In late January, the New England Journal of Medicine published a ringing endorsement of tobacco harm reduction.  The authors of “Smoke, The Chief Killer – Strategies for Targeting Combustible Tobacco Use,” are Michael Fiore and Timothy Baker from the University of Wisconsin, and Steven Schroeder from the University of California-San Francisco.  In the past, they strongly opposed the adoption of safer cigarette substitutes.

Fiore and colleagues acknowledge that it’s the smoke that kills:

[R]esearch now quite clearly highlights the specific harms of combustible tobacco use (cigarette, pipe, and cigar smoking): given that up to 98 percent of tobacco-related deaths are attributable to combustible products, the net harms of these products, including harms from secondhand smoke, dwarf those of other forms of tobacco use (e.g., smokeless tobacco).

The authors are not referring to research that has just been published “now.”  Rather, the anti-tobacco establishment is just “now” acknowledging the fact that the risks of burning tobacco “dwarf” those of smoke-free forms.

Fiore, et al, acknowledge the failure of all conventional cessation options: “current smoking-cessation treatments fail for the majority of smokers who use them.”

More importantly, they move on to a surprising endorsement of smoke-free tobacco:

One opportunity afforded by today’s changing landscape lies in the diverse alternative nicotine delivery vehicles available to smokers.  Evidence shows that all the noncombustible delivery vehicles are substantially less dangerous than combustible tobacco products, though that’s not to say that they are all totally safe.  Noncombustible forms include multiple nicotine-replacement therapies (NRTs) as well as smokeless tobacco (e.g., snus) and the electronic cigarette.

To be fair, Fiore and colleagues also devote a lot of attention to conventional approaches.  However, the change in attitude toward tobacco harm reduction is seen in their advice to clinicians:

1.  Advise patients that any tobacco product has risks, but that combustible tobacco is “by far the most harmful.”

2.  Counsel them to quit any tobacco product using the conventional methods.

3.  Try to get them to smoke fewer cigarettes.

4.  Advise patients who ask about e-cigarettes that “these devices are probably much safer than combustible tobacco products.”

Finally, after expressing some e-cigarette gateway concerns, Fiore finishes with a strong message:

Furthermore, we need to communicate intelligently about harm reduction: not all nicotine-containing products are equal, and the public health focus should be on eliminating combustible tobacco products, even if some people who give up combustibles will continue using FDA-approved medications, e-cigarettes or smokeless tobacco products indefinitely…New approaches must be adopted if we are to dramatically reduce the harms of tobacco use in the United States over the next decade. To achieve this goal requires that we recognize the unequaled dangers resulting from combustible tobacco use.

The commentary is accompanied by an audio interview with Matthew Myers, president of the Campaign for Tobacco-Free Kids and one of the most aggressive opponents of tobacco harm reduction.  While promoting cherished topics like increased state funding for tobacco control and an FDA-imposed menthol ban, Myers offers positive comments on tobacco harm reduction that are truly transformative.  Here are some excerpts:

We all continue to look for ways to get people to quit smoking cigarettes, the most dangerous product.  And e-cigarettes on the surface appear to hold potential to be another tool to do so.  One of the reasons that you see so many people interested in e-cigarettes is that, while current FDA-approved smoking cessation aids are shown to be effective and increase the likelihood of someone being able to quit, the success rates aren’t what anyone wants them to be.

But there will still be some patients, for certain, who, even after being provided that advice [on FDA-approved methods], they either don’t want to quit or they have been unable to quit…in those cases a physician should make an individual judgment whether or not smokeless tobacco or an e-cigarette might assist that individual.  In other words, we should keep trying, until that person actually quits.

What I would most like to see is the FDA take all the steps it can to maximize the extent to which it discourages the use of cigarettes, the most deadly products, and to encourage the use of FDA-approved cessation devices and other nicotine that is delivered safely without causing the kind of deaths and disease we’ve seen.

With this change in disposition among long-term obstructionists, tobacco harm reduction is gaining real momentum.

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