Tobacco harm reduction: the devil is in the deployment

The idea of tobacco harm reduction—that smokers who cannot wean themselves off nicotine should be encouraged to adopt less harmful ways of consuming it—has much to recommend it. It avoids the trap of making the excellent (complete cessation) the enemy of the good (reduced harm) and provides a way forward where otherwise there is only a cruel impasse. It also provides a clear focus on disease and premature death—rather than tobacco addiction or corporate power—and this enemy, like so many medical problems before it, will be defeated with rigorous evidence, effective medicines, and skilled treatment.

In the United Kingdom the National Institute for Health and Clinical Excellence has just produced draft guidelines on harm reduction approaches to smoking and the Medicines and Healthcare Products Regulatory Agency is considering licensing electronic cigarettes.1 These moves are in response to the emergence of a range of nicotine containing products that seem suitable for temporary or indefinite use as partial or complete substitutes for tobacco. These include nicotine replacement therapy (patches, sprays, gums, lozenges, inhalators), licensed by the MHRA as pharmaceutical treatments for smoking, and unlicensed products such as topical gels and a burgeoning array of electronic cigarettes (e-cigarettes). This proliferation of nicotine containing products raises the classic public health question: what happens when a good idea at an experimental level is taken to scale? The answer is complicated by business interests: both the tobacco and pharmaceutical industries are keen to exploit harm reduction.