A colleague of mine recently made me aware of a resolution in the Kansas House of Representatives "requesting the Kansas Department of Health and Environment to conduct a study regarding tobacco harm reduction." This cacophonous social debate centers on the idea of recommending chewing tobacco (i.e., snuff) to cigarette smokers to reduce societal harm associated with cigarette smoking. Cigarette smoking remains the leading cause of preventable death and disability in the United States, and tobacco harm reduction (THR) has been proposed as a way to mitigate this ongoing public health disaster. One way to more clearly understand this debate is to consider it at two levels: the societal and the individual.
At the societal level, one must envision the population impact of having all smokers switch to smokeless tobacco. Smokeless tobacco is associated with fewer health risks than cigarettes, but it is not "risk free." Statistical modeling has suggested that widespread public health advocacy of this approach could result in net population harm with some smokers becoming "dual users" (i.e., smoking cigarettes and using smokeless tobacco simultaneously). Dual use of tobacco may be associated with more risk than cigarette smoking alone. THR also undermines clear indoor air policies, which are effective in reducing cigarette consumption, because it allows smokers to maintain tobacco dependence by using smokeless tobacco at times when they cannot smoke. Not surprisingly, THR is endorsed by cigarette manufacturers who now also sell smokeless tobacco. THR advocates decree that the reduction in societal adverse health consequences if all smokers switched to smokeless would be significant. The likelihood of this occurring is probably overestimated as smokeless tobacco is already widely available and very few of my smokers are electing to switch.
At the individual level, it is important that primary care providers remain cognizant of the risks associated with our clinical recommendations. Whenever we prescribe or recommend treatment, we assume responsibility for both the clinical benefits and the adverse effects, or risks. Long-term use of smokeless tobacco is associated with an increased risk for adverse cardiovascular events (i.e., stroke and myocardial infarction) and cancer. If we were to recommend that our patients switch from cigarettes to smokeless tobacco, we would necessarily be assuming the responsibility for adverse health effects associated with smokeless tobacco. Regarding the medications currently available for tobacco dependence treatment, we can stand confident with the Food and Drug Administration approval for their use and the thousands of patients who have used these medications safely. If our patients develop cancer or have a heart attack or stroke from the smokeless tobacco that we recommended to treat their smoking addiction, who do we have to blame but ourselves?
Jon O. Ebbert, M.D., is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He has received support from Pfizer, maker of varenicline (Chantix), to conduct clinical trials for smoking cessation and has received consulting fees from GlaxoSmithKline, maker of Nicorette. The opinions expressed are solely those of the author. Send him an e-mail at ebbert.jon@mayo.edu.