Tobacco harm reduction (THR), the substitution of low-risk nicotine products for cigarette smoking, is increasingly recognized as offering huge public health benefits. Smoking is well known to be a very hazardous activity, but the main reason why people smoke - nicotine - does not itself cause much risk when separated from inhaling smoke. Extensive epidemiology shows that the use of Western oral smokeless tobacco (ST) causes a trivial fraction of the mortality risk from smoking, and it is believed that electronic cigarettes and pharmaceutical nicotine products (gums, patches, lozenges) have similarly low risks. Many smokers will keep smoking until they die from it because, when given only the options of smoking or completely giving up nicotine, many will not give it up. But many of them probably could be persuaded to switch to a low-risk source of nicotine, and the health benefits would be almost as good as quitting entirely.
Readers interested in background on THR that is beyond the present scope, including quantifications of its potential benefits and reports of past successes, can find them in our website , in various overview papers (Phillips CV, Heavner K, Bergen P. Tobacco - the greatest untapped potential for harm reduction. Submitted, Available at: http://www.tobaccoharmreduction.org/wpapers/006.htm) [2, 3], and in endorsements by British and American medical organizations [4, 5]. Other relevant contributions to the issue include studies that allow estimates of the potential benefits (Geertsema K, Phillips CV, Heavner K. University Student Smokers' Perceptions of Risks and Barriers to Harm Reduction, Submitted, Available at: http://tobaccoharmreduction.org/wpapers/001.htm) [6, 7], estimates of how much THR has already been employed in the past in the U.S. , and how it has largely succeeded in Sweden, where ST has substantially replaced smoking, resulting in the lowest tobacco-related disease rates in the Western world [9, 10].
Stated estimates for how much less risky ST is compared to smoking vary somewhat, but the actual calculations put the reduction in the range of 99% (give or take 1%), putting the risk down in the range of everyday exposures (such as eating french fries or recreational driving), that provoke limited public health concern . Even this low risk is premised on the unproven assumption that nicotine causes small but measurable cardiovascular disease risk (as do most mild stimulants such as decongestant medicines, energy drinks, and coffee), since such risks account for almost all of the remaining 1%. Perhaps just as important, even a worst-case scenario puts the risk reduction at about 95%, meaning that any scientifically plausible estimate shows THR has huge potential health benefits. There is no epidemiology for the new electronic cigarettes and very little useful epidemiology for assessing long term use of pharmaceutical nicotine products. But since most of the apparent risk from ST comes from nicotine, and the other ingredients in the non-tobacco products are believed to be quite benign, we can conclude that the risks across these product categories are functionally identical from the perspective of THR.
Because it is not necessary to distinguish among product categories for purposes of the present analysis, a collective description, THR products, is used. Product preferences vary and many smokers become attached to aspects of the smoking experience, including the aesthetics (flavor, smell, mouth and airway feel) and social behaviors for which no other product is a perfect substitute. The variety of THR products increases the chance that a given smoker will find one of them a sufficiently good substitute for smoking.
Harm reduction is a generally accepted public health principle that recognizes that eliminating an exposure is often not practical, welfare maximizing, or ethical, and so we should endeavor to reduce the harm from the exposure. The best example is encouraging the use of seatbelts without trying to curtail exposure to automotive transport. However, for politically controversial exposures (e.g., injection drug use, sexual activity outside of marriage, tobacco use) opponents of harm reduction often try to defend their beliefs that "just say no" (abstinence only) is the only acceptable option by observing that "lower risk does not mean no risk". But in the absence of quantification, this observation is merely a trivial vocabulary lesson, not a useful contribution to decision making. The present analysis offers a quantification that illustrates how a 99% reduction in risk is so close to zero risk that the "let's wait and see if we can do even better than current low-risk options" attitude is clearly killing more people than it could ever save. Rational decision strategies call for taking advantage of existing knowledge at some point, rather than continuing to search. If a risk is low enough, it is obviously better to accept that risk than to stick with high risk levels hoping that a way to achieve even lower risk will be discovered.
Harm reduction is particularly compelling for the use of nicotine because so many people have such a strong propensity for using it. Nicotine is a very beneficial drug for many people, providing alertness, focus, pleasure, and relief from a variety of psychological symptoms and pathologies. A substantial fraction of the population gets these benefits by smoking even though the health costs are so high, which means that demanding they quit entirely entails great welfare costs and is not likely to work.
Smoking can be described compellingly in terms of normal welfare economics, such that the consumer is maximizing his welfare by choosing among the available options (smoke or not smoke). Both choices have costs and benefits, and some consumers judge that the benefits of smoking outweigh its very high costs. However, for many such smokers, the possible reduction in benefits from switching to a less-enjoyed product would be greatly outweighed by the reduction in costs from health risks, so knowing about the benefits of switching to a THR product would be tremendously beneficial. Alternatively, it is often implicitly argued that smoking behavior does not conform to rational choice theory: Smokers do not choose smoking from among their options, but rather "addiction" (a rather slippery concept which is seldom actually defined, but is still widely invoked and accepted) or some related phenomenon prevents smokers from being able to choose to be abstinent. In that case, THR offers a health benefit that is not going to be achieved by choosing abstinence, and thereby also provides a great welfare benefit. Thus, either of these models of individual behavior leads to the same conclusion: Many people who are faced with the dichotomous choice of smoking and abstinence will not just quit, and many of them would be better off using nicotine in a low-risk form. Therefore, whether one believes that smokers are making a rational welfare-maximizing choice or are victims of a curse, THR makes sense from the perspective of both individual welfare and public health. (Further exploration of the policy-ethics arguments surrounding promotion of THR can be found in the collection of papers at http://www.tobaccoharmreduction.org/wpapers/010.htm.)
It might seem surprising that something as promising as THR is largely unknown and unimplemented as a policy. Much of the problem is that people (smokers, health educators, policy makers) hear the messages that THR products are not safe, that "all tobacco is deadly", and "the only safe choice is to quit entirely". This convinces people that THR either is not possible at all or represents only a marginal improvement that is not worth pursuing. Still, this begs the question of why anyone would choose to deliver the message that a 99% reduction in risk is almost as bad as continuing to smoke, rather than the obviously more accurate message that it is almost as good as quitting entirely. Answering this is useful for understanding the significance of the analysis presented here.
Why analyses like this one are needed
The discourse surrounding tobacco policy and education is dominated by people who pursue the most extreme possible goal regarding tobacco: unconditional elimination of its use. Explicit statements of that goal are very common. Their goal is not to design tobacco policies that maximize human welfare or even that maximally reduce physical health costs. Any such concerns are, at best, secondary to the goal of simply reducing consumption of all forms of tobacco, and usually also reducing any long-term self-administration of nicotine that has been extracted from the tobacco (i.e., electronic cigarettes and pharmaceutical products). Thus, while getting smokers to switch to using ST represents an almost perfect success from the public health perspective (and is even more attractive from the human welfare perspective), it represents little or no progress for someone pursuing the goal of unconditionally eliminating tobacco use from the world. Presumably those who believe that eliminating tobacco is the appropriate goal would not dispute this. With this in mind, it is much easier to understand why some people reject a 99% reduction in risk as not worth pursuing: reducing risk is not the major factor in their objective function.
(This, of course, does not address the question of why anti-tobacco extremists are motivated to pursue this goal. Exploring possible explanations is beyond present scope (they are discussed in a bit more depth in Phillips, Heavner & Bergen (Phillips CV, Heavner K, Bergen P. Tobacco - the greatest untapped potential for harm reduction. Submitted, Available at: http://www.tobaccoharmreduction.org/wpapers/006.htm)). The list includes: the economically absurd belief that nicotine products provide no benefits and thus no one really wants to use them, usually closely tied to the paternalistic notion that the activists are better able to determine what people really want than the consumers themselves; an irrational hatred of companies who make nicotine products (often with the exception of pharmaceutical companies who many anti-tobacco activists are closely allied with); the common drug-war mentality of wanting to purify everyone and considering users to be sinners; and simple involvement of individual ego, whereby the goals becomes about winning the race and defeating the opponent, without ever admitting that their strategy may not have been optimal, rather than trying to develop humane, rational, practical policies.)
Understanding this is critical because those pursuing the extreme anti-tobacco agenda are often thought to have risk reduction as their primary objective, and take advantage of this by making dozens of health risk claims. It is, of course, people's right to hold the political opinion that we should work toward eliminating all tobacco use, regardless of how pursuing that goal would affect people's welfare and health, and it is those advocates' right to campaign for their goal. The ethical problems and public confusion result when the primary goal is eliminating tobacco, but the rhetoric mostly consists of claims about health. When such a disconnect occurs, the claims are merely rationalizations or attempts to persuade those who might not be persuaded by the true goal, rather than representing true underlying motives. When the language of science is used to rationalize rather than analyze, the probability is high that the science will degenerate into pseudo-scientific rhetoric.
None of this should come as a great surprise given the history of other abstinence-only agendas presented in the guise of public health. It has long been accepted by the public health community that harm reduction strategies for illicit drug use, from needle exchanges to education about the advantages of moderation, save many lives. Nevertheless, anti-drug warriors who support a "just say no"-only strategy frequently try to shut down programs that promote harm reduction. Their explicit argument is never "those criminals deserve to die if they do not quit using drugs, so we should not try to lower their risk"; in fact, their public argument is often based on inaccurate claims that the harm reduction strategies increase risk. Similarly, it has been known for decades that abstinence-only approaches to sex education in the West produce inferior health outcomes compared to balanced harm-reduction-oriented education, combined with product and service provision. Activists who persist in claiming that promoting only sexual abstinence is health-improving seem to not be concerned with health so much as they are just annoyed that people are enjoying sex outside of marriage.
The politics and rhetoric of the abstinence-only approach to nicotine use have much in common with these other abstinence-only approaches, but this is not yet widely recognized. As a result, many people who are genuinely motivated by promoting personal and public health, and do not share the extreme anti-tobacco agenda, often believe the inaccurate health claims that are really rationalizations for the anti-tobacco position. Since this often is to the detriment of both public health and the scientific legitimacy of the health sciences, it is important for the public health and scientific communities to debunk these claims.
Debunking these claims is a difficult challenge. Anti-THR health claims are typically speculation or assertion, without the support of evidence or analysis, and thus actual scientists will immediately relegate them to the realm of, at best, speculative hypothesis. But it is easy to take advantage of laypeople's tendencies to accept at face value all manner of urban myths and other misconceptions, and to demand scientific proof that the claim is wrong . Endeavoring to disprove a long list of assertions is far more difficult than making up those claims in the first place. Indeed, the sheer number and ever-changing nature of those claims is further evidence of attempts to rationalize a pre-determined conclusion, not an exploration of real reasons: Generally when someone shops different claims to various populations to see which changes their behavior in the preferred way, we call it marketing, not science, education, or ethical public health policy.
Methods of responding to misleading claims
But though trying to disprove unsubstantiated claims is not considered necessary in scientific thinking and is obviously an epistemic nightmare, it is necessary to advance public health policy. Advocates of THR have endeavored to debunk some of the most erroneous anti-THR claims. Some claims have been debunked by simply pointing to existing scientific literature (e.g., claims that ST use causes substantial disease risk are contradicted by decades of epidemiologic evidence to the contrary). Some claims have required new directed empirical work (e.g., the claim that promoting THR would create a "gateway" to smoking required focused empirical research and analysis to debunk). Still others are hypothetical scenarios that require an analytic approach to show they are misleading or of minor consequence.
An example of such analysis is the debunking of the claim that if we allow smokers to learn that they have low-risk alternative sources of nicotine, then many people who might have had zero risk from consuming nicotine (because they would have quit entirely or not started) will choose to consume ST or pharmaceutical nicotine and suffer some small risk. This will, the claim goes, increase total population risk. But when it is demonstrated that net social risk could not conceivably increase in this manner, anti-THR activists sometimes counter with a second assertion: Even though total population risk will decrease, there are many smokers who would have quit nicotine entirely but instead switch to a low-risk product, and they will suffer greater risks than they otherwise would, and that this constitutes an argument against THR. Debunking this requires the additional analysis presented below.
One might argue that the ethical considerations make quantifying this claim irrelevant. The leading deontological tenet of modern health ethics is the obligation to provide people with accurate information so they can make informed autonomous decisions about their own health. Thus, whatever one might think about actively promoting THR as public policy, it is per se unethical to mislead people in order to manipulate their health behavior, even if it is "for their own good" (Phillips CV. The affirmative ethical arguments for promoting a policy of tobacco harm reduction. Submitted, Available at: http://www.tobaccoharmreduction.org/wpapers/010.htm). In other words, preventing a smoker from learning about a low-risk alternative, even if he is about to quit entirely, is clearly unethical. Moreover, a consequentialist analysis reveals that someone who chooses to forgo nicotine because of the high cost of smoking but, upon learning of a low-risk way to consume nicotine, chooses to consume low-risk nicotine must have concluded that the net welfare benefits of consumption (the benefits of nicotine, net of the health and other costs) are positive, even though the net benefits of smoking were negative. Therefore misleading people about the option necessarily has net negative welfare impact (Phillips CV. The affirmative ethical arguments for promoting a policy of tobacco harm reduction. Submitted, Available at: http://www.tobaccoharmreduction.org/wpapers/010.htm).
Nevertheless, some observers are unconcerned with these ethical arguments. More importantly, the claim brings up an interesting analytic question that is worth answering even apart from the politics of THR: In terms of physical health risks, someone who keeps smoking is clearly worse off than someone who switches immediately, who in turn is probably slightly worse off than someone who immediately quits entirely. But how long would someone have to keep smoking before his health risks would have been lower had he just switched today and used low-risk nicotine for the rest of his life? Or, equivalently, how much time can pass while powerful interests vilify THR products while waiting for theoretical perfect alternatives to emerge before that delay kills as many people as using THR products ever could? For anyone who is primarily concerned about maximizing health outcomes (even apart from rights to autonomy or welfare maximization), the answer to these questions should make it clear that THR should immediately be embraced using currently available alternative products.