“Harm reduction” is an established policy in public health.

For various reasons, some people sometimes find themselves doing things that are bad for their health. In an ideal world, no one would be a drug addict, prostitution would not exist and no one would smoke. All that public health would have to do is to make sure people were informed of the health risks of their behaviour, refer them to a program, and the problem would be solved.

In our real world, that rarely works. A harm reduction approach recognizes the reality that some people are unable to quit taking drugs, having sex with strangers or smoking cigarettes, even though these behaviours may have deadly consequences for themselves and harm the people around them. Harm reduction experts encourage people to seek help and find definitive solutions to their problems, but until they can achieve that goal they attempt to minimize the damage. For drug addicts, this may mean providing clean needles or a safe source of opioid drugs, for prostitutes it may include health checks and free condoms, and for smokers it involves informing them about, and providing access to safer sources of, nicotine.

Since the 1970’s scientists have known that nicotine is the part of cigarette smoke that provides the “buzz”. As someone becomes a smoker, their brain adapts and comes to require a regular source of nicotine for the smoker to feel normal. Attempting to quit leads to withdrawal symptoms and cravings, that often result in the smoker resuming tobacco use. A smoker who has become dependent on nicotine will typically smoke within 30 minutes of waking, as their nicotine levels will have fallen overnight. They will continue to smoke even if they are in bed with the flu or a sore throat. If they are forced to go without nicotine for a long time, such as on a flight, they will smoke at the last possible moment before entering the airport and resume smoking as soon as they leave the airport at their destination. In this respect, nicotine is similar to caffeine. Some people need a cup of coffee first thing n the morning to get their brain started, and develop a headache if they miss their afternoon coffee.

However, nicotine does NOT cause the cancer, heart disease and lung disease that eventually kills half of all people who smoke regularly. That is due to the carbon monoxide and 7,000 other chemicals produced by burning tobacco leaves.

There are a variety of products available that provide smokers with the nicotine that they have come to depend on, without the harmful chemicals produced by burning tobacco leaves.

Ideally, there would be a single product that would provide smokers with a safe source of nicotine that did not involve the consumption of tobacco, burning, or the inhalation of fumes, but there is not. It would be ideal if the product was also cheap and enjoyable, so as to make it attractive to smokers.

Cigarettes provide adequate amounts of nicotine. Some smokers still enjoy smoking, but most would prefer to quit if they could. Cigarettes involve tobacco, burning and inhalation, so they are by far the most dangerous form of nicotine.

Medical nicotine replacement therapy (NRT) often does not provide as much nicotine as smokers need. The patches can be irritating and may cause nightmares, However, NRT is tobacco-free, is not burnt and is not inhaled. NRT is relatively expensive unless it is covered by a drug plan or provided by a clinic.

Vape or e-cigarettes are a tobacco-free source of nicotine. They do not involve burning, but they do produce a cloud of vapour that is inhaled. They come in a variety of tobacco, fruit and dessert flavours that can make them enjoyable. They are much cheaper than cigarettes.

Heat-not-burn (HNB) products are devices that heat a small pouch of real tobacco. They are the most cigarette-like option. They do not involve burning but they do produce a vapour that is inhaled. They are probably less safe than vape or snus, but still much safer than cigarettes.

Snus are a small pouch of real tobacco that is treated to reduce its toxicity. They are held in the mouth, and not burnt or inhaled. Snus are very popular with Swedish men, who have the lowest smoking rates and lung cancer rates in Europe, but they are banned in the rest of the EU.

This graph gives some indication of the estimated risk of cigarettes and alternative less harmful sources of nicotine.

So, does tobacco harm reduction work? Is it possible to get smokers to switch to less harmful sources of nicotine, and does that save lives?

Related blog postings examine the success of less harmful nicotine products such as HNB in Japan, Snus in Sweden, and Vape in New Zealand.

(This article was written by Dr. John Oyston, a Canadian physician who has seen the disease, disability and death caused by tobacco. He is strongly opposed to tobacco smoking and believes that tobacco harm reduction is an essential component of any modern tobacco control strategy, He mostly researches, writes and speaks on this topic “pro bono”, funded the money he has earned providing medical care to smokers, but he does sometimes accept funding from tobacco and vaping companies where this allows him to amplify his message.)