Putting tobacco harm reduction in perspective: is it a viable alternative?

Abstract

Tobacco use is a global pandemic. Worldwide, there are about 1.1 billion smokers1, and nearly six million deaths annually are attributed to tobacco use2 and it is recognized to be the single most important cause of avoidable premature mortality in the world mainly from cancer, coronary heart disease, chronic obstructive pulmonary disease and stroke. Tobacco control policies as outlined in the WHO Framework Convention on Tobacco Control3 (including price and tax increases, pictorial warnings, prevention of smoking in public and work places, monitoring of tobacco use, offering help to quit, tobacco advertisement and promotion ban) have achieved reductions in smoking prevalence of at best1 per cent per year4. Additionally, these policies are not very effective if not properly implemented or do not have adequate funding support5. Nicotine dependence is a chronic relapsing condition. At an individual level, though most tobacco users want to quit but they are unable to do so because they are addicted to nicotine6 and relapse rates are staggeringly high. Currently available first line medications for tobacco cessation are known to double or triple this quit rate under experimental conditions but in real world settings these have had low uptake and inferior efficacy7. Further, it is increasingly recognized that nicotine is such an addictive compound that millions of people smoking today will be unable to quit8. In this scenario, a different approach is required to reduce the harm from cigarette smoking for people who are not ready to or cannot quit. Further, the adverse health effects that accrue from taking tobacco come not from nicotine, but from hundreds of other toxins and carcinogens like nitrosamines in tobacco and in the tar and carbon monoxide and nitrogen oxides in the smoke. Thus, though our primary strategy for reducing harm must be to encourage cessation, at least reducing or minimizing harm for those who are unable to quit may seem like a reasonable strategy. Within this context, the approach of tobacco harm reduction has gained momentum in recent years.