Tobacco harm reduction – no smoke without fire

Smoking kills millions of people every year and yet the medical community seems pathologically opposed to any measure to tackle the issue other than through the promotion of total abstinence.  Carl Phillips suggests in his paper in the Harm Reduction Journal this month that smoking for just one month is more dangerous than switching to a smokeless nicotine product for a lifetime.

Take a moment to take a deep drag on a few breathtaking statistics.

Across the world approximately 1.3 billion people use tobacco products and by 2030 it is estimated that 10 million people will die annually from smoking-related diseases and 70% of these deaths will be in developing countries. We’ve known about the harmful effects of smoking for over 50 years and yet over that same period 6 million Britons have died of tobacco-related disease.

It’s no secret that it’s hard to stop smoking. Bandolier published an interesting little analysis of trials which included smokers and heroin addicts. They asked: which is the most addictive? In a rather elegant twist they looked at the cessation rates in the placebo arms of all the relevant trials. Cessation rates for smokers were around 8-9% yet for opiates users were around 43%. No surprises there – smoking is extraordinarily difficult to stop. Even in those that are highly motivated 12 month cessation rates are often no better than 10%. Opposing a harm reduction approach might be doing a grave disservice to those that just find it too tough to stop.

I am intrigued by the concept of tobacco harm reduction – not least because it requires a considerable effort of will to put aside a pathological distrust of Big Tobacco. Some of this post is taken from one I posted over at doc2doc a few months ago. The very first comment on the blogpost at doc2doc sums up the gut reaction of many doctors:

I think we should dismiss this out of hand! This argument is like low tar cigarettes are healthier..so you can smoke more of them. There is no such things as a safe(r) cigarette. The safer cigarette makes no sense given my understanding of how nicotine receptors work, not to say addiction. Do not trust Big Tobacco who have a vested interest in not losing their customers.

End of. Decision made. One suspects that the notion of smokeless nicotine products is simply not endorsable by the scientific orthodoxy in any shape or form. Phillips addresses all the arguments and using a back of a fag packet (though he prefers an envelope) calculation suggests that:

Whatever the explanation for it, the present analysis shows that anti-THR [tobacco harm reduction] activism is deadly. Hiding THR from smokers, waiting for them to decide to quite entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.

If you are inclined to read the paper then flick to the back first and read the competing interests statement. Not for our Carl a bland ‘nothing to declare’ and instead it reads like a heartfelt plea that we pause, ignore the gut reaction and consider the evidence. It also speaks volumes for the ignominious role of mavericks in the scientific world; they may occasionally be lauded as heroes but more often they will be squeezed out of funding, shunned at the peer-review review stage and ostracised by their own community.

Within the wider medical community tobacco harm reduction remains an exercise in thinking the unthinkable. Doctors recommending it may be vilified and it opens up a researcher to accusations of acting as an industry patsy; labelled as a dull-eyed lackey in the pay of malignant giants. Yet it could save millions of lives and it certainly merits wider debate.

Phillips, C. (2009). Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments Harm Reduction Journal, 6 (1) DOI: 10.1186/1477-7517-6-29