Harm Reduction in a Persistent Smoker

By David J. Riley, MD, FCCP

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Objectives

1. Describe the concept of harm reduction and how it may be applied to persistent smokers.
2. Inform readers about the newly introduced tobacco products with claims of being "safer cigarettes."
3. Discuss the evidence for tobacco harm reduction.
4. Describe the issues related to use of nicotine replacement products and antidepressants to reduce cigarette smoking.
5. Describe the public health issues involved in instituting a tobacco harm-reduction program.

Key words

COPD; lung cancer; harm reduction; nicotine replacement products; smoking; tobacco control

Abbreviations

CO = carbon monoxide; FDA = Food and Drug Administration; IOM = Institute of Medicine; SR = sustained release

Cigarette smoking continues to be the single leading cause of preventable death in the United States. Because of the addictive property of nicotine, only about 2.5% of smokers are able to quit for a year. Because of this low quit rate, more attention has been given to making cigarettes less risky. This policy, called harm reduction, aims at minimizing harms without completely eliminating tobacco or nicotine use. A harm reduction strategy is designed to complement the primary goals of smoking cessation, preventing initiation, and eliminating environmental tobacco smoke. It is designed to help the persistent smoker who cannot stop smoking by reducing exposure and thereby reducing risk of disease.

A recent development has prompted a closer look at harm reduction. Tobacco products with claims of being "less hazardous" than conventional cigarettes have been introduced in several US cities. These products are reminiscent of the filtered and low-tar brands promoted in the 1950s and 1960s by tobacco companies as being "safer." In reality, there was no evidence that these products were more safe than conventional cigarettes. Those claims of "less hazardous" went unchallenged by independent scientific evidence because traditional tobacco products in the US were unregulated.

This time, the introduction of new products with health claims has drawn a response from the Food and Drug Administration (FDA), which has authority to regulate products with health claims. If the tobacco companies make health claims that new tobacco products are "less hazardous" than conventional products, the FDA may have the authority to demand proof of the claim before the product can be marketed. In anticipation of this, the FDA requested that the Institute of Medicine (IOM) review the science base of harm reduction. The IOM issued its report, Clearing the Smoke: Assessing the Science Base of Tobacco Harm Reduction, in 2001.¹ As a member of the IOM Committee, I thought it appropriate to review the report and offer my opinions on the management of the persistent smoker. Note that my opinions may not necessarily reflect those of the IOM.

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