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Harm reduction: concepts and practices.

[1.0] What is Tobacco Harm Reduction? - Anything that decreases the risks from using tobacco or nicotine.

Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco or nicotine. A very important part of tobacco harm reduction is simply educating people about the risks of different sources of nicotine. (Reading list.)

[1.1] How can a smoker reduce his or her risk? - Quit smoking or smoke less.

Smokers can quit nicotine entirely, that is, quit smoking and not use any other type of nicotine. They can also get nicotine from a much less harmful source. Neither one will immediately eliminate all of the health risks caused by their previous smoking, but both come very close.

Quitting entirely is probably the slightly healthier option for most people. This is because nicotine itself may slightly increase your risk of 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. Because the longer you smoke the worse it is for you, switching now may be better than quitting later.

You are probably aware of the many programs, drugs, and therapies available to help smokers quit using nicotine entirely. And we very much hope that if you are a smoker and elect to quit entirely, that you are successful. But since you are reading this, it is likely that you or someone you know has tried to quit and failed, or wants to continue using nicotine but wants to reduce the risk.

[1.2] What are highly-reduced-risk nicotine products? - Smokeless tobacco, electronic cigarettes or pharmaceutical nicotine products.

The most popular highly-reduced-risk nicotine product is smokeless tobacco (ST), specifically modern Western moist snuff (the Swedish word for which is snus) and chewing tobacco. A newer and rapidly growing alternative product is the electronic cigarette. Another product category is pharmaceutical nicotine (such as nicotine gum, lozenges, patches, and inhalers). Someone who uses any of these products rather than smoking reduces the risks by around 99%.

[3] Isn't harm reduction a controversial idea? - Yes.

But it shouldn't be. 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 though people would be at less risk of disease if they just avoided sex or gave up narcotics entirely, we cannot really expect that to happen.

In general, harm reduction is also our policy in matters of health. Even though driving is dangerous, we don't suggest that people give it up. We do not even ask them to limit it to "necessary" trips. 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. (Harm Reduction reading list.)

[1.4] Can't I be 100% safe? - No.

If you find yourself dealing with someone who seems to be insisting that comparative risk does not matter - that a lot better is not good enough and therefore not worth pursuing - think about this.

Eating more fruits and vegetables reduces the risk of stomach and colon cancers and is beneficial in many other ways. Yet this too is not without its own dangers. There are a fair number of cases of foodborne disease that are traced to plant foods, some of which are fatal. People die from allergic reactions to fruits. Fruits and vegetables contain pesticides (some natural, some not) and other organic chemicals, heavy metals (calcium, lead), and even radioactive isotopes that probably sometimes cause cancers and other diseases.

Though you are much better off (or safer) eating more fruits and vegetables rather than less, it is not perfect. But, it is still very good.

[1.5] Can tobacco harm reduction really work? - Yes.

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 ST 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 happening in Norway right now, where ST 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.

The rapidly growing popularity of electronic cigarettes, a much safer nicotine source that is not even available in many brick and mortar stores, indicates that people are looking for alternatives.


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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