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The prospects for tobacco harm reduction
International Journal of Drug Policy 16 (2005) 139–142
Commentary
The prospects for tobacco harm reduction Wayne D. Hall ∗ Office of Public Policy and Ethics, Institute for Molecular Bioscience, University of Queensland, St Lucia, Qld. 4072, Australia Received 17 March 2005; received in revised form 4 April 2005; accepted 5 April 2005
Abstract Tobacco harm reduction (THR) policies aim to reduce the prevalence of tobacco-related harm by encouraging smokers who are unable or unwilling to quit to adopt less harmful ways of obtaining nicotine, such as pharmaceutical nicotine and oral tobacco snuff. Proponents of THR argue that the effects of tobacco control policies have reduced smoking as much as they reasonably can and that we can best reduce tobacco-related harm by encouraging smokers to use these methods, which substantially reduce the health risks of smoking. Critics argue that THR policies will undermine the two traditional tobacco control goals of preventing the uptake of smoking by young people and encouraging smokers to quit. I assess the main arguments and evidence advanced for and against THR. © 2005 Elsevier B.V. All rights reserved. Keywords: Tobacco policy; Harm reduction; Pharmaceutical nicotine; Smokeless tobacco
Over the past 40 years tobacco control policies – including high taxes on cigarettes, advertising bans and restrictions on smoking – have almost halved the prevalence of adult cigarette smoking in Australia and the USA (Chaloupka, Wakefield, & Czart, 2001; World Health Organization, 1998). Nonetheless, around one in five adults in these countries still smoke tobacco, new smokers continue to be recruited, and tobacco smoking continues to make a large contribution to the burden of disease (Ezzati, Lopez, Rodgers, Vander Hoorn, & Murray, 2002; Murray & Lopez, 1997). The persistence of smoking in a substantial minority of adults in these countries has prompted some researchers to advocate “tobacco harm reduction” (THR) policies. These policies aim to reduce the public health consequences of tobacco smoking by encouraging smokers who are unable or unwilling to quit to adopt less harmful ways of obtaining nicotine (Shiffman, Gitchell, Warner, Slade, Henningfield, & Pinney, 2002; Stratton, Shetty, Wallace, & Bandurant, 2001). THR, it is argued, would very substantially reduce the public health burden of tobacco use and the economic costs of treating tobacco-related diseases (e.g. Ault, Ekelund, Jackson, & Saba, 2004; Kozlowski, O’Connor, & Edwards, 2003; Shiffman et al., 2002; Stratton et al., 2001). Concurrently, the ∗
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tobacco industry has begun to market “safer” tobacco products (Stratton et al., 2001; Warner, Slade, & Sweanor, 1997). Tobacco harm reduction products The main harm reduction products under debate can be listed in order of probable potential for reducing tobaccorelated harm, as follows (Shiffman et al., 2002; Stratton et al., 2001). • Pharmaceutical nicotine: These are in the form of gum, patches, inhalers, and sprays. These products are safe, effective and cost-effective ways to assist smokers to quit, with minimal risk of abuse, in part because they have been deliberately designed that way (Fagerstrom, 2000; Song, Raftery, Aveyard, Hyde, Barton, & Woolacott, 2002; Warner, 2001). Pharmaceutical nicotine can also be used over the long-term as an alternative to cigarette smoking (Warner et al., 1997). • Smokeless tobacco products: These include traditional chewing tobacco and oral snuff, including snus, a low nitrosamine oral snuff (Foulds, Ramstrom, Burke, & Fagerstrom, 2003; Ramstrom, 2000). • Less hazardous cigarettes and cigarette-like devices: These include cigarettes made with low nitrosamine tobacco and devices developed by the tobacco industry
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W.D. Hall / International Journal of Drug Policy 16 (2005) 139–142
(Eclipse and Premier) that aim to minimise tars and maximise nicotine by heating rather than burning tobacco (Shiffman et al., 2002; Stratton et al., 2001).
Will THR products reduce harm to users? Opponents of THR policies question whether they will reduce harm. First, they argue that it will take 50 or more years to fully evaluate the long-term safety of many THR products (Pierce, 2002; Stratton et al., 2001). They also invoke the example of a failed effort at “tobacco harm reduction” (e.g. Gray, 2004; Pierce, 2002; Stratton et al., 2001): the campaign conducted by the tobacco industry in the 1970s and 1980s to persuade smokers to use “low tar” or “light” tobacco cigarettes because they were safer than standard cigarettes (Stratton et al., 2001). By the 1990s most smokers had switched to these cigarettes in the mistaken belief that they would reduce the health risks of smoking when, as we now know, smokers unconsciously subverted the possible health benefits from using low-tar and low-nicotine cigarettes by making compensatory changes in the way that they smoked them, such as inhaling more deeply, smoking more cigarettes and more of each cigarette, and blocking ventilation holes designed to reduce smoke exposure (Stratton et al., 2001). THR critics argue that similar compensatory changes will nullify any benefits from THR products that involve the combustion of tobacco (Pierce, 2002). Proponents of THR accept that the experience with light cigarettes presents strong reasons for opposing cigarette-like nicotine delivery devices to be promoted as THR products (Stratton et al., 2001; Warner, 2001). This argument does not apply to PN and snus. The safety of pharmaceutical nicotine is well established in the short to medium term with users having been followed for up to 5 years (Shiffman et al., 2002; Stratton et al., 2001). Pharmaceutical nicotine may carry some residual health risks, such as an increased risk of cardiovascular disease arising from chronic nicotine intake, but these are trivial by comparison with those of cigarette smoking (Benowitz, 2000). The health risks of smokeless tobacco products are probably larger than those for pharmaceutical nicotine because they may also include an increased risk of head and neck cancers for some types of oral tobacco (Critchley & Unal, 2003; Winn, 1997). These risks are probably lower for snus because it has been treated to reduce levels of the carcinogenic nitrosamines (Foulds et al., 2003; Ramstrom, 2000). Studies in Sweden where men have used snus for 20 years have so far failed to detect any increase in the risks of cardiovascular disease or oral cancers (Asplund, 2003; Critchley & Unal, 2003; Foulds et al., 2003) and any risk that is detected in future studies is likely to be at most a small fraction of the risks of tobacco smoking (Ramstrom, 2000). Proponents of THR argue that we already have enough evidence from large observational evaluations of the Swedish experience with snus to justify its adoption for THR (Kozlowski, 2003).
Effects of THR on aggregate harm Opponents argue that any reduction in health risks from THR will be outweighed by adverse effects on public health because these products will deter smokers from quitting, encourage former smokers to resume use, and increase rates of smoking among adolescents by serving as a “gateway” to smoking (Pierce, 2002; Stratton et al., 2001; Warner & Martin, 2003). They point to the effects that introducing “light cigarettes” had on smoking cessation and initiation rates (Pierce, 2002). Again this argument is most convincing in the case of combustible THR products. For the following reasons it is not a compelling objection to THR using pharmaceutical nicotine or snus. First, Kozlowski, Strasser, Giovino, Erickson, & Terza (2001) have shown that the would still be a net population health gain from their adoption, even on the most pessimistic assumptions about their residual health risks and assuming that they were used by the whole adult population. Second, pharmaceutical nicotine and snus are less likely to initiate new nicotine users than cigarettes because they deliver nicotine at a much slower rate, produce a steadier blood level of nicotine, and hence are less rewarding than tobacco smoking in nicotine-na¨ıve users (Benowitz, 2001; Fagerstrom, 2000; Hennigfield & Fant, 2000; Warner, 2001). Third, Swedish experience with snus contradicts the pessimistic view about the population impact of THR (Foulds et al., 2003). The uptake of snus among Swedish men increased over the past 20 years, with as many Swedish men now using snus as smoking cigarettes (Ramstrom, 2000). The increase in snus use was accompanied by a decline in cigarette smoking (from 40% in 1976 to 15% in 2002) (Ramstrom, 2000). Contrary to the gateway hypothesis, there were no increases in rates of smoking among adolescent males who were the heaviest users of snus (Foulds et al., 2003). Most continuing snus users are ex-smokers who used it to quit smoking (Foulds et al., 2003; Ramstrom, 2000). The same patterns have been found in smokeless tobacco use and cigarette smoking in American males (Ault et al., 2004; O’Connor, Kozlowski, Flaherty, & Edwards, 2005). Most critically, the increase in snus use was accompanied by a decline in lung cancer mortality and the absence of an increase in either cardiovascular mortality or head and neck cancers (Foulds et al., 2003). The plausibility of a causal relationship between increased snus use and these good health outcomes was strengthened by (1) the absence of any similar changes in smoking prevalence or lung cancer mortality in Swedish women who did not adopt snus at the same rate as men (Foulds et al., 2003).
Ethical issues The THR policy debate also raises the important ethical issues of paternalism (Kozlowski et al., 2001): do public health practitioners have the ethical right to prevent smokers from
W.D. Hall / International Journal of Drug Policy 16 (2005) 139–142
being informed about THR products for fear that this may increase population nicotine use? Those who argue that we should not tell smokers how to reduce their risks adopt a paternalistic policy in the smokers’ own interests and the public good. As Kozlowski (2002) argues, telling smokers about THR is an effective public health measure that properly respects their autonomy. One also suspects that some opposition to THR reflects the unstated belief that the goal of tobacco control policy should be the elimination of nicotine use (e.g. Pierce, 2002). Some opponents also take the view that THR is morally wrong because it involves the long-term use of an addictive substance even if it is much less risky than smoking cigarettes (Warner et al., 1997). This contrasts with the consequentialist ethical views of THR proponents who argue for it on the grounds that its benefits outweigh its harms (e.g. Kozlowski, 2002).
Options for promoting THR There are a number of ways in which we could promote THR (Warner et al., 1997). Foremost among these is creating more equal competition between different nicotine delivery devices by making it harder to introduce new cigarette-like devices and easier to introduce and promote the use of THR products (Stratton et al., 2001; Warner et al., 1997). We could encourage smokers who failed to quit to use pharmaceutical nicotine as a long-term alternative (Kozlowski, 2002). This cautious step is one of the few THR strategies that is supported by the majority of US tobacco control advocates (Warner & Martin, 2003). It would probably have a limited public health impact because it is aimed at high-risk smokers, only a minority of whom seek medical or other treatment, and probably only a small proportion of whom would adopt this strategy because of the unattractiveness of existing forms of pharmaceutical nicotine (Stratton et al., 2001; Warner et al., 1997). A larger public health impact probably requires efforts to encourage as many smokers as possible to switch to pharmaceutical nicotine or snus. Swedish experience suggests that this may be easier for snus than pharmaceutical nicotine (Foulds et al., 2003; Ramstrom, 2000), unless regulators allow forms of pharmaceutical nicotine to be developed that are more attractive to smokers. Smokers might also be encouraged to make a switch by a combination of policies (Room, 2000) that include: public education campaigns in favour of pharmaceutical nicotine and snus; over-the-counter sale of nicotine replacement therapy and snus combined with tighter restrictions on where tobacco cigarettes can be sold; and differential taxes on smoked and non-smoked forms of tobacco to make nicotine replacement therapy and snus much cheaper than smoked tobacco (Foulds et al., 2003; Ramstrom, 2000). We could also allow a private market in smokeless tobacco products, much like that which exists for snus in Sweden (Ramstrom, 2000) by repealing legislative bans on these
141
products in Australia and Europe. This may be more attractive to governments that are loathe to increase regulation of the existing tobacco market without allowing the tobacco industry to develop new markets to satisfy existing demand for nicotine. Many critics of THR within the tobacco control community would oppose any such policy because of concerns that the promotional activities of the tobacco industry will increase the existing market for nicotine products, especially among adolescents and young adults. This possibility would need to be addressed by tight regulation of the type of promotion allowed for THR products (Stratton et al., 2001).
Harm reduction: tobacco and illicit drugs As the THR debate reveals, concerns about the unintended consequences of harm reduction are not confined to the illicit drugs field. The illegality of some forms of drug use undoubtedly amplifies the difficulties in telling users how to reduce drug-related harm but the similarities in the arguments used by opponents of harm reduction in the tobacco and illicit drug policy arenas are striking. Both argue that we can’t be sure that “safer” use is truly safe, that harm reduction messages may increase the population prevalence of drug use, and that the perception of safer use will produce risk compensation that nullifies any reduction in harm. In the case of THR, the example of light cigarettes provides a cautionary example of miscarried harm reduction that is heavily relied upon by opponents of newer forms of THR. The major novelty in the THR debate for those in the illicit drug field is finding Sweden in the novel position of a harm reduction pioneer, an anomalous position given that country’s long-standing opposition to harm reduction policies in the illicit drug field.
Conclusions There is a compelling case for THR policies that encourage existing smokers to use pharmaceutical nicotine and snus. The THR case is much less compelling for “safer” cigarette or cigarette-like devices that involve some form of tobacco combustion; concerns about risk compensation, and maintenance of cigarette smoking in the population, apply with particular force to these types of THR. The major uncertainties about the impact of THR using pharmaceutical nicotine and snus are whether they will prove acceptable to existing smokers under plausible regulatory regimes. Clearly, an empirically based THR policy requires good regulation of all tobacco products and the careful monitoring and evaluation of the effects of THR on cigarette use, if we are to ensure that THR measures reduce tobacco-related harm in the ways that they promised to do without producing any offsetting unintended adverse consequences (Stratton et al., 2001).
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Acknowledgements The work reported in this paper was funded by start up funding for the Office of Public Policy and Ethics provided by the Institute for Molecular Bioscience and the Vice Chancellor’s Strategic Fund of the University of Queensland. I would like to thank Sarah Yeates for her invaluable assistance in locating the research literature and in preparing this paper for publication. References Asplund, K. (2003). Smokeless tobacco and cardiovascular disease. Progress in Cardiovascular Diseases, 45, 383–394. Ault, R. W., Ekelund, R. B., Jackson, J. D., & Saba, R. P. (2004). Smokeless tobacco, smoking cessation and harm reduction: An economic analysis. Applied Economics, 36, 17–29. Benowitz, N. L. (2000). Nicotine toxicity. In R. Ferrence, J. Slade, R. Room, & M. Pope (Eds.), Nicotine and public health (pp. 65–75). Washington, DC: American Public Health Association. Benowitz, N. L. (2001). The nature of nicotine addiction. In P. Slovic (Ed.), Smoking: Risk perception and policy (pp. 159–187). Thousand Oaks: Sage. Chaloupka, F. J., Wakefield, M., & Czart, C. (2001). Taxing tobacco: The impact of tobacco taxes on cigarette smoking and other tobacco use. In R. L. Rabin & S. D. Sugarman (Eds.), Regulating tobacco (pp. 39–71). Oxford: Oxford University Press. Critchley, J. A., & Unal, B. (2003). Health effects associated with smokeless tobacco: A systematic review. Thorax, 58, 435–443. Ezzati, M., Lopez, A. D., Rodgers, A., Vander Hoorn, S., & Murray, C. J. (2002). Selected major risk factors and global and regional burden of disease. Lancet, 360, 1347–1360. Fagerstrom, K. O. (2000). Nicotine-replacement therapies. In R. Ferrence, J. Slade, R. Room, & M. Pope (Eds.), Nicotine and public health (pp. 199–207). Washington, DC: American Public Health Association. Foulds, J., Ramstrom, L., Burke, M., & Fagerstrom, K. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 12, 349–359. Gray, N. (2004). The ethics of policies for the prevention of tobacco disease. Acta Oncologica, 43, 8–10. Hennigfield, J. E., & Fant, R. V. (2000). Nicotine delivery systems: Implications for abuse potential, medications development and public health. In R. Ferrence, J. Slade, R. Room, & M. Pope (Eds.), Nicotine and public health (pp. 229–249). Washington, DC: American Public Health Assocation. Kozlowski, L. T. (2002). Harm reduction, public health, and human rights: Smokers have a right to be informed of significant harm reduction options. Nicotine and Tobacco Research, 4(Suppl. 2), S55– S60.
Kozlowski, L. T. (2003). First, tell the truth: A dialogue on human rights, deception, and the use of smokeless tobacco as a substitute for cigarettes. Tobacco Control, 12, 34–36. Kozlowski, L. T., O’Connor, R. J., & Edwards, B. Q. (2003). Some practical points on harm reduction: What to tell your lawmaker and what to tell your brother about Swedish snus. Tobacco Control, 12, 372–373. Kozlowski, L. T., Strasser, A. A., Giovino, G. A., Erickson, P. A., & Terza, J. V. (2001). Applying the risk/use equilibrium: Use medicinal nicotine now for harm reduction. Tobacco Control, 10, 201–203. Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet, 349, 1436–1442. O’Connor, R. J., Kozlowski, L. T., Flaherty, B., & Edwards, B. Q. (2005). Most smokeless tobacco use does not cause cigarette smoking: Results from the 2000 National Household Survey on Drug Abuse. Addictive Behaviors, 30, 325–336. Pierce, J. P. (2002). Harm reduction or harm maintenance? Nicotine and Tobacco Research, 4(Suppl. 2), 53–54. Ramstrom, L. M. (2000). Snuff—An alternative nicotine delivery system. In R. Ferrence, J. Slade, R. Room, & M. Pope (Eds.), Nicotine and public health (pp. 159–174). Washington, DC: American Public Health Association. Room, R. (2000). Control systems for psychoactive substances. In R. Ferrence, J. Slade, R. Room, & M. Pope (Eds.), Nicotine and public health (pp. 37–61). Washington, DC: American Public Health Association. Shiffman, S., Gitchell, J. G., Warner, K. E., Slade, J., Henningfield, J. E., & Pinney, J. M. (2002). Tobacco harm reduction: Conceptual structure and nomenclature for analysis and research. Nicotine and Tobacco Research, 4(Suppl. 2), S113–S129. Song, F., Raftery, J., Aveyard, P., Hyde, C., Barton, P., & Woolacott, N. (2002). Cost-effectiveness of pharmacological interventions for smoking cessation: A literature review and a decision analytic analysis. Medical Decision Making, 22, S26–S37. Stratton, K., Shetty, P., Wallace, R., & Bandurant, S. (2001). Clearing the smoke: Assessing the science base for tobacco harm reduction. Washington, DC: National Academy Press. Warner, K. E. (2001). Reducing harm to smokers: Methods, their effectiveness and the role of policy. In R. L. Rabin & S. D. Sugarman (Eds.), Regulating tobacco (pp. 111–142). Oxford: Oxford University Press. Warner, K. E., & Martin, E. G. (2003). The US tobacco control community’s view of the future of tobacco harm reduction. Tobacco Control, 12, 383–390. Warner, K. E., Slade, J., & Sweanor, D. T. (1997). The emerging market for long-term nicotine maintenance. Journal of American Medical Association, 278, 1087–1092. Winn, D. M. (1997). Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco. Advances in Dental Research, 11, 313–321. World Health Organization. (1998). Guidelines for controlling and monitoring the tobacco epidemic. Geneva: WHO.
Commentary
The prospects for tobacco harm reduction Wayne D. Hall ∗ Office of Public Policy and Ethics, Institute for Molecular Bioscience, University of Queensland, St Lucia, Qld. 4072, Australia Received 17 March 2005; received in revised form 4 April 2005; accepted 5 April 2005
Abstract Tobacco harm reduction (THR) policies aim to reduce the prevalence of tobacco-related harm by encouraging smokers who are unable or unwilling to quit to adopt less harmful ways of obtaining nicotine, such as pharmaceutical nicotine and oral tobacco snuff. Proponents of THR argue that the effects of tobacco control policies have reduced smoking as much as they reasonably can and that we can best reduce tobacco-related harm by encouraging smokers to use these methods, which substantially reduce the health risks of smoking. Critics argue that THR policies will undermine the two traditional tobacco control goals of preventing the uptake of smoking by young people and encouraging smokers to quit. I assess the main arguments and evidence advanced for and against THR. © 2005 Elsevier B.V. All rights reserved. Keywords: Tobacco policy; Harm reduction; Pharmaceutical nicotine; Smokeless tobacco
Over the past 40 years tobacco control policies – including high taxes on cigarettes, advertising bans and restrictions on smoking – have almost halved the prevalence of adult cigarette smoking in Australia and the USA (Chaloupka, Wakefield, & Czart, 2001; World Health Organization, 1998). Nonetheless, around one in five adults in these countries still smoke tobacco, new smokers continue to be recruited, and tobacco smoking continues to make a large contribution to the burden of disease (Ezzati, Lopez, Rodgers, Vander Hoorn, & Murray, 2002; Murray & Lopez, 1997). The persistence of smoking in a substantial minority of adults in these countries has prompted some researchers to advocate “tobacco harm reduction” (THR) policies. These policies aim to reduce the public health consequences of tobacco smoking by encouraging smokers who are unable or unwilling to quit to adopt less harmful ways of obtaining nicotine (Shiffman, Gitchell, Warner, Slade, Henningfield, & Pinney, 2002; Stratton, Shetty, Wallace, & Bandurant, 2001). THR, it is argued, would very substantially reduce the public health burden of tobacco use and the economic costs of treating tobacco-related diseases (e.g. Ault, Ekelund, Jackson, & Saba, 2004; Kozlowski, O’Connor, & Edwards, 2003; Shiffman et al., 2002; Stratton et al., 2001). Concurrently, the ∗
Tel.: +61 7 3346 2150; fax: +61 7 3346 2159. E-mail address: [email protected].
0955-3959/$ – see front matter © 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2005.04.002
tobacco industry has begun to market “safer” tobacco products (Stratton et al., 2001; Warner, Slade, & Sweanor, 1997). Tobacco harm reduction products The main harm reduction products under debate can be listed in order of probable potential for reducing tobaccorelated harm, as follows (Shiffman et al., 2002; Stratton et al., 2001). • Pharmaceutical nicotine: These are in the form of gum, patches, inhalers, and sprays. These products are safe, effective and cost-effective ways to assist smokers to quit, with minimal risk of abuse, in part because they have been deliberately designed that way (Fagerstrom, 2000; Song, Raftery, Aveyard, Hyde, Barton, & Woolacott, 2002; Warner, 2001). Pharmaceutical nicotine can also be used over the long-term as an alternative to cigarette smoking (Warner et al., 1997). • Smokeless tobacco products: These include traditional chewing tobacco and oral snuff, including snus, a low nitrosamine oral snuff (Foulds, Ramstrom, Burke, & Fagerstrom, 2003; Ramstrom, 2000). • Less hazardous cigarettes and cigarette-like devices: These include cigarettes made with low nitrosamine tobacco and devices developed by the tobacco industry
140
W.D. Hall / International Journal of Drug Policy 16 (2005) 139–142
(Eclipse and Premier) that aim to minimise tars and maximise nicotine by heating rather than burning tobacco (Shiffman et al., 2002; Stratton et al., 2001).
Will THR products reduce harm to users? Opponents of THR policies question whether they will reduce harm. First, they argue that it will take 50 or more years to fully evaluate the long-term safety of many THR products (Pierce, 2002; Stratton et al., 2001). They also invoke the example of a failed effort at “tobacco harm reduction” (e.g. Gray, 2004; Pierce, 2002; Stratton et al., 2001): the campaign conducted by the tobacco industry in the 1970s and 1980s to persuade smokers to use “low tar” or “light” tobacco cigarettes because they were safer than standard cigarettes (Stratton et al., 2001). By the 1990s most smokers had switched to these cigarettes in the mistaken belief that they would reduce the health risks of smoking when, as we now know, smokers unconsciously subverted the possible health benefits from using low-tar and low-nicotine cigarettes by making compensatory changes in the way that they smoked them, such as inhaling more deeply, smoking more cigarettes and more of each cigarette, and blocking ventilation holes designed to reduce smoke exposure (Stratton et al., 2001). THR critics argue that similar compensatory changes will nullify any benefits from THR products that involve the combustion of tobacco (Pierce, 2002). Proponents of THR accept that the experience with light cigarettes presents strong reasons for opposing cigarette-like nicotine delivery devices to be promoted as THR products (Stratton et al., 2001; Warner, 2001). This argument does not apply to PN and snus. The safety of pharmaceutical nicotine is well established in the short to medium term with users having been followed for up to 5 years (Shiffman et al., 2002; Stratton et al., 2001). Pharmaceutical nicotine may carry some residual health risks, such as an increased risk of cardiovascular disease arising from chronic nicotine intake, but these are trivial by comparison with those of cigarette smoking (Benowitz, 2000). The health risks of smokeless tobacco products are probably larger than those for pharmaceutical nicotine because they may also include an increased risk of head and neck cancers for some types of oral tobacco (Critchley & Unal, 2003; Winn, 1997). These risks are probably lower for snus because it has been treated to reduce levels of the carcinogenic nitrosamines (Foulds et al., 2003; Ramstrom, 2000). Studies in Sweden where men have used snus for 20 years have so far failed to detect any increase in the risks of cardiovascular disease or oral cancers (Asplund, 2003; Critchley & Unal, 2003; Foulds et al., 2003) and any risk that is detected in future studies is likely to be at most a small fraction of the risks of tobacco smoking (Ramstrom, 2000). Proponents of THR argue that we already have enough evidence from large observational evaluations of the Swedish experience with snus to justify its adoption for THR (Kozlowski, 2003).
Effects of THR on aggregate harm Opponents argue that any reduction in health risks from THR will be outweighed by adverse effects on public health because these products will deter smokers from quitting, encourage former smokers to resume use, and increase rates of smoking among adolescents by serving as a “gateway” to smoking (Pierce, 2002; Stratton et al., 2001; Warner & Martin, 2003). They point to the effects that introducing “light cigarettes” had on smoking cessation and initiation rates (Pierce, 2002). Again this argument is most convincing in the case of combustible THR products. For the following reasons it is not a compelling objection to THR using pharmaceutical nicotine or snus. First, Kozlowski, Strasser, Giovino, Erickson, & Terza (2001) have shown that the would still be a net population health gain from their adoption, even on the most pessimistic assumptions about their residual health risks and assuming that they were used by the whole adult population. Second, pharmaceutical nicotine and snus are less likely to initiate new nicotine users than cigarettes because they deliver nicotine at a much slower rate, produce a steadier blood level of nicotine, and hence are less rewarding than tobacco smoking in nicotine-na¨ıve users (Benowitz, 2001; Fagerstrom, 2000; Hennigfield & Fant, 2000; Warner, 2001). Third, Swedish experience with snus contradicts the pessimistic view about the population impact of THR (Foulds et al., 2003). The uptake of snus among Swedish men increased over the past 20 years, with as many Swedish men now using snus as smoking cigarettes (Ramstrom, 2000). The increase in snus use was accompanied by a decline in cigarette smoking (from 40% in 1976 to 15% in 2002) (Ramstrom, 2000). Contrary to the gateway hypothesis, there were no increases in rates of smoking among adolescent males who were the heaviest users of snus (Foulds et al., 2003). Most continuing snus users are ex-smokers who used it to quit smoking (Foulds et al., 2003; Ramstrom, 2000). The same patterns have been found in smokeless tobacco use and cigarette smoking in American males (Ault et al., 2004; O’Connor, Kozlowski, Flaherty, & Edwards, 2005). Most critically, the increase in snus use was accompanied by a decline in lung cancer mortality and the absence of an increase in either cardiovascular mortality or head and neck cancers (Foulds et al., 2003). The plausibility of a causal relationship between increased snus use and these good health outcomes was strengthened by (1) the absence of any similar changes in smoking prevalence or lung cancer mortality in Swedish women who did not adopt snus at the same rate as men (Foulds et al., 2003).
Ethical issues The THR policy debate also raises the important ethical issues of paternalism (Kozlowski et al., 2001): do public health practitioners have the ethical right to prevent smokers from
W.D. Hall / International Journal of Drug Policy 16 (2005) 139–142
being informed about THR products for fear that this may increase population nicotine use? Those who argue that we should not tell smokers how to reduce their risks adopt a paternalistic policy in the smokers’ own interests and the public good. As Kozlowski (2002) argues, telling smokers about THR is an effective public health measure that properly respects their autonomy. One also suspects that some opposition to THR reflects the unstated belief that the goal of tobacco control policy should be the elimination of nicotine use (e.g. Pierce, 2002). Some opponents also take the view that THR is morally wrong because it involves the long-term use of an addictive substance even if it is much less risky than smoking cigarettes (Warner et al., 1997). This contrasts with the consequentialist ethical views of THR proponents who argue for it on the grounds that its benefits outweigh its harms (e.g. Kozlowski, 2002).
Options for promoting THR There are a number of ways in which we could promote THR (Warner et al., 1997). Foremost among these is creating more equal competition between different nicotine delivery devices by making it harder to introduce new cigarette-like devices and easier to introduce and promote the use of THR products (Stratton et al., 2001; Warner et al., 1997). We could encourage smokers who failed to quit to use pharmaceutical nicotine as a long-term alternative (Kozlowski, 2002). This cautious step is one of the few THR strategies that is supported by the majority of US tobacco control advocates (Warner & Martin, 2003). It would probably have a limited public health impact because it is aimed at high-risk smokers, only a minority of whom seek medical or other treatment, and probably only a small proportion of whom would adopt this strategy because of the unattractiveness of existing forms of pharmaceutical nicotine (Stratton et al., 2001; Warner et al., 1997). A larger public health impact probably requires efforts to encourage as many smokers as possible to switch to pharmaceutical nicotine or snus. Swedish experience suggests that this may be easier for snus than pharmaceutical nicotine (Foulds et al., 2003; Ramstrom, 2000), unless regulators allow forms of pharmaceutical nicotine to be developed that are more attractive to smokers. Smokers might also be encouraged to make a switch by a combination of policies (Room, 2000) that include: public education campaigns in favour of pharmaceutical nicotine and snus; over-the-counter sale of nicotine replacement therapy and snus combined with tighter restrictions on where tobacco cigarettes can be sold; and differential taxes on smoked and non-smoked forms of tobacco to make nicotine replacement therapy and snus much cheaper than smoked tobacco (Foulds et al., 2003; Ramstrom, 2000). We could also allow a private market in smokeless tobacco products, much like that which exists for snus in Sweden (Ramstrom, 2000) by repealing legislative bans on these
141
products in Australia and Europe. This may be more attractive to governments that are loathe to increase regulation of the existing tobacco market without allowing the tobacco industry to develop new markets to satisfy existing demand for nicotine. Many critics of THR within the tobacco control community would oppose any such policy because of concerns that the promotional activities of the tobacco industry will increase the existing market for nicotine products, especially among adolescents and young adults. This possibility would need to be addressed by tight regulation of the type of promotion allowed for THR products (Stratton et al., 2001).
Harm reduction: tobacco and illicit drugs As the THR debate reveals, concerns about the unintended consequences of harm reduction are not confined to the illicit drugs field. The illegality of some forms of drug use undoubtedly amplifies the difficulties in telling users how to reduce drug-related harm but the similarities in the arguments used by opponents of harm reduction in the tobacco and illicit drug policy arenas are striking. Both argue that we can’t be sure that “safer” use is truly safe, that harm reduction messages may increase the population prevalence of drug use, and that the perception of safer use will produce risk compensation that nullifies any reduction in harm. In the case of THR, the example of light cigarettes provides a cautionary example of miscarried harm reduction that is heavily relied upon by opponents of newer forms of THR. The major novelty in the THR debate for those in the illicit drug field is finding Sweden in the novel position of a harm reduction pioneer, an anomalous position given that country’s long-standing opposition to harm reduction policies in the illicit drug field.
Conclusions There is a compelling case for THR policies that encourage existing smokers to use pharmaceutical nicotine and snus. The THR case is much less compelling for “safer” cigarette or cigarette-like devices that involve some form of tobacco combustion; concerns about risk compensation, and maintenance of cigarette smoking in the population, apply with particular force to these types of THR. The major uncertainties about the impact of THR using pharmaceutical nicotine and snus are whether they will prove acceptable to existing smokers under plausible regulatory regimes. Clearly, an empirically based THR policy requires good regulation of all tobacco products and the careful monitoring and evaluation of the effects of THR on cigarette use, if we are to ensure that THR measures reduce tobacco-related harm in the ways that they promised to do without producing any offsetting unintended adverse consequences (Stratton et al., 2001).
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