with a smaller number of users availing themselves of non-inhalant cigars, pipes, and smokeless tobacco. The political climate over the last few decades has led to both restrictions in the sale and use of tobacco and widespread information (and misinformation) about the negative health effects of tobacco use. Despite this, tobacco in all its forms has remained a legal product in most societies. A notable exception is the European Union, where the most dangerous products (cigarettes) are available but smokeless tobacco products, which are far less hazardous, are banned.[2] The exception is Sweden, where there is a long tradition of smokeless tobacco use among men.

Harm reduction, a modality of dealing with other drug use, is beginning to be applied to tobacco use. In October 2008 the American Association of Public Health Physicians (AAPHP) became the first medical organization in the U.S. to officially endorse tobacco harm reduction as a viable strategy to reduce the death toll related to cigarette smoking.[3][4][5][6] Joel Nitzkin, MD, of the AAPHP wrote: "So if we can figure that the nicotine in the e-cigarettes is basically a generic version of the same nicotine that is in prescription products, we have every reason to believe that the hazard posed by e-cigarettes would be much lower than one percent, probably lower than one tenth of one percent of the hazard posed by regular cigarettes."[7]

"Safer cigarettes"[edit]

Cigarette manufacturers have attempted to design safer cigarettes for almost 50 years, but results have been marginal at best.[8] Filters were introduced in the early 1950s, and manufacturers were selling low-yield cigarettes by the late 1960s.[8] Initially it was thought that these innovations were harm reducing.[9] For example, in 1976 investigators at the American Cancer Society published research concluding that light cigarettes were safer.[10] The study authors wrote that "total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked 'low' tar-nicotine cigarettes than for those who smoked 'high' tar-nicotine cigarettes."

Smokeless tobacco[edit]

It has been established that use of Swedish and American smokeless tobacco confers only 0.1% to 10% of the risks of smoking,[1] though smokeless products in India and Asia contain higher levels of contaminants and thus confer greater risks.[11] Two respected medical groups believe that ST may play a role in reducing smoking-attributable deaths. In 2007, Britain's Royal College of Physicians concluded "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved."[11]

Electronic cigarettes[edit]

Electronic cigarettes are battery-powered devices that deliver vaporized propylene glycol or vegetable glycerin (or a mixture of both) and nicotine when users inhale while using them.[12] Manufacturers of electronic cigarettes often market them as a "cessation aid," claiming that they lack deadly chemicals while also satisfying both smokers' psychological and physiological needs.[13] The regulatory status of e-cigarettes in many countries is uncertain, while in others the use or sale of electronic cigarettes with the nicotine is officially illegal (e.g. Hong Kong).[14] There is a growing census of opinion that when seen as an alternative to smoking rather than a cessation route, the electronic cigarette does indeed have a valid place within tobacco harm reduction strategy. This new ideology has given rise to a relatively new way of regarding the electronic cigarette as a form of Recreational Nicotine Product.

Propellant-based nicotine delivery[edit]

An alternative nicotine delivery platform based on existing asthma inhaler technology is under development by a UK-based healthcare company, Kind Consumer Limited. The technology is currently under development and the company has submitted a Marketing Authorisation Application to the UK MHRA for licensing of the technology as an approved nicotine containing product. The technology is under licence to Nicoventures Limited a subsidiary of British American Tobacco who are responsible for the launch and commercialisation of the technology as an approved nicotine replacement therapy product.

Nicotine Pyruvate Technology[edit]

Philip Morris International bought the rights to a nicotine pyruvate technology developed by Jed Rose at Duke University.[15] The technology is based around the chemical reaction between nicotine acid and a base which produces a nicotine pyruvate vapour for inhalation.[16] It has undergone preliminary clinical evaluation which has shown delivery of nicotine to the lungs.[17]


Proponents of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths.[1][11] Opponents argue that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation.[18][19] Additionally, smokers remain confused about tobacco harm reduction. In a 2004 survey, about 80-100% of participants incorrectly perceived low-yield cigarettes as harm-reducing, while 75-80% mistakenly believed that switching to smokeless tobacco conferred no risk reduction.[20]

See also[edit]


  1. ^ a b c Rodu, Brad; Godshall, William T. (2006). "Tobacco harm reduction: An alternative cessation strategy for inveterate smokers". Harm Reduction Journal 3: 37. doi:10.1186/1477-7517-3-37. PMC 1779270. PMID 17184539. 
  2. ^ Bates C, Fagerstrom K, Jarvis MJ, Kunze M, McNeill A, Ramstrom L, 2003. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control 12: 360-367.
  3. ^ Update on the Scientific Status of Tobacco Harm Reduction, 2008-2010. Prepared for the American Association of Public Health Physicians. Brad Rodu, DDS and Joel L Nitzkin, MD. June 28, 2010.
  4. ^ Principles to Guide AAPHP Tobacco Policy. American Association of Public Health Physicians.
  5. ^ Rodu, B. (2011). "The scientific foundation for tobacco harm reduction, 2006-2011". Harm Reduction Journal 8: 19–99. doi:10.1186/1477-7517-8-19. PMC 3161854. PMID 21801389.  edit
  6. ^ Joel L Nitzkin. LinkedIn.
  7. ^ "Electronic Cigarette Interview with Dr Joel Nitzkin.". The Smokers ANgel. Retrieved 25 November 2013. 
  8. ^ a b Rigotti NA & Tindle HA, 2004. The fallacy of light cigarettes. BMJ 328:278-279. [1]
  9. ^ Russell MAH. 1974. Realistic goals for smoking and health: a case for safer smoking. Lancet 1:254-258.
  10. ^ Hammond EC, Garfinkel L, Seidman H, Lew EA, 1976. "Tar" and nicotine content of cigarette smoke in relation to death rates. Environ Res 12:263-274.
  11. ^ a b c "Harm reduction in nicotine addiction: Helping people who can't quit". Tobacco Advisory Group of the Royal College of Physicians. October 2007. Retrieved 21 April 2012. 
  12. ^ Wlesenthal, Kelly (2013). "Electronic Cigarette History". Retrieved 25 November 2013. 
  13. ^ "Electronic Cigarette Info". 17 April 2012. Retrieved 25 November 2013. 
  14. ^ Hong Kong – E-Cigarette Laws. October 21, 2013 in Aussie ECigarette Reviews.
  15. ^ "News Release May 26, 2011". 
  16. ^ "New smoking cessation therapy proves promising". e! Science News. 2010-02-27. 
  17. ^ Rose, J. E.; Turner, J. E.; Murugesan, T.; Behm, F. D. R. M.; Laugesen, M. (2010). "Pulmonary delivery of nicotine pyruvate: Sensory and pharmacokinetic characteristics". Experimental and Clinical Psychopharmacology 18 (5): 385–394. doi:10.1037/a0020834. PMID 20939642.  edit
  18. ^ Sumner W, 2005. Permissive nicotine regulation as a complement to traditional tobacco control. BMC Public Health 5:18. [2]
  19. ^ Tomar SL, Fox BJ, Severson HH, 2009. Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking? Int J Environ Res Public Health 6: 10-24.
  20. ^ Haddock CK, Lando H, Klesges RC, Peterson AL, Scarinci IC, 2004. Modified tobacco use and lifestyle change in risk-reducing beliefs about smoking. Am J Prev Med 27: 35-41.