Harm Reduction in a Persistent Smoker

By David J. Riley, MD, FCCP

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The IOM Report

The Committee's charge was not to recommend whether or not tobacco harm reduction should be pursued, but to formulate scientific methods and standards by which potentially harm-reducing products could be assessed. Potentially harm-reducing products are tobacco products or pharmaceuticals developed for their harm-reducing potential. The major conclusions of the IOM Report are shown in Table 1. A key conclusion was that it is "feasible" that reducing exposure to tobacco toxicants may reduce the risk of diseases attributable to tobacco use. Little is known about the health effects of using these products, however, and it will take many years to collect and analyze data on their effects. Until adequate data are available, the Committee called for new regulations of these new products as well as existing products. The report did not discourage cigarette manufacturers from developing potentially harm-reducing tobacco products. A harm-reduction claim was to be permitted, however, with the qualifier that "the 'substantial reduction' in exposure should be sufficiently large that independent scientific experts would anticipate finding a measurable reduction in the morbidity and/or mortality in subsequent clinical or epidemiological studies."¹ The report distinguished between harm reduction for a population and risk reduction for an individual. It is possible to have reduced risk in individuals but no reduction in harm in a population. This distinction is important because a health claim would only be permitted for demonstration of reduction in harm, not simply risk reduction in individuals.

The Committee recognized the possibility that aggregate harm from tobacco products might be increased if the public believed "safer" products were available. It is possible that smokers who would otherwise quit might not quit, exsmokers might resume smoking, or nonsmokers might begin to smoke. If these effects outweigh reduced risk to individuals, total harm to the public would be increased. In view of this, the Committee called for future research to include basic, clinical, and epidemiologic studies to establish whether potentially harm-reducing products cause less harm to individuals and populations. To permit valid comparisons with conventional tobacco products, it was recommended that epidemiologic studies be implemented as a part of a comprehensive tobacco-control program. To accomplish tobacco control, regulation of existing products was considered essential. In summary, the IOM Committee concluded that harm reduction is a feasible and justifiable public health policy but to be implemented only if regulation and surveillance are in place to allow risk assessment.

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