Today is tobacco-free day in Europe, with journalists doing a traditional scan of which countries that have instigated a ban on smoking in the public areas. The public often gets the impression that tobacco control policies are clearcut. In reality, a debate regarding tobacco and public health policies have been brewing as an undercurrent.
Recently, an interesting and controversial scientific conference in Warsaw was held on the issue of the harm reduction perspective.
Policies in Europe regarding alcohol, tobacco and drugs are most often instituted with a prohibitionist approach ("quit or die") but the harm reduction perspective takes another approach to public health.
Discussing the use of the harm reduction strategy on legal drugs is a relatively new development, but it is obvious that it has been fruitful in the area of tobacco control.
The harm reduction approach states that it is unlikely to rid the world completely of nicotine in the near future, and despite the recent regulations worldwide tobacco consumption has not decreased. Do we wish to punish sinners or help people, that is the issue at the core of the harm reduction debate.
Nicotine has in itself proven relatively less harmful, it is the smoke- the combustion in the oral cavity of tobacco that is the greatest risk with smoking. People smoke for the nicotine, but get killed by the smoke. The question is then, in the harm reduction perspective, are there less harmful alternatives for nicotine delivery?
There are three conditions for tobacco control programs that are to be met for a new product
1) It prevents initiation
2) Assists tobacco cessation
3) No environmental effects
and one might add that it should reduce the harm suffered for the smoker.
The best example so far in harm reduction is Sweden where more and more men are using a smokeless suckling tobacco know as "snus" (presently 22% of the population) and less and less men smoke (currently down to 14%). Among adolecents boys (16 years of age) daily smoking is 4% and snus use 11%. This reflects itself in the low figures for lung cancer with Sweden's 22.6 cases a year/ 100.000 inhabitants compared with Belgium's 69.9 cases a year/100.000 inhabitants (the lowest and highest rates in Europe respectively). Sweden also scores the lowest number of oral cancer cases, in Europe with Switzerland ranking highest.
A switch from cigarettes to smokeless tobacco, like snus, was calculated at the conference to reduce the harm by at least 90% and even more if nicotine replacement products were more widely accepted or legal.
So, why isn't this alternative to cigarettes discussed? The reason is that the European Union banned the sale of snus in all of Europe, with Sweden receiving an exception when it entered in 1995. Today the sale of snus is only legal in Sweden.
The harm reduction perspectives introduces a continuum of risk when it comes to regulation of nicotine delivery systems. Today, the less safe product, the cigarette is the least regulated. This is also because of ignorance with both the public and policy makers, as most associate the reduction of risk with a safer cigarette, not with smokeless tobacco or other nicotine replacement products.
The discussion about harm reduction is already rocking the public health community, where grave accusations are flying of this being a ploy big tobacco companies to keep people using some form of tobacco product. But discussion is unlikely to just go away, as the news of the Swedish alternative is spread around Europe.