Harm Reduction in a Persistent Smoker

By David J. Riley, MD, FCCP

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Commentary on Tobacco Harm Reduction

Managing the persistent smoker is a challenge because almost no data exist to guide the clinician on whether reducing smoking reduces risk. Controlled laboratory studies suggest that potential harm-reducing products might decrease exposure to tobacco toxicants. However, decreased exposure does not necessarily lead to less harm as measured by morbidity and mortality. Clearly, cessation is the only way to confidently assure the patient of risk reduction. If harm reduction is recommended, the practitioner is obligated to inform the patient that no scientific data support this approach. As a practical matter, I prefer that the clinician devote his or her effort to smoking cessation rather than harm reduction. This may require using an aggressive approach combining nicotine replacement products, antidepressants, and counseling. The FDA has approved these pharmacologic products only for smoking cessation to be used for no longer than 3 months. It is intuitively appealing, however, to believe that reducing the amount smoked can lead to less risk from cigarettes. Based on this, some clinicians may choose to recommend reduced smoking as an option for persistent smokers. A general scheme of strategies for tobacco control is outlined in Figure 1. This shows harm reduction for the persistent smoker with continued attempts to move toward cessation. Once smoking ceases, the goal should be to prevent resumption of smoking and to avoid second-hand smoke.

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