Canadians Who Care About Tobacco Harm Reduction

Toronto’s Non-Smokers’ Rights Association has just become the first Canadian organization to endorse tobacco harm reduction. Together with the Smoking and Health Action Foundation, the NSRA published “Harm Reduction in Tobacco Control: What is it? Why should you care?”

The report (available here) is an accurate and balanced discussion of the issue. It describes smokeless tobacco products (including Swedish snus) and e-cigarettes, and it makes the following recommendations:

1. “Establish a regulatory framework for nicotine products.”

In theory, this is a reasonable approach; a regulatory agency could evaluate all tobacco and nicotine products with consistent criteria. The report suggests that “…availability, price/taxation, and permitted forms of promotion should all be related to the level of risk inherent in their use.” It is unfortunate that American legislation giving the FDA authority over tobacco contained no provisions for regulating tobacco products according to risk.

2. “Shift current tobacco users to the least harmful nicotine product – [pharmaceutical] nicotine replacement therapy.”

The report recommends that smokers be given accurate information about nicotine, specifying that it “is not the harmful substance in cigarettes.” It also points out that pharmaceutical nicotine should be made more affordable and accessible.

3. “Shift smokers who are unable to quit or unwilling to make a quit attempt to a less harmful product – snus.”

The report strongly counsels against misinforming smokers: “The public has the right under Canadian tort law to accurate information about the relative risks of using tobacco products and to make choices based on the facts. The current warning on smokeless tobacco products, ‘This product is not a safe alternative to smoking,’ is woefully inadequate as it provides no information regarding relative risks.

“Governments and health organizations must improve messaging, both on the product and in other media, about the relative risks of cigarettes, smokeless tobacco products, and non-tobacco nicotine products to ensure that the public is better informed and does not rely on tobacco companies for risk information.”

Although NSRA doesn’t trust tobacco manufacturers, it’s ironic that governments and health organizations are now the dominant sources of inaccurate risk information.

4. “Monitor the impact of alternative nicotine products.”

The report calls on “Health Canada and or other government authorities” to “conduct post-market surveillance of the promotion…” and “health impact of alternative nicotine products” like e-cigarettes, as well as safer smokeless alternatives. That’s a reasonable requirement. In comparison, the U.S. FDA legislation requires manufacturers of safer tobacco products to prove that they will have no population effect BEFORE they are marketed (described here).


The NSRA joins three other respected professional organizations in endorsing tobacco harm reduction. In 2006, the strategy was endorsed by the American Council on Science and Health, whose mission is to promote sound science in regulation and in public policy and to assist consumers in distinguishing real health threats from purely hypothetical ones. Throughout its history, ACSH has published many articles about the health risks of smoking, and it has held the tobacco industry accountable for its role in the devastating toll from tobacco. In the late 1970s, ACSH founder Elizabeth Whelan published a landmark anti-smoking book, A Smoking Gun: How the Tobacco Industry Gets Away with Murder. More information is available here.

In 2007, Britain’s Royal College of Physicians, one of the oldest and most prestigious medical societies, strongly endorsed tobacco harm reduction. The Royal College concluded “…that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved… Harm reduction is a fundamental component of many aspects of medicine and, indeed, everyday life, yet for some reason effective harm reduction principles have not been applied to tobacco smoking.” The Royal College report is available here.

In 2008, the American Association of Public Health Physicians became the first U.S. medical organization to formally adopt a policy of “…encouraging and enabling smokers to reduce their risk of tobacco-related illness and death by switching to less hazardous smokeless tobacco products.” Their report is available here.

It is gratifying to see the sound medical principles of tobacco harm reduction being adopted by the broader public health community.

Public Library of Scientific Shame

Last week the journal PLoS Medicine announced that it will not accept for review any research studies funded in whole or part by the tobacco industry. PLoS stands for Public Library of Science, “a nonprofit organization of scientists and physicians committed to making the world's scientific and medical literature a freely available public resource.” But PLoS Medicine’s action restricts the availability of scientific and medical research.

PLoS Medicine joins only the journals of the American Thoracic Society in banning tobacco industry-sponsored research. Still, this is an ominous development that potentially affects scientific research at universities throughout the U.S.

PLoS Medicine used standard rhetoric in defending its ban. “First, tobacco is indisputably bad for health.” This is an incredible admission that the journal editors don’t understand anything about smokeless tobacco and health risk. Further, as noted by Jeff Stier of the American Council on Science and Health, “By deciding to no longer allow for research funded in any part by the tobacco industry, [journal editors are] acknowledging that they're no longer able to evaluate science.”

PLoS Medicine editors know that virtually all university research projects are funded by sponsors with vested interests. This includes pharmaceutical manufacturers, the National Institutes of Health and non-profit organizations like the American Cancer Society. It is the responsibility of the university to ensure both the quality of the research and the integrity and reputation of faculty investigators. While some controversial funding sources might warrant special scrutiny, the solution isn't prohibition. In fact, banning tobacco industry funded research and its publication is a pernicious development. Right now it's Big Tobacco. But what about activists who believe that the devil's work is carried out by Big Oil, Big Alcohol, Big Pharma, Big Defense, Big Auto and Big Food? All of these are controversial industries and sources of research funding. Universities are already threatened by declining state and federal support. If PLoS Medicine’s ban is followed by other journals, university faculty and their research programs will become the pawns of social activists of all stripes.

Is PLoS Medicine’s ban of industry-funded research also applicable to the American Legacy Foundation? Legacy was created and funded by a multi-billion dollar voluntary settlement between tobacco manufacturers and states’ attorneys general in 1998. Legacy is worth over a billion dollars; it has given out over $150 million in grants, and it funds the Schroeder Institute for Tobacco Research and Policy Studies . There is no doubt that Legacy is funded by the tobacco industry; will Legacy-supported research studies be banned from PLoS Medicine?

A university’s faculty must be free to pursue research regarding all legitimate subjects, pursue research funding from all legitimate sources, and publish findings in all legitimate scientific and medical journals. By bending to the whims of social and political activists, editors at PLoS Medicine have discredited their journal.

Nonsense from the American Cancer Society

Last week, the New York City Council voted to ban all flavored tobacco products. While the ban excludes menthol cigarettes, it effectively prohibits many smokeless tobacco products that are vastly safer alternatives to cigarettes. This action means smokers who wish to quit without abstaining from nicotine will have fewer options available. That’s perfectly acceptable to tobacco prohibitionists, who claim that the law will prevent smoking by children, even though adolescent smokers overwhelmingly prefer unflavored cigarettes (see my post on flavored products, here).

On October 16, Jeff Stier, associate director of the American Council on Science and Health, wrote a commentary in the New York Post that was justifiably critical of the ban. Stier observed that smokeless tobacco and e-cigarettes “are noncombustible, eliminating almost all smoking risks. They could be a lifesaver; the only reason to crack down is the ideology of the public-health movement, which has decided that anything that has tobacco in it, or even looks like a cigarette, must be illegal, even for sale to adult smokers trying to stop smoking.” Stier concluded that these types of “government actions will do nothing to protect kids. The only effect is to promote the most dangerous form of tobacco use, smoking cigarettes.” Stier’s comments reflect ACSH’s position as a relentless opponent of smoking, but a strong supporter of tobacco harm reduction.

On October 22, the American Cancer Society responded to Stier with a letter to the Post from Clare Bradley, Chief Medical Officer of the Eastern Division. What Dr. Bradley said was pure nonsense.

Dr. Bradley claims that “using snus does not eliminate the risk of lung cancer. Smokers who use smokeless tobacco as a supplemental source of nicotine in an effort to quit smoking actually increase their risk of lung cancer.” Is it possible that a Cancer Society official actually believes that smokeless tobacco increases the risk for lung cancer?

Dr. Bradley’s prescription for smokers desperate to quit: “The best way to quit smoking is not to start.” She tells smokers who may not be able to accomplish that task that “nicotine-replacement therapy [NRT], when paired with a program to help change behavior, is a proven cessation method.”

What is “proven” about NRT is that it works for only 7% of smokers who try it.

By opposing tobacco harm reduction, the American Cancer Society is working against the health and welfare of smokers.