Beyond the myopia of prevention: the promise of harm reduction

Author: John Luik
Article Published: 20/09/2004

Ever since the publication of the US National Academy of Sciences Institute of Medicine’s 2001 report Clearing the Smoke: Assessing the Science Basis for Tobacco Harm Reduction, much of the tobacco control community, particularly in the US, has engaged in a campaign to discredit harm reduction- the provision of lower risk tobacco products to smokers unable or unwilling to stop smoking- and insure that it does not find it way onto the tobacco control policy agenda.
There are sufficient laboratory and human data to suggest that harm reduction might be an achievable goal for persons who cannot stop smoking…"

Institute of Medicine, 2001

The opening salvo in the campaign came from the National Cancer Institute in the catchingly titled monograph Risks Associated with Smoking Cigarettes with Low Machine-Measured Yields of Tar and Nicotine, published just months after the IOM had first suggested the legitimacy of harm reduction. Though not specifically looking at the issue of the future potential of harm reduction through lower risk products, the NCI argued that on the basis of the historical record, reduced tar cigarettes did not provide a public health benefit. According to the NCI, reduced tar cigarettes had three significant problems: first, the available epidemiological evidence showed that they did not provide a reduction of risk for smokers, second, smokers defeated the purpose of reduced tar products by smoking them more intensely to compensate for their lower tar content and third, reduced tar cigarettes hindered smoking cessation and promoted initiation. As the senior editor of the report, Dr. David Burns of the University of California, noted “The take-home message of this report is that the only proven way to reduce the disease risks associated with smoking is to quit.”

But Dr. Burns is being far too modest, for the take-home message about quitting being the only answer to the smoking problem is not simply the message of the NCI report but the core faith of the public health establishment and the anti-smoking movement. Since the beginning of the tobacco wars until the appearance of the IOM report on harm reduction it has been an unquestioned article of faith that the foundation of tobacco control policy is the elimination, not merely the reduction of smoking. Cigarettes are inherently dangerous, there is no threshold of safe smoking and the only proper policy response to these two facts is an unwavering and unqualified commitment to smoking cessation. How else, for instance, can one make any sense of such ludicrous goals as smoke-free societies by 2000? The idea that providing those smokers unable or unwilling to quit with safer smoking is heretical in this church. The logic is simple- if we can’t prevent smoking, either through stopping initiation or encouraging quitting, then we won’t do anything else. In short, there should be no options for smokers who continue to smoke other than disease and death, both apparently of no concern to the public health community.

The NCI’s report on the “history”, and one needs to use the word with appropriate caution in this connection, of low tar products, however was only the beginning of the campaign against harm reduction. Since 2001 there has been a steady stream of articles in tobacco research journals and books on tobacco policy warning of the dangers of allowing harm reduction a place at the tobacco control table. This year in particular has seen the publication of three major articles and an editorial on harm reduction in Tobacco Control, the leading journal of the anti-tobacco movement. The most critical of the articles was, quite incredibly, funded by GlaxoSmithKline, a major marketer of nicotine replacement products. Indeed, one of the authors of that article is Vice President, Smoking Control and Strategic Development at GlaxoSmithKline. Summarizing this skepticism of the public health community to harm reduction, Ken Warner of the University of Michigan observed that “the position of the mainstream public health community on the issue of the development of less hazardous cigarettes and pseudo-cigarettes seems clear. In general, that community appears to believe that there is no such thing as a safe cigarette and that all attempts to create one are either naïve… or disingenuous.” This misstatement of the goals of harm reduction is itself one of the reasons why harm reduction is rejected by the public health community. The concept of harm reduction, borrowed from the debate over illicit drug use, is not to eliminate tobacco related harms through the creation of a SAFE cigarette but rather to reduce harms, both individual and a population basis, to those unable or unwilling to quit smoking through the use of SAFER cigarettes. The attempt to frame the concept as one endorsing safe cigarettes is simply a red herring.

Running throughout both the recent batch of articles on harm reduction and the NCI report about low tar cigarettes are at least four arguments against the idea of harm reduction, virtually all of which are bedeviled with a mixture of bad logic, inaccurate science and outright myth. First, harm reduction provides no genuine reduction in harm to the average smoker. Second, harm reduction increases the total harm from tobacco use through reducing cessation, encouraging relapse and abetting initiation. Third, harm reduction undermines the entire tobacco control agenda through “sending the wrong message” about society’s view of tobacco. Fourth, harm reduction provides the tobacco industry with a place at the tobacco control policy table and an undeserved legitimacy.

The most crucial claim of the case against harm reduction is that it is nothing more than a tobacco industry public relations strategy since there is no reduction in risk to a typical smoker. The basis for this claim is the experience of smokers’ use of filtered, low tar cigarettes beginning in the late 1960’s in the United Kingdom and the United States. Since 1968, for instance, there has been a 44% reduction in standard tar yield. According to this argument, the tobacco industry never saw low tar products as risk-reducing so much as a way of reassuring smokers who were intending to quit. Moreover, the compensating behaviours of smokers who used low tar products actually “increased their smoking-attributable disease risk” (Warner, 2001) The logic here is curious since whether low tar products reduced harms to smokers is a scientific question with an answer irrespective of what the industry intended low-tar products to do. Again, the claim that low-tar products cannot reduce risk sits uneasily alongside the assertion that it is the behaviour of certain smokers, as opposed to the product itself, that works against risk reduction.

Whatever the logic of these claims, the scientific evidence about reduced tar products does not support the charge that they fail to reduce harms to smokers, let alone the assertion that they increase disease risk. The scientific basis for harm reduction in general and reduced harm products specifically comes from a number of epidemiological studies that show that not only does the risk of smoking to health increase with the number of cigarettes smoked, but that certain types of tobacco-related diseases are proportionate to the tar level of cigarettes. The Surgeon General’s 1979 report Smoking and Health, for instance, details several major studies that show that half a pack a day smokers have roughly 25% of the lung cancer risk of two pack a day smokers. This sort of dose-response relationship was confirmed by the EPA in its 1993 report on ETS in which it noted that in eight major studies there was a “gradient of increasing risk for lung cancer mortality with increasing number of cigarettes smoked per day.”

Sir Richard Doll’s examination of smoking related mortality in the UK from 1950-1984 found that the decline in death rates was not due to reduced prevalence but rather to the changes in the constituents of cigarettes, for instance, lower tar levels. Similarly, the UK’s Independent Scientific Committee on Smoking and Health concluded in 1988 that “past reductions in the yields of tar and associated cigarette smoke components have reduced the risk of lung cancer and possibly of chronic obstructive airways disease”.

Indeed, this evidence of risk reduction for smokers is precisely what led the Committee to conclude that product modifications that reduced tar further with “proportionately higher nicotine yields” would be “beneficial tothe health of the public.”

In the US, Stellman and Garfinkel (1989), using the massive American Cancer Society database of one million males, found that risk was lower for smokers of low-tar cigarettes compared to higher tar products. The authors of the IOM report on harm reduction concluded that “most of the … studies suggest that the use of filtered or low-tar cigarettes was associated with lower lung cancer risk, even though there is clearly an increased risk of all types of lung cancer with all types of cigarettes.”(p. 404) In 2003, Kabat, reviewing a series of studies on low-tar products from the last fifty years, concluded that the studies suggested a reduction in lung cancer risk of 20-30 %. He also noted that the better studies indicated a reduced risk of about 10% of heart disease for smokers of low-tar cigarettes. Of the seven studies that examined total mortality, “five show a statistically significant reduction on the order of 10-20 percent among smokers of lower-tar cigarettes.”(Inhalation Toxicology, 2003) Finally, even the NCI’s attack on low tar cigarettes, admits that the epidemiological evidence about filtered, low-tar products indicates lower lung cancer risks. As the senior editor notes “the clear impression from these studies taken as a whole is that there is a lower risks of lung cancer among populations of smokers who use lower yield products.”(p. 81)

Despite the abundance of scientific evidence, virtually all of it from government funded and sponsored reports, the anti-tobacco movement and the public health community remain unconvinced. Writing earlier this year in a way that suggested that the IOM report had never been produced, Hatsukami et al noted that ”there is little evidence that individuals who smoked light cigarettes… experience any benefit with respect to heart and lung disease”.(Annual Review of Public Health) Part of this reluctance is a product of the rigid hold of the dogma of prevention that insists that the only legitimate goal of tobacco control policy is the end of smoking. But part of the resistance to harm reduction stems from the stubborn refusal of the anti-tobacco movement to accept the fact that smoking risk is dose determined, which in turn provides the foundation for harm reduction. Seduced by their rhetoric of no safe cigarettes and refusing to accept the truth of dose-response, the anti-tobacco advocates have backed themselves into a corner in which it is very difficult to support a harm reduction strategy that begins with a risk-dose relationship.

But what about the claims that whatever the potential benefit of harm reduction, smoker’s compensation for reduced tar through harder or more frequent puffing or blocking air vents, effectively eliminates the advantages of reduced risk products? There have been numerous studies of the ways in which the tar delivery of low-tar products might be increased by smokers. The problem with many of these studies is that while they establish the ways in which smokers might compensate for reduced tar they fail to provide reliable information about how frequently this behaviour might occur. And it is precisely this sort of information that is necessary to determine whether, on balance, there is no net reduction in smoker risk. In effect the fact that some smokers might use low-tar products in ways that reduce their benefits is not in itself an argument against harm reduction provided that there is still an overall reduction in smoker risk. For example, though some individual smokers might puff more frequently or cover some of the vents on low-tar cigarettes and thus defeat the purpose of the cigarette, this does not mean that there is no benefit from low-tar cigarettes for smokers who do not compensate, or indeed even for smokers that do compensate. For instance, in an exhaustive review of the literature on compensation, Baker and Lewis (1997) found that vent blocking does not occur in a significant percentage of low-tar smokers and when it does occur it does not substantially increase tar yields. But even if this were not the case, it still does not undermine the legitimacy of harm reduction.

The debate about compensation and published tar yields is beside the point since it is by now a truism that people smoke cigarettes in ways that are different from the machine produced tar ratings. Even if it were to be found that substantial numbers of low-tar smokers compensated in some way for the reduced tar, this does not count against either low-tar cigarettes or harm reduction. This is because the epidemiological evidence about the overall population benefits of low-tar cigarettes indicates a significant reduction in premature mortality for those who use them.

What then of the claim that harm reduction reduces cessation, encourages relapse and promotes smoking initiation? The claim about initiation is the most curious since there is no published scientific evidence that filtered or low tar products have affected the rate of smoking initiation. As for cessation and relapse the best evidence comes again from the massive Cancer Prevention Study (CPS) by the American Cancer Society. Hammond (1980) followed smokers from 1959-1972 to determine the connection between quit rates and tar levels. He found that smokers of low-tar products were most likely to have quit. In a recent study funded by GlaxcoSmithKline which looked at smokers interest in Eclipse, only 6.2% of ex-smokers said they were somewhat or very likely to purchase Eclipse. Contradicting their own findings that a harm reduction product did not promote relapse the authors nevertheless concluded that “ALTHOUGH WE DIE NOT FIND THIS EFFECT IN THE SURVEY (our emphasis) it seems plausible that smokers… who perceive the product as being totally safe may take up the new product instead of quitting… “(Shiffman et al, 2004) These tobacco specific arguments are supported by research in other fields where harm reduction has been used which found that the chance of increases in harm due to initiation or relapse were slight. In short, none of the evidence about relapse, cessation or initiation undermines the case for harm reduction. When coupled with the epidemiological evidence about low-tar cigarettes, this creates a strong presumption for the fact that a rigorous cost –benefit analysis would show that harm reduction provides a significant reduction in harm to smokers without increasing overall smoking prevalence.

The final arguments against harm reduction are that it sends the wrong message about smoking and provides an undeserved legitimacy for the tobacco industry. The claim about sending the wrong message is found in a variety of harm reduction discussions, such as school condom programs or teaching controlled drinking skills, but it is rarely articulated in any detail as its proponents appear to believe that it is self-evident. What it appears to mean is that harm reduction will actually encourage risky behaviour, in this case smoking. But this is clearly untrue in terms of the evidence of low-tar cigarettes and quitting, relapse and smoking initiation. Examples from other areas of harm reduction such as needle exchange for illicit drug users also suggest that there is not a net increase in risky behaviour. Moreover it is difficult to see how the message of harm reduction is a mixed message since it is specifically directed to a particular group of smokers- those unable or unwilling to quit and it acknowledges the ideology of the anti-tobacco movement that it is only because of addiction that smokers can’t or won’t stop. Thus what the harm reduction message actually says is:

1. Smoking is dangerous.

2. You should quit.

3. We can help you quit.

4. But if you can’t or won’t quit because of the strength of your addiction, we can help you to smoke less harmfully.

From the public health perspective the message about smoking is consistent- it is dangerous and you should avoid it. It is only when the preferred option of quitting fails that harm reduction becomes legitimate.

There is undoubtedly a degree of truth to the claim that harm reduction provides a place at the tobacco control policy table and thus a certain legitimacy for the industry. But it is unclear precisely why this need be a genuine worry for anyone other than the fanatics within the anti-tobacco and public health communities. For one thing the denormalization of the industry and its exclusion from the formulation of tobacco control policy works against the success of tobacco control in general and the interests of smokers unable or unwilling to quit. For another thing the collaborative (industry-government- public health community) development of harm reduction within a rigorous scientific framework means that a new generation of safer products would have to offer genuine risk reductions to smokers.

The case against harm reduction on closer inspection turns out like so much of the controversy about tobacco, whether about marketing, ETS, addiction, youth initiation or taxation, to be a mixture of bad science, faulty logic and myth. Indeed, it highlights just how vapid is the claim that tobacco control is evidence-based. Neither the logic of harm reduction nor its history suggests that it is anything but a promising approach to tobacco-related harm. No where else in disease prevention would the either-or approach of a tobacco control fundamentalism that offers only abstinence or death be accepted on either scientific or moral grounds. For instance, in both AIDS and malaria control there is no conflict between simultaneously working toward preventing the disease and reducing exposure to and treating the disease.

No where else would the solid scientific evidence of harm reduction’s past success and the scientific endorsement of its future potential through a careful analysis like that of the IOM count for so little. No where else would we be held captive to a policy that believed that because we could not reduce all of the risks of smoking we should not try to reduce some of the risks. No where else in disease prevention would we find such an immoral indifference to the fate of millions of smokers who either cannot or choose not to quit.

And no where else would we find such a stubborn commitment to avoiding the practical implications of the key insight of harm reduction: “Physicians recognize that some diseases can neither be eradicated nor cured. They simply do the best they can to reduce the harm, acknowledging and accepting that not every problem has a totally satisfactory solution.” (Goldstein, 1994)

John Luik -- Published by Tobacco Reporter, September 2004

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