Principles of tobacco harm reduction (THR)
Cigarette smoking is the single most preventable cause of disease in the United States. It has been associated with a number of diseases, including cancer and heart disease.
For more than 50 years, a range of efforts and strategies have been deployed to encourage smokers to quit and to discourage smoking initiation. As a result of those efforts, smoking rates have reached historic lows among adults and youth. Specifically:
- Adult smoking has declined significantly from 42.4 percent at its peak to 17.8% (1965-2013); and
- Prevalence of current cigarette use by high school students has dropped from 15.8% to 9.2% (2011-2014).
However, the rate of decline for both adults and high school age youth has slowed. Moreover, some 42.1 million Americans continue to smoke despite near-universal awareness of the health risks associated with cigarette smoking.
Tobacco-control programs have traditionally relied on strategies intended to reduce the number of people who start smoking and encourage those who smoke to quit. More recently, some members of the public health community have advocated that tobacco harm reduction (THR) be included as part of a more comprehensive strategy for reducing the health risks associated with cigarette smoking.
THR and science
Harm reduction encourages public health initiatives that have the potential to decrease the harm associated with a particular behavior without necessarily eliminating that behavior. That is not to say that the alternative behavior does not pose some risk; it is that the behavior poses less risk.
Examples of public health programs seeking to minimize the impact risky behaviors have on society include alcohol use (e.g., minimum age laws, designated drivers, limiting store hours/locations), road safety laws and needle exchanges for intravenous drug users.
Given the success of harm reduction strategies with these other behaviors, a number of scientists and public health officials are embracing tobacco harm reduction as an additional tool to reduce the harm associated with cigarette use.
In general, the use of smokeless tobacco products has been shown to present less risk than does the use of cigarettes; therefore, they may play a valuable role in reducing tobacco consumers' risks.
For example, in 2004 a nine-member panel of experts selected based on their knowledge of the health risks associated with both smokeless tobacco and cigarette use concluded that the risks associated with using low-nitrosamine smokeless tobacco products were substantially less than those associated with smoking. Overall, the panel found that using smokeless tobacco products instead of cigarettes reduced health risks by at least 90 percent. The risk of lung cancer among smokeless users as compared to smokers was found to be reduced by 100 percent.
The panel also found that the risk of oral cancer associated with using smokeless tobacco products is much lower than that of smoking. Since many Americans believe that smokeless tobacco use presents equal or greater risk of contracting oral cancer than cigarette smoking, it's important to note that the panel actually found the risk associated with oral cancer among smokeless tobacco users to be about 70 to 85 percent lower than that of cigarette smokers.
This research and other studies indicate that it is the combustion of tobacco (i.e., cigarette smoking) rather than the nicotine that exposes tobacco consumers to the most risk.
Other studies support the use of smokeless tobacco as a way to obtain nicotine rather than smoking. A 2007 report from the Royal College of Physicians states that it is the process that one goes through to get nicotine, not the nicotine itself, that determines risk levels.
These researchers similarly concluded that, depending on the product, smokeless tobacco was on the order of 10-1,000 times less hazardous than cigarette smoking; and, if nicotine could be provided in a form that was acceptable and effective as a cigarette substitute (e.g., smokeless tobacco), millions of lives could be saved.
These and other researchers suggest the existence of a pronounced "continuum of risk" of tobacco and nicotine products.
Tobacco Harm Reduction and public policy
In 2008, the American Association of Public Health Physicians noted that the addition of tobacco harm reduction to current policies "…could yield a 50% to 80% reduction in tobacco-related illness and death over the first ten years, and a likely reduction of up to 90% within 20 years."
For their part, government health agencies and many tobacco control organizations have not endorsed tobacco harm reduction as a viable addition to existing abstinence policies, leaving the status quo in place.
It is a Guiding Principle for RAI and it operating companies that governments, public health officials, tobacco manufacturers and others share a responsibility to provide adult tobacco consumers with accurate information about the various health risks and comparative risks associated with the use of different tobacco and nicotine products.
RAI's operating companies are committed to engaging with the Food and Drug Administration on the issue of tobacco harm reduction and education. Discussion about the shaping of appropriate tobacco harm reduction policies can also extend to legislative arenas.
Legislative opportunities to improve public health and reduce state health-care costs may present themselves as revenue bills. For example, policy makers could consider modifying the tax structure on tobacco products based on their comparative risk. Another possibility is exploring whether states could "tier" health insurance rates for state employees who use tobacco based on comparative risk of the form of tobacco used, potentially reducing state employees' health care costs. At a minimum, legislators should be challenged to explore the enormous potential that tobacco harm reduction could have for society.
RAI and its operating companies are committed to significantly reducing the death and disease caused by smoking. By embracing tobacco harm reduction principles and working with manufacturers, policy makers could herald a new era that fundamentally changes the impact of tobacco use on society. Today, public policy leaders and companies like RAI have a unique opportunity to lead that change.