Tobacco harm reduction

Tobacco harm reduction (THR) is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. It is an example of the concept of harm reduction, a strategy for dealing with the abuse of other drugs. Tobacco smoking is widely acknowledged as a leading cause of illness and death, and preventing smoking is vital to public health.

In the developed world, a reduction in the prevalence of smoking has been primarily achieved through reducing the uptake of smoking among younger people rather than improving the rates of quitting in established smokers. It is, however, this latter group who will generate the greatest source of population burden of morbidity and premature mortality caused by smoking in the next twenty years.

Nicotine itself, however, is not very harmful, as inferred from the long history of use for nicotine replacement therapy products. Nicotine increases heart rate and blood pressure and has a range of local irritant effects but is not carcinogenic (cancer causing). Indeed, none of the three main causes of mortality from smoking, lung cancer, COPD and cardiovascular disease, is caused primarily by nicotine. The main hazardous component is the smoke which results from the combustion of tobacco, so if nicotine could be effectively and acceptably delivered without smoke, it is likely that most if not all the harm of smoking could be avoided. THR measures have been focused on reducing or eliminating the use of combustible tobacco by switching to other nicotine products, including:

It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, approved smoking cessation methods have a 90% failure rate, when used as directed. In addition, there is a considerable population of smokers who are unable or unwilling to achieve abstinence. Harm reduction is likely of substantial benefit to these smokers and public health. Providing reduced-harm alternatives to smokers is likely to result in lower total population risk than pursuing abstinence-only policies.

The strategy is controversial: proponents of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths. Opponents have argued that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation. However, surveys carried from 2013 to 2015 in the UK and France suggest that on the contrary, the availability of safer alternatives to smoking is associated with decreased smoking prevalence and increased smoking cessation.

The concept of tobacco harm reduction was established in 1976 when Professor Michael Russell wrote: "People smoke for nicotine but they die from the tar" and suggested that the ratio of tar to nicotine could be the key to safer smoking. Since then, the harm from smoking has been well-established as being caused almost exclusively by toxins released through the combustion of tobacco. In contrast, non-combustible tobacco products as well as pure nicotine products are considerably less harmful, although they still have the potential for addiction.

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