Science and Harm reduction

Tobacco harm reduction aims at minimising tobacco-related disease and death without requiring complete tobacco/nicotine abstinence. Tobacco harm reduction has been much debated and questioned by those who consider that tobacco use cessation & prevention as the main strategy to reduce tobacco-related harm, i.e. proponents for tobacco harm elimination. This strategy leaves the cigarette smoker with two options only: quit or die. Some believe condemning smokers who can not or will not quit to a premature death is harsh, particularly if viable harm-reduction alternatives to cessation exist(16).

(16). Warner, K.E., 2002. Tobacco harm-reduction: Promise and perils. Nicotine and Tobacco Research Vol 4, Supplement 2; pp61-71.

A tobacco harm reduction product was defined in 2001 by the Institute of Medicine in the USA as "harm reducing if it lowers total tobacco related mortality and morbidity even though the use of that product may involve continued exposure to tobacco related toxicants."(17)

(17). Stratton, K., Shetty, P., Wallace, R., and Bondurant, S. (eds.).  2001.  Clearing the smoke: Assessing the science base for tobacco harm reduction. District of Columbia: Institute of Medicine, National Academy Press.

According to Martin et al (2004)(18) harm reduction products should show substantial disease risk reduction, have minimal unintended consequences – individual vs. population, be non-combustible (smokeless) and have low levels of toxins, be acceptable to consumers including satisfying nicotine dose and economic feasibility and have documented scientific basis for harm reduction

(18). E. G. Martin et al. 2004. Tobacco harm reduction: what do the experts think? Tob. Control 13:123-128.

Tobacco harm reduction hence involves the use of alternative sources of nicotine, including modern smokeless tobacco products, by those who are unable or unwilling to quit tobacco and nicotine entirely. Snus has often been discussed as a tobacco harm reduction product and the rationale behind is given below.

Cigarette smoking is associated with high health risks including cancer and cardiovascular and respiratory diseases. There is, however, a continuum of harmfulness among tobacco products with low-nitrosamine smokeless tobacco products at the lower end.

• Rodu and Cole (1994) estimated that use of smokeless tobacco confers only about 2% of the health risks of smoking(19).
  
  Rodu, B.1994. An alternative approach to smoking control. Am. J. Med. Sci. 308:32-34.
  
  (19). Rodu, B. and Cole, P. 1994. Tobacco-related mortality. Nature 370:184.
  
  Rodu, B. and Cole, P. 1995. The rewards of smoking cessation. Epidemiol. 7:111-112.
  

• The Royal College of Physicians of London in its report “Protecting Smokers, Saving Lives” (2002) stated “As a way of using nicotine, the consumption of non-combustible tobacco is on the order 10-1,000 times less hazardous than smoking, depending on the product.”
  
  
• A panel of experts compared the risks of use of low-nitrosamine smokeless tobacco products such as snus with cigarette smoking (2004). The panellists reported that “In comparison with smoking, experts perceive at least a 90% reduction in the relative risk of low-nitrosamine smokeless tobacco use."(20)
  
  (20). Levy, D.T., Mumford, E.A., Cummings, K.M., Gilpin, E.A., Giovino, G., Hyland A., Sweanor, D. and Warner, K.E.  2004. The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: Estimates of a panel of experts. Cancer Epidemiol. Biomarkers Prev. 13:2035-42.
  
  
• Phillips et al (2006) made a refined calculation of risks from smoking and from use of Swedish or American smokeless tobacco products. They estimated that compared with smoking, the risks associated with use of smokeless tobacco were in the range of 1% or 2%, and that possibly less were most consistent with the epidemiologic evidence."(21)
  
  (21). Phillips, C.V., Rabiu, D., and Rodu, B. Calculating the comparative mortality risk from smokeless tobacco versus smoking. Congress of Epidemiology, June 23 2006.

The impact of on smokeless tobacco on public health has also been discussed in the scientific literature and is manifested in cancer and in smoking-related mortality statistics.

• Foulds et al (2003) stated that "In Sweden we have a concrete example in which availability of a less harmful tobacco products has probably worked to produce a net improvement of health in that country."(22)
  
  

  (22). Foulds, J., Ramström, L., Burke, M., and Fagerström, K.  2003.  The effect of smokeless tobacco (snus) on smoking and public health in Sweden.  Tobacco Control. 12:349-359.

• The Public Health Report issued by the Swedish National Board of Health and Social Welfare stated that "it is impossible to conclude that there are risks associated with snus, although they are minor compared to smoking. For every snus user who takes up smoking, there are four smokers who switch to snus when they give up smoking. Taken together these results indicate that the net effects of the changes in tobacco habits are positive in public health terms."(23).
  
  (23). National Board of Health and Social Welfare. 2005. Folkhälsorapport 2005 (Public Health Report 2005).  
  
  
• The rates of bronchus, lung, oral and bladder cancer are lower in Sweden than in other EU countries(24).
  
  (24). LaVecchia, C., Lucchini, F., Negri, E., Boyle, P., Maisoneuve, P., and Levi, F. 1992. Trends of cancer mortality in Europe, 1955-1989: II and IV. Eur. J. Cancer 28:514-599. 28A:1210-1281.
  
  
• Swedish men have the lowest percentage of male deaths related to smoking of all developed countries(25).
  
  (25).Peto, R., Lopez, A. D., Boreham, J., and Thun, M. 2003. Mortality from Smoking in Developed Countries 1950-2000, 2nd edition, data updated 15 July 2003, http://www.ctsu.ox.ac.uk/~tobacco

• Rodu and Cole (2004) estimated that 200,000 smoking-related deaths would be avoided each year if all EU men (15-country) smoked at the age-specific prevalence rates of Swedish men. Since women in Sweden smoke at rates more similar to those of women in other EU countries only 1,100 smoking-related deaths would be avoided for women in the EU(26).
  
  (26). Rodu, B. and Cole, P. 2004. The burden of mortality from smoking: comparing Sweden with other countries in the European Union. Europ. J. Epidemiol. 19:129-131.