International Journal of Drug Policy 21 (2010) 129–130 Contents lists available at ScienceDirect International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo Commentary Harm reduction policies for tobacco users Coral Gartner * , Wayne Hall School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4008, Australia article info Article history: Received 16 September 2009 Received in revised form 26 October 2009 Accepted 27 October 2009 Keywords: Tobacco harm reduction Smoking Smokeless tobacco Snus Pharmaceutical nicotine abstract Tobacco harm reduction is a controversial policy due to the experience with filtered and ‘light’ cigarettes and concerns that the tobacco industry will use reduced harm products to undermine tobacco control strategies. The most promising harm reduction products are high dose pharmaceutical nicotine prepa- rations and low nitrosamine smokeless tobacco, such as Swedish snus. However, despite widespread availability, existing pharmaceutical nicotine preparations have not been taken up by smokers as an alternative to smoking. In Sweden, increased snus use was associated with decreased cigarette smoking and mortality from tobacco-related disease. We suggest a graduated series of policies to explore of the public health costs and benefits of encouraging smokers to switch to these less harmful nicotine products. © 2009 Elsevier B.V. All rights reserved. Tobacco harm reduction is a controversial policy because of history: a miscarried attempt at developing “safer” cigarettes in the 1950s was dishonestly used by the tobacco industry to deter smokers from quitting. When the harms of cigarette smoking first became apparent in the 1950s it seemed sensible to design less harmful cigarettes (Brandt, 2007; Parascandola, 2005). The first such “reduced harm” product was the filtered cigarette, followed by “light”, “low tar” or “low nicotine” cigarettes, all of which proved attractive to smokers and were supported by the National Cancer Institute and the US Public Health Service (Parascandola, 2005). Tobacco industry documents reveal that the industry knew these “safer” cigarettes did not benefit smokers because of compensatory smoking (e.g. drawing harder on the cigarette, covering the fil- ter holes, smoking more cigarettes) (Pollay & Dewhirst, 2002). The industry nonetheless aggressively used these products to reassure smokers that they could continue smoking whilst reducing their risks. This experience is routinely invoked by opponents of any form of tobacco harm reduction, a less appropriate argument in the case of more defensible forms of tobacco harm reduction such as using low nitrosamine smokeless tobacco and pharmaceutical nicotine (PN) products that are not smoked. In Sweden, a form of moist oral snuff, known as snus, has lower levels of nitrosamines than snuffs from other parts of the world due to its method of manufacture. This traditional tobacco product resurged in popularity in the 1970s and 80s amongst Swedish men, assisted by marketing campaigns and a lower taxation rate com- pared to cigarettes. Patterns of use in Sweden suggest that snus has * Corresponding author. Tel.: +61 7 33655543; fax: +61 7 33655442. E-mail address: c.gartner@sph.uq.edu.au (C. Gartner). been used as a cessation aid by existing male smokers and as an alternative to smoking by younger males (Gartner & Hall, 2009). Increased snus use was associated with decreased cigarette smoking and mortality from tobacco-related disease (Foulds, Ramström, Burke, & Fagerström, 2003). Because it is not smoked, snus does not carry any of the risks associated with smoked tobacco (e.g. exposure to carbon monoxide, fine particulates, etc.). Epidemi- ological studies suggest that snus use poses a low risk of oral or lung cancer, but may increase the risk of pancreatic cancer compared to no tobacco use (Broadstock, 2007). Epidemiological modelling suggests that the health gains from switching to low nitrosamine smokeless tobacco (LNSLT) are nearly as large as those from quitting all tobacco use (Gartner et al., 2007). Another approach to tobacco harm reduction involves using pharmaceutical or “clean” nicotine products (PN). Its major disad- vantage is that it has not been taken up by smokers as an alternative to smoking despite its wide availability in many developed coun- tries. This seems to be because the PN products that have been approved by the regulatory authorities have been engineered for smoking cessation and with the aim of minimising their abuse potential. They are also not marketed in a way that would make them attractive long-term alternatives to tobacco smoking. For these products to gain popularity, we would need to liberalise the regulation of PN products to allow them to be reengineered to increase their attractiveness to inveterate smokers. Concerns about tobacco harm reduction: Many health profession- als are reasonably concerned that the tobacco industry will use LNSLT to discourage smokers from quitting. Indeed, as public smok- ing bans have expanded throughout the United States, cigarette manufacturers have marketed these products, using cigarette brand names (e.g. Camel snus, Lucky Strike snus, Marlboro snus), as 0955-3959/$ – see front matter © 2009 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2009.10.008