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Combusted tobacco products inhaled into the lungs are the greatest cause of health-related harms resulting from use of tobacco products. Though not welcomed by all tobacco control authorities, there has been support for including harm reduction strategies as one of the many traditional strategies for reducing the death and disability caused by tobacco use, particularly cigarette smoking. Nicotine, at the dosage levels smokers seek, is a relatively innocuous drug commonly delivered by a highly harmful device, cigarette smoke. An intensifying pandemic of disease caused or exacerbated by smoking demands more effective policy responses than the current one: demanding that nicotine users abstain. A pragmatic response to the smoking problem is blocked by moralistic campaigns masquerading as public health, by divisions within the community of opponents to present policy, and by the public-health professions antipathy to any tobacco-control endeavors other than smoking cessation. Yet, numerous alternative systems for nicotine delivery exist, many of them far safer than smoking. A pragmatic, public-health approach to tobacco control would recognize a continuum of risk and encourage nicotine users to move themselves down the risk spectrum by choosing safer alternatives to smoking — without demanding abstinence.

In efforts aimed at reducing the risk of death, injury or disease from any behavior there are four broad areas of possible intervention. These include efforts to prevent the behavior ever taking place, efforts aimed at ending the behavior, efforts aimed at preventing the activity from harming third parties and efforts aimed at reducing the risks of those who engage in the behavior. The interaction of these four pillars of public health intervention can be seen in everything from pharmaceutical policy, the rules of sport, automobile regulation, workplace safety standards and food processing and preparation regimes. Interestingly, when dealing with issues of sexual behavior and the use of licit and illicit drugs there is often strong opposition to efforts aimed at the reduction of risks among those who will engage in the behavior in question. This schism appears to be the result of a persistent tension between a rational, scientific program and a behavioral, moralistic approach

The conflict over means traces to a fundamental disagreement about aims: Is the purpose of an intervention to make people healthier or safer? Or is it to create better moral souls, to make people less “bad”? The availability of ‘risk reduction’ among accepted interventions can be seen as a key distinguishing feature between scientific public health interventions whose aims are pragmatic, and moralistic ones, whose aims are impossible to measure. If the goal of public policy interventions on tobacco is to achieve the greatest possible reduction in deaths, injury and disease, then it is necessarily pragmatic. Therefore, it is necessary for policy makers to seriously consider the role of risk reduction for continuing users of tobacco/nicotine products. This does not mean that risk reduction strategies must replace other strategies any more than protection of third parties needs to replace cessation strategies. An ideal public health approach rationally combines the various possible interventions in pursuit of the greatest achievable reduction in deaths, injuries and disease. It is estimated that cigarette smoking resulted in the deaths of roughly 100 million people in the last century, and that at current trends in consumption will kill 10 times that many this century. Roughly half of long-term smokers will die as a direct result of diseases caused by their smoking, and half of those deaths will occur during middle age. In terms of drug related deaths cigarettes dwarf the toll from other drugs. The primary reason for smoking cigarettes is to obtain nicotine. The cigarette is an effective — but almost uniquely hazardous — delivery device for the drug, nicotine. As with the use of other drugs the pursuit of nicotine can be attributed to a combination of recreation, addiction and self-medication. The extent of each of these motivations will vary over time and between smokers just as the reasons behind the pursuit of alcohol or caffeine will vary between consumers and change over time. We stress that nicotine is the primary cause of tobacco consumption. But it is not the nicotine that causes the harm: the inhalation of tobacco smoke is responsible for the pandemic of cancers, heart disease, respiratory diseases and other deadly results of tobacco consumption. Nicotine itself is comparatively benign. A fatal dose of nicotine would require roughly 60 mg for an average person, but, as with a fatal dose of caffeine, such a quantity is far more than is sought or attained by consumers.

In Sweden a smokeless tobacco product known as ‘snus’ has come to dominate the tobacco market, with sales rising as cigarette sales have fallen. Many former smokers have switched to snus, far more males use snus than smoke, and snus sales amongst females — which had long lagged male usage — is now evidently growing rapidly. As a result, Sweden has the lowest level of tobacco related disease in males among OECD countries, and has reported male smoking prevalence that has now hit single digit percentages in parts of the country.

As more alternatives to conventional cigarettes are considered, it is clear that there is a wide range of possibilities on the continuum of risk. The variation of risk among interchangeable products creates a strong basis for regulatory intervention aimed at shaping the market. It should also be the basis for accurate communications to consumers. The fact that alternative products can meet the needs of some significant number of those who would likely otherwise smoke cigarettes also raises key issues about just what sort of products might be available, what sort of information consumers can be given about relative risks and what sort of policy environment could achieve maximum public health bene- fits through the greatest transition of smokers to less toxic alternatives. The critical issue in looking at consumer safety, and one that makes tobacco/nicotine an ideal area for harm reduction interventions, is that smokers are capable of moving down the risk continuum when offered alternative products and accurate information on relative risks. A pragmatic goal would be to move current smokers as far down the continuum of risk as possible, without depriving consumers of all choice. The consumer who rejects (or cannot achieve) abstinence but will use a product that reduces risk by 90% should not be prevented from making that preferred choice. Indeed, it is exactly the forced choice between smoking and abstinence that reinforces the current dominance of cigarettes.

The Department of Health (UK/England) has committed itself to tobacco harm reduction. It endorses the important role of electronic cigarettes for smokers who are otherwise unable to quit.

‘The best thing a smoker can do for their health is to quit smoking. However, the evidence is increasingly clear that e-cigarettes are significantly less harmful to health than smoking tobacco’. Department of Health United Kingdom.

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