Many thanks to Darkwing for pointing out and providing the article! The Lancet is one of the oldest scholarly medical journals in the world. This was the editorial in their most recent issue, which also featured several academic papers which were related.
Adding harm reduction to tobacco control
“There is no good reason why a switch from tobacco
products to less harmful nicotine delivery systems
should not be encouraged.” So stated a 1991 Lancet
Editorial, yet 16 years later cigarettes continue to
dominate the nicotine-delivery system market, despite
their clear health risks. Most smokers want to quit but
continue to smoke because they are addicted to nicotine,
and cigarettes deliver high doses of the drug rapidly to
the brain. But the adverse health effects come mostly
from nitrosamines and other carcinogens in the tar and
carbon monoxide and nitrogen oxides in the smoke.
Half of all smokers will die prematurely if they continue
smoking. With 1·6 billion smokers expected worldwide
by 2025, all opportunities to reduce the harm caused by
tobacco smoking must be seized.
Current tobacco control policies as outlined in the
WHO Framework Convention on Tobacco Control
(including price and tax increases, and prevention
of smoking in public and work places) have typically
achieved reductions in smoking prevalence of at best
1% per year in countries where cigarette smoking is
common. Given the limitations of tobacco control,
argue John Britton and Richard Edwards in a Viewpoint
published online on Oct 5, radical reform of nicotine and
tobacco product regulation is needed. Based on a report
published by the UK’s Royal College of Physicians (RCP),
Britton and Edwards apply harm-reduction principles
to smoking and conclude that a wide range of nicotine
products, including medicinal nicotine (currently
marketed as nicotine-replacement therapy) and low-
nitrosamine smokeless tobacco products, such as snus,
should be developed, regulated rationally in relation to
each other, and made available in inverse proportion
to their hazards. They argue that as smoked tobacco
(cigarettes, cigars, pipes) causes far more disease than
most forms of smokeless tobacco, which in turn are
more hazardous than medicinal nicotine, efforts should
be channelled into developing low-risk products capable
of delivering nicotine as efficiently as cigarettes, while
subjecting smoked tobacco products to increasing
restrictions. Stopping smoking and cessation of nicotine
product use is the ultimate goal, but for those who
cannot quit, or who want to reduce the harm related to
smoking, less hazardous methods of obtaining nicotine
should be available.
However, Martin McKee and Anna Gilmore argue in
our Correspondence section that snus has not been
proven to be an effective aid to quitting smoking and
that the risks of dual snus and cigarette use have to
be considered. They are correct. Controlled trials are
needed to confirm the Swedish observational studies
that suggest snus helps quitting. Moreover, widening
access to snus could increase the profits of tobacco
manufacturers who are now busily marketing snus as
a harm-reduction product. British American Tobacco,
for example, has introduced Lucky Strike snus into
Sweden and South Africa. Meanwhile, Marlboro snus
and Camel snus are being marketed by Philip Morris USA
and R J Reynolds, respectively. In McKee and Gilmore’s
view, permitting such snus branding might encourage
continuing nicotine addiction which could mitigate
the effects of smoke-free legislation. Allowing tobacco
companies to get yet another wedge in the tobacco
market is a serious concern. But so long as there are
progressively increased restrictions on smoked tobacco,
effective and familiar branding of harm-reduction
products may help smokers to switch.
No tobacco product has been shown to be totally risk-
free. Observational data suggest, for example, that snus
is associated with an excess risk of pancreatic cancer, but
not oral or lung cancer, in Swedish male construction
workers who were followed up for 20 years. The gener-
alisability of such data remains to be tested in other
populations, and long-term follow-up of users of nicotine
and smokeless tobacco products is needed to identify all
possible risks. Of relevance here too is the likelihood that
medicinal nicotine and low-toxicity smokeless tobacco will
be far less hazardous to non-users than smoked tobacco.
Quantifying this relative benefit would be useful.
Britton, Edwards, and the other members of the
RCP’s Tobacco Advisory Group advocate a courageous
approach to nicotine addiction. Greater availability of
medicinal nicotine, and perhaps even of low-toxicity
smokeless products, along with increasing restrictions
on smoked tobacco, is likely to reduce tobacco-related
mortality and morbidity. Given the known hazards of
smoked tobacco, and the numbers of people who smoke,
innovative thinking is needed. We support tobacco harm
reduction alongside rigorously applied tobacco control
policies.
■ The Lancet
Adding harm reduction to tobacco control
“There is no good reason why a switch from tobacco
products to less harmful nicotine delivery systems
should not be encouraged.” So stated a 1991 Lancet
Editorial, yet 16 years later cigarettes continue to
dominate the nicotine-delivery system market, despite
their clear health risks. Most smokers want to quit but
continue to smoke because they are addicted to nicotine,
and cigarettes deliver high doses of the drug rapidly to
the brain. But the adverse health effects come mostly
from nitrosamines and other carcinogens in the tar and
carbon monoxide and nitrogen oxides in the smoke.
Half of all smokers will die prematurely if they continue
smoking. With 1·6 billion smokers expected worldwide
by 2025, all opportunities to reduce the harm caused by
tobacco smoking must be seized.
Current tobacco control policies as outlined in the
WHO Framework Convention on Tobacco Control
(including price and tax increases, and prevention
of smoking in public and work places) have typically
achieved reductions in smoking prevalence of at best
1% per year in countries where cigarette smoking is
common. Given the limitations of tobacco control,
argue John Britton and Richard Edwards in a Viewpoint
published online on Oct 5, radical reform of nicotine and
tobacco product regulation is needed. Based on a report
published by the UK’s Royal College of Physicians (RCP),
Britton and Edwards apply harm-reduction principles
to smoking and conclude that a wide range of nicotine
products, including medicinal nicotine (currently
marketed as nicotine-replacement therapy) and low-
nitrosamine smokeless tobacco products, such as snus,
should be developed, regulated rationally in relation to
each other, and made available in inverse proportion
to their hazards. They argue that as smoked tobacco
(cigarettes, cigars, pipes) causes far more disease than
most forms of smokeless tobacco, which in turn are
more hazardous than medicinal nicotine, efforts should
be channelled into developing low-risk products capable
of delivering nicotine as efficiently as cigarettes, while
subjecting smoked tobacco products to increasing
restrictions. Stopping smoking and cessation of nicotine
product use is the ultimate goal, but for those who
cannot quit, or who want to reduce the harm related to
smoking, less hazardous methods of obtaining nicotine
should be available.
However, Martin McKee and Anna Gilmore argue in
our Correspondence section that snus has not been
proven to be an effective aid to quitting smoking and
that the risks of dual snus and cigarette use have to
be considered. They are correct. Controlled trials are
needed to confirm the Swedish observational studies
that suggest snus helps quitting. Moreover, widening
access to snus could increase the profits of tobacco
manufacturers who are now busily marketing snus as
a harm-reduction product. British American Tobacco,
for example, has introduced Lucky Strike snus into
Sweden and South Africa. Meanwhile, Marlboro snus
and Camel snus are being marketed by Philip Morris USA
and R J Reynolds, respectively. In McKee and Gilmore’s
view, permitting such snus branding might encourage
continuing nicotine addiction which could mitigate
the effects of smoke-free legislation. Allowing tobacco
companies to get yet another wedge in the tobacco
market is a serious concern. But so long as there are
progressively increased restrictions on smoked tobacco,
effective and familiar branding of harm-reduction
products may help smokers to switch.
No tobacco product has been shown to be totally risk-
free. Observational data suggest, for example, that snus
is associated with an excess risk of pancreatic cancer, but
not oral or lung cancer, in Swedish male construction
workers who were followed up for 20 years. The gener-
alisability of such data remains to be tested in other
populations, and long-term follow-up of users of nicotine
and smokeless tobacco products is needed to identify all
possible risks. Of relevance here too is the likelihood that
medicinal nicotine and low-toxicity smokeless tobacco will
be far less hazardous to non-users than smoked tobacco.
Quantifying this relative benefit would be useful.
Britton, Edwards, and the other members of the
RCP’s Tobacco Advisory Group advocate a courageous
approach to nicotine addiction. Greater availability of
medicinal nicotine, and perhaps even of low-toxicity
smokeless products, along with increasing restrictions
on smoked tobacco, is likely to reduce tobacco-related
mortality and morbidity. Given the known hazards of
smoked tobacco, and the numbers of people who smoke,
innovative thinking is needed. We support tobacco harm
reduction alongside rigorously applied tobacco control
policies.
■ The Lancet
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