A tobacco-free society or tobacco harm reduction? Which objective is best for the remaining smokers in Scandinavia?

Abstract

ENGLISH SUMMARY: Harm reduction means that cigarette smokers who are either unable or unwilling to stop using nicotine products are encouraged to switch to nicotine products with much lower health risk. Harm reduction has previously been debated in various forms in the area of tobacco when filter cigarettes were introduced in the 1960s, and when so-called «light cigarettes» with reduced tar and carbon monoxide content were introduced in the 1980s. However, epidemiological research has shown that the health benefits associated with switching to such products have been small – perhaps even nonexistent. The result of such previous negative experience is that the health authorities in most countries have shown very little enthusiasm for new preventive strategies that include switching to tobacco and nicotine products that are less damaging. However, the current debate about harm reduction is different from the previous debates in that this time real risk-reducing products (snus, medicinal nicotine products and other non-medicinal nicotine products) are being discussed. There is consensus that a switch from cigarettes to such products would involve a significant reduction in risk for individual smokers. The reason for current scepticism is primarily uncertainty about what a harm reduction strategy could lead to at the population level. In addition, the established measures that the authorities in Scandinavia have introduced to reduce smoking have been very effective, and why not just intensify their use? If snus were added to the arsenal of harm-reducing products, for example, this would go against the stated aim of the authorities to achieve a totally tobacco-free society. Some of the important areas that are discussed in this report: • Despite the fact that measures to prevent smoking have been effective, and the proportion of smokers is decreasing in Scandinavia, the need for harm reduction measures has become greater because: – There is an imbalance between the motive to stop smoking that the authorities have created with campaigns, duties, restrictions etc, and the help that is offered to people who are trying to stop smoking. Nicotine replacement products are used to a small extent. The amount of assistance provided by health care personnel is moderate. In addition, the effect of nicotine replacement products and the effect of interventions provided by doctors is very limited. – The remaining group of smokers increasingly contains a higher proportion of people with social, mental and demographic characteristics associated with reduced ability to stop smoking. – For twenty years there has been a social gradient in smoking pattern in Scandinavia. The search for measures that are tailor-made for smokers with specific characteristics, for example short education, has been going on for a long time. Literature reviews have not identified measures that the authorities could implement in order make the social gradient in smoking pattern less steep. – In Scandinavia, nearly all the political measures recommended by WHO for reducing smoking have already been implemented. There is probably little potential for further reduction by using publically-regulated control of tobacco. Despite the fact that tobacco control measures are utilized to such a degree, the proportion of deaths due to smoking among adults is still very high. – Intensifying the existing measures against smoking that have been effective up to now would probably give only a moderate return (diminishing marginal returns). – Cigarette smoking is ideal for a harm reduction strategy, because the substance that causes addiction – nicotine – is not the cause of the health risk. People smoke because of nicotine, but die from tobacco smoke. Much less hazardous nicotine products are available. • Harm reduction is an obvious strategy for a many other areas of risk. The reason why the debate about harm reduction in the area of tobacco has come later, is probably related to the widespread belief that it is possible to achieve a tobaccofree society. • If the authorities in the Scandinavian countries wish to even out future social differences in health in the population, a harm reduction strategy in the field of tobacco may be appropriate. • In order for harm reduction to be successful, consumers must receive correct information about the relative health risks of different types of nicotine products. Today, both smokers and general practitioners are misinformed. The ban that exists in several Scandinavian • countries against «new types of tobacco and nicotine products» can function today as a barrier to effective harm reduction in the remaining segment of smokers, and should be replaced with regulations that control «new» nicotine products. • Production of nicotine products that have higher potential for use than currently available medicinal nicotine products, and that is more effective in stopping smoking, should be stimulated. • Harm reduction policy must be made legitimate by the authorities. It is clearly a disadvantage and a hindrance for harm reduction if the snus industry is the most visible proponents of harm reduction. Snus as a harm-reducing alternative: • The health authorities in Norway and Sweden – where sale of snus is allowed – provide information about the health risks associated with the use of snus, but do not inform smokers about the health benefits that can be achieved by switching from cigarettes to snus. At worst, this can mean that nicotine-addicts remain smokers with no motive to try a harm-reducing alternative. • The cigarette industry are in the process of buying themselves into the snus industry, and wish to sell snus in addition to – and not instead of – cigarettes. They regard snus as a so-called «bridging product» that can be used in social arenas where there are smoking restrictions in order to keep smokers dependent on nicotine (nicotine maintenance policy). In addition, there are several examples from Scandinavia that the snus industry are carrying out innovative product development with a view to recruiting young people of both sexes. • Reviews of the scientific literature show that snus is substantially less hazardous than cigarettes. The magnitude of the overall reduction in hazard has been estimated to at least 90 %. • Much research remains to be done before we know the precise effects of snus from a public health perspective. Several issues are not possible to research, but the pattern of use of snus in Sweden and Norway suggests that availability of snus must have a positive net effect on public health. This can be an argument for withdrawing the ban on snus in the EU, but it can also be argued that the pattern of use observed in Scandinavia not necessarily will occur in other countries. • There is little empirical data from Scandinavia to support the hypothesis that snus increases the risk of starting to smoke. There is some empirical data to support the hypothesis that snus reduces the risk of starting to smoke. • There are no randomized controlled studies in which the effect of snus on smoking cessation has been measured. Observational data from Scandinavia are consistent in demonstrating that snus leads to an increase in the quit rate for smoking. Self-reports from Norwegian quitters indicates that the effect is greater than the effect of nicotine replacement products. • An argument for including snus in the arsenal of harm-reducing products is that it has great potential for use in marginalized smoking populations, which include people who have high immunity for traditional preventive measures for smoking. The structure of the report The report starts with a discussion of what should be the overall aim of future tobacco policy in countries with an advanced tobacco epidemic: a tobacco-free society or reduction in tobacco-related diseases? Does striving towards a tobaccofree society hinder harm-reducing measures that could save lives? In the report, the harm reduction debate is presented. The difficult climate for discussion, resulting from harm reduction being an ethical issue, is discussed. In a society where tobacco has become «our worst enemy», that everyone can be united in fighting against, it is easy to regard harm reduction as an untimely course of action, and to dismiss it by labelling it as tobacco liberalism. I then show how harm reduction will become increasingly relevant and appropriate in Scandinavia, among other things because political measures can have attained their full effect, while levels of harm remain high. Harm reduction may also become appropriate because the group of remaining smokers in Scandinavia will consist of more and more people with the psycho-social characteristics of people who are difficult to influence just by more intensive use of the traditional preventive measures against tobacco. I argue that harm reduction will be an appropriate measure for achieving the aim of the authorities to reduce inequalities in health between different social groups. Harm reduction may also become appropriate because there is an imbalance between the strong desire for smokers to stop smoking that the authorities have created (with campaigns, restrictions and duties), and the moderate supply and mediocre effect of the help that is offered to people who are trying to stop smoking. We also discuss how biased information about the relative health risks associated with the use of different tobacco products has created misinformed consumers who are unable to make optimal choices.