Harm Reduction
[1.0] What is Tobacco Harm Reduction?
Most people who smoke do so to get nicotine. But smoking is a terribly unhealthy way to get nicotine. You probably know smoking is very bad for your health. But what you probably do not know – because there are a lot of people trying to mislead you – is that nicotine is not very bad for you. Neither is tobacco, as long as it is not on fire. The danger from smoking is almost entirely due to inhaling concentrated smoke, which is bad for you no matter what is burning.
A lot of people want nicotine, and they do not realize they can get it without all the dangers of smoking. Tobacco harm reduction focuses on allowing nicotine users to keep using nicotine (because they cannot or will not quit), but to reduce the huge risks from smoking. Unfortunately, most major health organizations (particularly the United States government and certain U.S. advocacy organizations) have only one message for smokers: Quit, or die. If you are unable or unwilling to quit using nicotine, they offer you nothing other than the severe health risks of smoking. We would like to offer you another option.
[1.1] How can a smoker reduce his or her risk?
There are two ways a smoker can reduce the risks from smoking. One is quitting nicotine entirely, quitting smoking and not substituting another source of nicotine. The other is getting nicotine from a much less harmful source. Unfortunately, neither one will immediately eliminate all of the health risks caused by smoking, but both come very, very close.
Of the two, quitting entirely is probably the slightly healthier option for most people (we say "probably" and "most people" because there are some health benefits from nicotine that for some people might outweigh the very small risks from highly-reduced-risk nicotine products). This is because nicotine itself may slightly increase your risk of cardiovascular disease (heart attack and stroke), though not nearly as much as smoking does. But switching to a highly-reduced-risk nicotine product is almost as good as quitting entirely. Those products have only about 1/100th the risk of smoking.
We are sure that you are aware of the many programs, drugs, and therapies available to help smokers quit using nicotine entirely. You should have no trouble finding one of those if you want, and we very much hope that if you are a smoker and elect to quit entirely, that you do succeed. But since you are reading this, we assume that you or someone you know is among the large majority of smokers who have tried to quit and failed, or wants to use nicotine but wants to minimize the risk.
[1.2] What are highly-reduced-risk nicotine products?
The most popular highly-reduced-risk nicotine product is smokeless tobacco, specifically modern Western moist snuff (the Swedish word for which is snus) and chewing tobacco. The other class of products is pharmaceutical nicotine products (such as nicotine gums, patches, and inhalers). Someone who uses one of these products rather than smoking reduces the risks by about 99%.
TobaccoHarmReduction.org focuses on certain moist snuff products from the United States and Scandinavia (particularly Sweden) because we think they have the most potential as substitutes for smoking, for reasons that we explain later in the FAQ. But if you are a smoker and switch to any of these products, the benefits are almost as good as the benefits from quitting entirely.
[1.3] Isn't harm reduction a controversial idea?
Anti-tobacco advocates think that it is, but this is simply not true. Most all of public health, and a large part of medical care, is devoted to harm reduction.
The term "harm reduction" is most often used in controversial contexts, like encouraging condom use and other safe sex practices, or providing heroin users with clean needles or methadone. Calling it "harm reduction" reminds us that people would be at less risk of disease if they avoided sex or gave up narcotics entirely, but we cannot expect that to happen.
But harm reduction is also our policy in most matters of health. Driving and other transport is a dangerous activity, but we do not suggest that people give it up. We do not even tell them to limit it to "necessary" trips, avoiding vacations or trips to the video store. Instead, we have rules of the road that make it safer, encourage (or mandate) seatbelt use, and build cars with safety features. Similarly, we do not tell people they have to give up playing hockey, bicycling, or other sports, even though there is some risk, but we do try to encourage the use of protective equipment.
When physicians or public health practitioners try to get you to change your cholesterol, eat less meat, or exercise more, the target is to improve your health but seldom do they insist that you have only one choice: Do the best possible thing or forget it. Taking most health advice will reduce your health risks but not get them to the lowest possible level.
When it comes to diet, exercise, sex, transportation, sports, and even heroin use, public health experts generally agree that scolding people to do the healthiest thing possible is just not practical or reasonable (indeed, it would be downright cruel in most cases). Instead we realize that people will decide that the benefits of certain behaviors are worth some risks, so we try to help them reduce their risks. Of all the things people do, nicotine use is about the only one where health officials do not promote harm reduction, and think they have a right to just demand you do what they want; and will even lie to you to keep you from learning about reduced harm alternatives.
[1.3.1] Safer just isn't good enough when it comes to my health.
If you find yourself dealing with someone who seems to be insisting that comparative risk does not matter - that a lot better is not perfect and therefore not worth pursuing - try having this conversation (exact details might vary, but we would bet not by much):
You: Do you think it is good to tell people to eat more fruits and vegetables? If so, why?
Ostensible Public Health Expert: Yes, certainly. Eating more fruits and vegetables reduces the risk of digestive system cancers (stomach and colon cancers) and is beneficial in many other ways.
You: So you are saying that someone who eats lots of fruits and vegetables will never get colon cancer.
Expert: No, of course not. We cannot eliminate all the risk, but the benefits are still very impressive.
You: Ah, well, at least you can tell me that absolutely no one has ever died from eating lots of fruits and vegetables, right?
Expert: Strictly speaking, no. There are a fair number of cases of foodborne disease that are traced to plant foods, some of which are fatal. People die from allergies, including allergies to fruits. Fruits and vegetables contain pesticides (some naturally occurring, some added by humans) and other organic chemicals, heavy metals (calcium, lead), and even radioactive isotopes that probably sometimes cause cancers and other diseases. On net, on average, you are much better off eating more fruits and vegetables rather than less, but it is not perfect. Don't be distracted by the fact that it is not perfect. It is still very good.
You: So eating fruits and vegetables does not entirely eliminate the risk of any disease, and is not perfectly safe but is still a great idea. That sounds kind of familiar.
[1.4] Can tobacco harm reduction really work?
The male population of Sweden is living proof that tobacco harm reduction can work. Smokeless tobacco has a long history in Sweden and, though it was largely replaced by cigarettes when they became popular in the early 20th century, it made a comeback. Over the last few decades, men in Sweden have smoked less and used more "snus" (the Swedish word for moist snuff) instead.
This was not caused by any public health campaign or government meddling. It was a normal social process of people changing their tastes. But the result was a huge public health triumph. Swedish men have a very low rate of lung cancer and other smoking related diseases, as we would expect from a population that quit smoking. The scientific evidence shows that the widespread use of smokeless tobacco is not causing any substantial disease risk. (Swedish women, unfortunately, continue to smoke at the higher rates typical of other countries, and their rates of smoking-related diseases remain high [1].
Could the Swedish experience be repeated elsewhere? It might be spontaneously happening in Norway right now, where smokeless tobacco is also culturally popular. But to duplicate it in other cultures will require some effort on the part of health promoters to educate people and persuade them of the advantages of harm reduction. That is what we are attempting to do.
References
1. Rodu & Cole, 2004. The Burden of Mortality from Smoking: Comparing Sweden with Other Countries in the European Union. European Journal of Epidemiology 19: 129-131. Posted on For Smokers Only.
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