The concept of Harm Reduction
Harm reduction is a well established public health concept that seeks pragmatic ways to minimise the health impact of an activity or behaviour which carries inherent risks. For example, a widely accepted harm reduction idea is the use of seat belts and airbags in cars, needle exchange programs for drug users, condom provision to prevent STDs and safety standards for food, environment and workplaces.
Harm reduction and tobacco
Tobacco harm reduction aims at minimising tobacco-related disease and death without requiring complete tobacco/nicotine abstinence, but e.g. switching to a smokefree tobacco product, such as snus.
In recent years, support for tobacco harm reduction has grown. An increasing number of public health and tobacco control advocates, while continuing to support cessation initiatives, have endorsed harm reduction approaches - such as encouraging smokers to switch to a less harmful smokeless tobacco product - as a way to reduce tobacco-related harm.
What is the tobacco harm reduction strategy?
The harmful effects of cigarette smoking arise mainly through the burning of tobacco. The harm reduction approach is based on the recognition that the health hazards of cigarette smoking can largely be avoided by switching to smokefree sources of nicotine. This could be accomplished through either smokefree tobacco-based products (such as snus) or through nicotine-replacement products (such as patches or chewing gum). There is some evidence that smokers may be more likely to accept alternative tobacco products, and thus have greater success in quitting smoking, than with the nicotine-replacement products. See smoking cessation
What evidence is there that the health risks associated with use of snus are lower than those associated with cigarette smoking?
Based on observations from the "Swedish experience," it has commonly been accepted among researchers that the use of snus is less harmful than smoking.
Among Swedish men, the rate of snus consumption exceeds the rate of cigarette consumption and the prevalence of lung cancer and oral cancer is also significantly lower. Several researchers (e.g. Foulds et al. 2003, Henningfield and Fagerström 2001, Rodu et al. 2003) have suggested that the low prevalence of smoking in Sweden is related to such factors as the use of snus.
Recently, researchers have attempted to quantify the difference in risks associated with cigarette smoking and the use of snus. A quantitative analysis provided evidence that the health risks associated with snus are significantly lower than those associated with smoking for the following outcomes: lung cancer, oral cancer, gastric cancer, cardiovascular disease, and all-cause mortality (Roth et al. 2005). An expert panel concluded that mortality associated with use of low-nitrosamine smokefree products (such as snus) is at least 90% lower than that associated with smoking (Levy et al. 2004).
Same total tobacco consumption and lowest mortality in Sweden
*EU 25 refers to the 25 EU member states before expansion on January 1, 2007.
is at least as high in Sweden as in other European countries, the risk of being afflicted by a smoking-related fatal disease is significantly lower. Many researchers believe that this is because snus replaces more harmful cigarettes in Sweden.
Sources: Proportion of daily smokers among men: WHO, European Commission and national statistics authorities for the Nordic countries.
see Swedish experience
What is the future for the tobacco harm reduction approach?
It is undoubtedly an area that will continue to be controversial. However, many influential researchers believe that it would be unethical not to continue exploring the use of smokefree tobacco products as an alternative to cigarettes (Martinet et al. 2006). They note the importance of pursuing this issue in a scientifically based manner, and of considering all of the concerns mentioned above.
Why do some researchers oppose this approach?
>Opponents to the harm reduction approach argue that it could lead to undesired health-related consequences. For example, an individual might begin using snus in an attempt to quit smoking, but end up using both snus and cigarettes (Henningfield et al. 2002). Other individuals who perhaps would never have taken up smoking might adopt the use of snus, believing it to be harmless.
Critics of the harm reduction approach contend that the only risk-free solution is quitting tobacco altogether. They emphasize that snus may carry less risk than cigarettes, but that switching to snus is not without some risk of its own.
- Foulds, J., Ramstrom, L., Burke, M., Fagerstrom, K. 2003. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob. Control 12(4):349-359. Henningfield, J.E. and Fagerström, K.O. 2001. Swedish Match Company, Swedish snus and public health: A harm reduction experiment in progress? Tob. Control 10:253-257.
- 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. 13:2035-2042.
- Martinet, Y., Bohadana, A., and Fagerstrom, K. 2006. Would alternate tobacco products be better than smoking? Lung Cancer [Epub ahead of print] doi:10.1016/j.lungcan.2006.03.006.
- Rodu, B., Stegmayr, B., Nasic, S., Cole, P., and Asplund, K. 2003. Evolving patterns of tobacco use in northern Sweden. J. Int. Med. 253:1-6. Roth, H.D., Roth, A.B., and Liu, X. 2005. Health risks of smoking compared to Swedish snus. Inhal. Toxicol. 17:741-748.
- World Health Organization. 2006. Why is tobacco a public health priority? Finns på: http://www.who.int/tobacco/health_priority/en/print.html.