18.0 Introduction

Last updated: August 2016 

Suggested citation: Greenhalgh, EM, & Scollo, MM 18.0 Introduction. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/18-0-introduction

Harm reduction is an approach within public health that aims to reduce the harmful consequences of drug use, without necessarily eliminating or even reducing consumption.1 This approach has been successfully and widely adopted within the areas of alcohol and illicit drug use. For example, needle exchange programs are now considered best practice, and have led to reduced rates of infection transmission among injecting drug users.2 Other examples include opioid substitution therapy with methadone or buprenorphine for heroin dependence, and blood alcohol limits and random breath testing for drivers to reduce harms of alcohol use.3

Robust evidence demonstrates that quitting smoking leads to significant health benefits. Large-scale cessation would likely lead to benefits greater than any other public health effort. However, many smokers fail to quit, despite knowledge of the substantial health risks from tobacco use.4 For these smokers, harm reduction has been proposed as an alternative to what has been termed a ‘quit or die’ strategy, which promotes cessation as the only viable alternative to smoking in order to reduce health risks.5

Harm reduction within the framework of tobacco control was first considered in the 1950s, when evidence of the harmfulness of smoking first came to light. For decades, attempts were made to develop cigarettes that were less harmful, such as “light”, “low-tar”, and “low-nicotine” products,6,7 which ultimately failed to reduce health risks due to compensatory smoking,8 and were used deceptively by the tobacco industry to keep smokers smoking.9,10 The concept of harm reduction then became salient again in the 1990s, when public health experts proposed a range of regulatory approaches to minimise the enormous harms caused by tobacco. A seminal article by Warner, Slade, and Sweanor suggested that, rather than banning the use of all nicotine delivery products, a more realistic approach might be to discourage use of the most dangerous products (cigarettes), while making less hazardous products readily available to adults.11 Reducing the addictiveness, rather than harmfulness, of cigarettes was a contrasting approach that was proposed about the same time. A report presented by the American Medical Association (AMA) Council on Scientific Affairs in 1998 recommended that cigarettes be modified to contain less nicotine, and therefore be less addictive.12 In a 1999 review, Australian researchers floated the idea of a single regulatory framework for tobacco and all other nicotine delivery systems; one that reduced secondhand exposure to tobacco products, reduced the risk of young people becoming addicted to nicotine, and changed the design of existing cigarettes and alternative nicotine products so that they were less harmful and/or addictive.13 This regulatory approach has also been advocated in the UK, but has not been adopted in either Australia or the UK.14,15

In the context of tobacco control, smokefree laws, which reduce the exposure of non-smokers to secondhand smoke, and mandatory standards for reduced ignition propensity cigarettes, which reduce the risk of fires caused by discarded cigarettes, are examples of harm reduction approaches that have been universally supported and widely adopted.16 Harm reduction for the individual smoker would be achieved by reducing their exposure to carcinogens and other toxins to the greatest extent possible.17 For smokers who are unable or unwilling to quit, options to potentially reduce their health risks might include attempts to make cigarettes less harmful—see Section 18.2, or individuals switching to alternative products that may carry fewer risks than traditional cigarettes4,11—see InDepths 18A and 18B.

Some smokers believe they will reduce the risk of harm by switching to products such as cigars, waterpipe tobacco or smokeless tobacco.18 Cigars may be associated with a lower risk of lung cancer if used infrequently and not inhaled, but, like waterpipes, still pose similar health risks to those associated with smoking cigarettes—see Chapter 3, Section 3.27. Some types of smokeless tobacco such as low-nitrosamine Swedish snus would appear to be less toxic (see InDepth 18.A) and, like dissolvable nicotine products,19 might be regarded as an ‘alternative nicotine delivery systems’ (ANDS).11

Products that have been developed for their tobacco harm reduction potential are frequently referred to as Potential Reduced Exposure Products (PREPs).17  Examples of PREPs include modified cigarettes that may be less toxic and carcinogenic (see Section 18.2), and electronic nicotine delivery systems (ENDS) or e-cigarettes, referred to by some marketing commentators now as ‘personal vapourisers’  including ‘cigalikes’ and tank systems  (see InDepth 18B). Another harm reduction strategy might be for smokers to reduce the number of cigarettes they consume each day. Unless supported by nicotine replacement products (NRT), this approach has not proved to be feasible in reducing intake of the harmful constituents of tobacco smoke, and consequently is widely discredited as an approach to reducing harm (see Section 18.3).20 Other strategies that can be considered ‘harm reduction’ include chemoprevention (see Section 18.5) and screening (see Section 18.6). A contrasting or possibly complementary approach to harm reduction would be to reduce the addictiveness of cigarettes gradually over time; either as a ‘mass weaning’ strategy, or in order to facilitate switching to less harmful tobacco products or cigarette alternatives (see Section 18.4).

Harm reduction has been a contentious and divisive issue within the tobacco control community. Proponents argue that it is a necessary option for those who are unable to stop using tobacco products, and that substituting cigarettes with lower-risk nicotine or tobacco products offers enormous individual and public health benefits. They argue that failing to provide smokers with accurate information and access to alternative sources of nicotine is unethical, and dissuades smokers from quitting the most harmful method of consuming nicotine— inhaling smoke.21,22 An additional argument is that having less harmful alternatives more widely available could provide justification for greater regulation of (and perhaps even eventually a complete phase out of) smoked tobacco.23

Opponents believe that the harm reduction approach diverts smokers from the safest option—complete cessation.21,22 They argue that prevalence rates have continued to fall using proven effective population based approaches, including making tobacco products expensive, highly regulated, non-advertised, plain packaged, and out of consumers’ sight in retail outlets.24 Tobacco harm reduction, they argue, may be an ‘unnecessary distraction’ from these strategies.25 There is also hesitancy in trusting tobacco companies to develop and market a less harmful alternative,13 given the history of ‘harm reduction’ products ultimately proving to cause enormous harm.26 For example, the introduction of supposedly safer low tar and filter cigarettes led to greater numbers of smokers, deeper inhalation patterns, and/or higher daily consumption.17 Continuing use of any smoked tobacco is harmful, with the risk of cardiovascular disease elevated for even low levels of use, thus greatly compromising potential reductions in harm if smokers engage in dual use (of smoked products along with alternative products) instead of complete switching.21  

The possibility of dual use and the potential for alternative products to act as a gateway to traditional products raises concerns whether harm reduction approaches would ultimately result in a net reduction of harm at the population level. Proponents counter that smokers have a right to information to assist them make the best possible choice about their own health regardless of the wider consequences to public health,27,28 and that regulation, such as tighter controls and disincentives to smoke, can be used to minimise this risk.28

These issues have led to fierce debates about the most ethical and appropriate way to communicate public health messages regarding the risks and efficacy of potentially harm reducing products, and a lack of consensus about the most appropriate ways to regulate their sale and use.21

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1. Des Jarlais DC. Harm reduction--a framework for incorporating science into drug policy. American Journal of Public Health, 1995; 85(1):10–2. Available from: http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.85.1.10

2. Wodak A and Cooney A. Do needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Substance Use & Misuse, 2006; 41(6–7):777–813. Available from: http://informahealthcare.com/doi/abs/10.1080/1082608060066957

3. Rhodes T and Hedrich D. Harm reduction: evidence, impacts and challenges, Lisbon: European Monitoring Centre for Drugs and Drug Addiction; 2010.  Available from: http://www.emcdda.europa.eu/publications/monographs/harm-reduction .

4. Rodu B and Godshall WT. Tobacco harm reduction: an alternate cessation strategy for inveterate smokers. Harm Reduction Journal, 2006; 3(1):37. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1779270

5. Warner KE and Pollack HA. The Nicotine Fix. The Atlantic, 2014. Available from: http://www.theatlantic.com/features/archive/2014/11/the-nicotine-fix/382666/

6. Gori GB. Toward less hazardous cigarettes : the second set of experimental cigarettes. Bethseda, Maryland: U.S. Dept. of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Cancer Institute, Smoking and Health Program, 1976. Available from: http://search.slv.vic.gov.au/primo_library/libweb/action/dlDisplay.do?vid=MAIN&reset_config=true&docId=SLV_VOYAGER1281833

7. Russell M. Low-tar medium-nicotine cigarettes: a new approach to safer smoking. British Medical Journal, 1976; 1(6023):1430–33. Available from: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1640397&blobtype=pdf

8. National Cancer Institute Expert Committee. NCI monograph no. 8: changes in cigarette-related disease risks and their implication for prevention and control. NIH Publication no.97–4312, 383–475.Bethesda, MD: National Institutes of Health, 1997. Available from: http://onlinebooks.library.upenn.edu/webbin/book/lookupid?key=olbp24454 .

9. Anderson SJ, Ling PM, and Glantz SA. Implications of the federal court order banning the terms "light" and "mild": what difference could it make? Tobacco Control, 2007; 16(4):275–9. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/16/4/275   

10. Hall W and Gartner C. Supping with the Devil? The role of law in promoting tobacco harm reduction using low nitrosamine smokeless tobacco products. Public Health, 2009; 123(3):287–91. Available from: http://www.sciencedirect.com/science/article/pii/S0033350608003533

11. Warner K, Slade J, and Sweanor D. The emerging market for long-term nicotine maintenance. Journal of the American Medical Association, 1997; 278(13):1087–92. Available from: http://cat.inist.fr/?aModele=afficheN&cpsidt=2833297

12. Henningfield JE, Benowitz NL, Slade J, Houston TP, Davis RM, et al. Reducing the addictiveness of cigarettes. Tobacco Control, 1998; 7(3):281-93. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/7/3/281

13. Borland R and Scollo M. Opportunities for harm minimization in tobacco control. Drug and Alcohol Review, 1999; 18(3):345–53. Available from: http://dx.doi.org/10.1080/09595239996518

14. Britton J and McNeill A. Why Britain needs a nicotine regulation authority: to bring consistency and regulation to tobacco and alternative nicotine products. British Medical Journal, 2001; 322(7294):1077–8. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120223/

15. Royal College of Physicians, Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority. RCP; 2002. Available from: https://www.rcplondon.ac.uk/publications/protecting-smokers-saving-lives .

16. Gartner CE, Hall WD, and McNeill A. Harm reduction policies for tobacco, in Harm reduction: Evidence, impacts and challenges.  Rhodes T HD, Editor Lisbon: European Monitoring Centre for Drugs and Drug Addiction; 2010. p 255–73.

17. Stratton K, Padma S, Wallace R, and Bondurant S. Clearing the smoke: assessing the science base for tobacco harm reduction. Institute of Medicine, 2001. Available from: http://www.nap.edu/books/0309072824/html/ .

18. Cohn A, Cobb CO, Niaura RS, and Richardson A. The other combustible products: prevalence and correlates of little cigar/cigarillo use among cigarette smokers. Nicotine & Tobacco Research, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25634932

19. Slade J. Innovative nicotine delivery devices from tobacco companies, in Nicotine and Public Health.  Ferrence R, et al., Editors. Washington, DC: American Public Health Association; 1997. p 209–28.

20. Hurt RD, Croghan GA, Wolter TD, Croghan IT, Offord KP, et al. Does smoking reduction result in reduction of biomarkers associated with harm? A pilot study using a nicotine inhaler. Nicotine & Tobacco Research, 2000; 2(4):327–36. Available from: http://ntr.oxfordjournals.org/content/2/4/327.short

21. Alderman J, Dollar KM, and Kozlowski LT. Commentary: understanding the origins of anger, contempt, and disgust in public health policy disputes: applying moral psychology to harm reduction debates. Journal of Public Health Policy, 2010; 31(1):1–16. Available from: http://www.palgrave-journals.com/jphp/journal/v31/n1/abs/jphp200952a.html

22. Polosa R, Rodu B, Caponnetto P, Maglia M, and Raciti C. A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduction Journal, 2013; 10(1):19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24090432

23. Gartner C and Malone RE. Duelling letters: which one would you sign? Tobacco Control, 2014; 23(5):369–70. Available from: http://tobaccocontrol.bmj.com.ezproxy.une.edu.au/content/23/5/369.short

24. Chapman S. Should electronic cigarettes be as freely available as tobacco cigarettes? No. British Medical Journal, 2013; 346:f3840. Available from: http://www.bmj.com/content/346/bmj.f3840?view=long&pmid=23771038

25. Joseph AM, Hennrikus D, Thoele MJ, Krueger R, and Hatsukami D. Community tobacco control leaders' perceptions of harm reduction. Tobacco Control, 2004; 13(2):108–13. Available from: http://tc.bmjjournals.com/cgi/content/abstract/13/2/108

26. Cahn Z and Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes? Journal of Public Health Policy, 2011; 32(1):16–31. Available from: http://www.palgrave-journals.com/jphp/journal/v32/n1/full/jphp201041a.html

27. Kozlowski LT and Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tobacco Control, 2005; 14(Suppl 2):ii3–7. Available from: http://tc.bmjjournals.com/cgi/content/abstract/14/suppl_2/ii3   

28. Hall W, Gartner C, and Forlini C. Ethical issues raised by a ban on the sale of electronic nicotine devices. Addiction, 2015; 110(7):1061–7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25845485

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