In late January the
New England Journal of Medicine published
a ringing endorsement of tobacco harm reduction (
here).
The authors of “Smoke, The Chief
Killer – Strategies for Targeting Combustible Tobacco Use, are Michael Fiore
and Timothy Baker from the University of Wisconsin, and Steven Schroeder from
the University of California San Francisco.
In the past, they strongly opposed the
adoption of safer cigarette substitutes.
Fiore and colleagues acknowledge that it’s the smoke that
kills: “…research now quite clearly highlights the specific harms of combustible
tobacco use (cigarette, pipe, and cigar smoking): given that up to 98% of
tobacco-related deaths are attributable to combustible products, the net harms
of these products, including harms from secondhand smoke, dwarf those of other
forms of tobacco use (e.g., smokeless tobacco).”
The authors are not referring to research that has just been
published “now.” Rather, the
anti-tobacco establishment is just “now” acknowledging the fact that the risks
of burning tobacco “dwarf” those of smoke-free forms.
Fiore et al. acknowledge the failure of all conventional
cessation options: “…current smoking-cessation treatments fail for the majority
of smokers who use them…”
More importantly, they move on to a surprising endorsement
of smoke-free tobacco: “One opportunity afforded by today’s changing landscape
lies in the diverse alternative nicotine delivery vehicles available to
smokers. Evidence shows that all the noncombustible
delivery vehicles are substantially less dangerous than combustible tobacco
products, though that’s not to say that they are all totally safe. Noncombustible forms include multiple
nicotine-replacement therapies (NRTs) as well as smokeless tobacco (e.g., snus)
and the electronic cigarette.”
To be fair, Fiore and colleagues also devote a lot of
attention to conventional approaches. However, the change in attitude toward tobacco
harm reduction is seen in their advice to clinicians:
1. Advise patients
that any tobacco product has risks, but that combustible tobacco is “by far the
most harmful.”
2. Counsel them to
quit any tobacco product using the conventional methods.
3. Try to get them to
smoke fewer cigarettes.
4. ADVISE PATIENTS
WHO ASK ABOUT E-CIGARETTES THAT “THESE DEVICES ARE PROBABLY MUCH SAFER THAN
COMBUSTIBLE TOBACCO PRODUCTS.” (emphasis added)
Finally, after expressing some e-cigarette gateway concerns,
Fiore finishes with a strong message:
“Furthermore, we need to communicate intelligently about
harm reduction: not all nicotine-containing products are equal, and the public
health focus should be on eliminating combustible tobacco products, even if
some people who give up combustibles will continue using FDA-approved
medications, e-cigarettes, or smokeless tobacco products indefinitely…New
approaches must be adopted if we are to dramatically reduce the harms of
tobacco use in the United States over the next decade. To achieve this goal
requires that we recognize the unequaled dangers resulting from combustible
tobacco use.”
The commentary is accompanied by an audio interview with
Matthew Myers (
here), president of the Campaign for Tobacco-Free Kids and one of the most aggressive
opponents of tobacco harm reduction.
While promoting cherished topics like increased state funding for
tobacco control and an FDA-imposed menthol ban, Myers offers positive comments
on tobacco harm reduction that are truly transformative.
Here are some excerpts:
“We all continue to look for ways to get people to quit
smoking cigarettes, the most dangerous product.
And e-cigarettes on the surface appear to hold potential to be another
tool to do so. One of the reasons that
you see so many people interested in e-cigarettes is that, while current
FDA-approved smoking cessation aids are shown to be effective and increase the
likelihood of someone being able to quit, the success rates aren’t what anyone
wants them to be.”
“But there will still be some patients, for certain, who,
even after being provided that advice [on FDA-approved methods], they either
don’t want to quit or they have been unable to quit…in those cases a physician
should make an individual judgment whether or not smokeless tobacco or an
e-cigarette might assist that individual.
In other words, we should keep trying, until that person actually
quits.”
“What I would most like to see is the FDA take all the steps
it can to maximize the extent to which it discourages the use of cigarettes,
the most deadly products, and to encourage the use of FDA-approved cessation
devices and other nicotine that is delivered safely without causing the kind of
deaths and disease we’ve seen.”
With this change in disposition among long-term
obstructionists, tobacco harm reduction is gaining real momentum.
