Harm Reduction in a Persistent Smoker

By David J. Riley, MD, FCCP

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Commentary on Tobacco Harm Reduction

Nicotine Replacement Products and Antidepressants

Nicotine replacement products and antidepressants such as bupropion SR may play a role in tobacco harm reduction. These pharmacologic products have demonstrated efficacy as aids for smoking cessation.¹¹ At this time, the FDA has approved these products only as cigarette smoking cessation aids and not solely for reducing cigarette consumption. In theory, nicotine replacements are likely to reduce harm simply by decreasing exposure to pyrolysis products (products that are burned) that are primarily responsible for harm. The FDA has imposed a requirement that ancillary behavioral treatments be provided along with these products because behavioral treatment augments the success rate of medications alone.¹¹ It is likely that behavioral therapy will need to be incorporated into a harm-reduction program.

The use of nicotine replacement products for the primary purpose of reducing cigarette consumption has shown significant decreases in the number of cigarettes smoked.^12-14 Ten 2-mg pieces of nicotine gum per day reduced cigarette consumption by more than one half and reduced carbon monoxide (CO) levels after 2 months.¹² Smokers assigned to use a nicotine replacement product (gum, patch, spray, or tablet) for 2 weeks had reductions in cigarette consumption, CO levels, and withdrawal symptoms compared with baseline.¹³ Also, smokers assigned to use a nicotine inhaler had reduced smoking and CO levels after 24 months compared with control subjects given placebo.¹⁴ No serious adverse effects were observed in any of these studies.

One concern about using nicotine replacement products is potential toxicity when used chronically. Studies have found no major adverse effects with high doses of the nicotine patch or in smokers with cardiovascular disease (reviewed in the IOM report¹). Nicotine replacements are contraindicated in pregnancy. Another concern is that the availability of nicotine replacement products may deter individuals from becoming abstinent, but studies have shown this does not occur (reviewed in the IOM report¹). When used for 1 year, bupropion SR was found to delay smoking relapse compared with placebo.¹⁵ Strategies using a combination of nicotine replacements, antidepressants, and behavior-modification therapies might be more effective in reducing harm than a single agent alone. In summary, evidence suggests that nicotine replacements may be effective in reducing smoking and appear to be safe in concurrent smokers.

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