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Nicotine Addiction: Harm Reduction by E-cigarettes and Snus

Joel L. Nitzkin, MD, Public Health Physician, New Orleans, LA

Q: Tobacco smoking remains the most preventable primary form of cancer causation in Americans. A recent Medscape column urged that harm reduction for confirmed nicotine addicts is the kindest and most effective strategy. How can products like “snus” be helpful?

A: As noted by Dr. Michael Russell in 1976, people smoke for the nicotine, but die from the tar. According to CDC, about half of long-term smokers will die of a smoking-related disease. They estimate that about 480,000 Americans die from cigarette smoking each year, including about 50,000 from the environmental tobacco smoke. According to our best current estimates, snus and the other smokeless products used by American men pose little or no risk of cancer of the mouth or any other cancer. E-cigarettes, having no combustion and no tobacco, are likely similarly low in risk.
Snus, e-cigarettes, and other smokeless nicotine delivery products offer an interesting and unusual approach to reducing the deadly toll of addition to cigarette smoke. Rather than present themselves as drugs to treat a deadly disease, these products offer recreational substitutes for cigarettes that already enable large numbers of smokers to satisfy their urge to smoke while reducing the risk of potentially fatal cigarette-related cancer and other diseases by more than 95% (likely more than 99%). This is a public health benefit that can be secured for many more smokers, (at no cost to the taxpayer) by simply advising them of this difference in risk. Sweden, where most men use snus rather than cigarettes to satisfy their urge for nicotine, has the lowest rate of lung cancer among men in the Western world. There is even one small study that shows that e-cigarettes can get smokers not interested in quitting to quit by switching to this much lower risk product. All it takes is informing them of this difference in risk.
American public health authorities recognize that snus and e-cigarettes are much lower in risk than cigarettes. Their objection to allowing manufacturers to claim lower risk, however, is based on a very different concern. They object on the basis that advertising these products as lower in risk might attract teens and other non-smokers to tobacco-related products; and from there to cigarettes. Research published this last decade provides substantial evidence that such advertising would not be likely to attract teens to these lower-risk products who otherwise would not have taken up smoking.
For many years, the goal of public anti-smoking programming has been “a tobacco-free society.”This goal has been based on the premise that all non-pharmaceutical nicotine products are so addictive and so hazardous that none should be tolerated. This goal has also been interpreted as ruling out any consideration of any non-pharmaceutical nicotine product in any public health initiative. Now that we know that we can communicate reduced risk without attracting teens who otherwise would not have taken up smoking, the time has come to use this knowledge to further reduce the burden of addiction, illness, and death that cigarettes have imposed both in the USA and worldwide.
Joel Nitzkin’s contact info is included in the author affiliations at the top of this page.
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