Health Promotion and Harm Reduction

It happens in almost every city and town in the country: a woman stands up in a small meeting on a Tuesday night and says, “Hi, I’m Lisa and I’m an alcoholic.” AA meetings are part of the community woof and warp, woven together with Little League and Fire Department fund raisers. As traditional as the existence and format of an AA meeting is the fact that a big chunk of Lisa’s audience is smokers. Because of the anonymous nature of AA membership, there are no readily available data on who goes to AA, how many attend, and of course, what is their success regarding controlling alcohol abuse.

Nevertheless, is it conventional wisdom that a very large segment of AA members smoke cigarettes; typical meetings are smoke-filled. The purist health promoter wants to get these individuals to stop both abusive drinking and smoking. However, a more measured attitude is that cigarettes do little harm except serious illness and death beginning in middle age, while alcohol ruins everything: family, employment, health, safety, moral decision making, financial security, and self respect. This perspective believes that if people can control drinking they have dodged a nuclear explosion to the bullet of cigarettes. They would leave a concern for smoking to another day. First things first.

This certainly does illustrate, however, that many people, not just alcoholics, struggle mightily with quitting smoking. Fifty years into the international anti-tobacco campaign we still have 45 million U.S. smokers. This in spite of heart-to-heart advice from physicians, public media campaigns, package and advertising warning messages, local ordinances banning smoking in places open to the public, the dissemination of many tools for quitting, such as nicotine replacement skin patches, and dramatically increased price. All of this to no avail for all these millions of addicts.

So here is the question. What should be our approach to all those millions who are truly addicted to nicotine, and in spite of their best efforts, are unable to break their habit? There are basically two answers. The first is to continue to encourage, to provide new opportunities and new resources, provide more social support, teach quitting skills, and keep reinforcing the importance of stopping smoking. There is always hope that the next quitting attempt will be successful. This approach is certainly in the mainstream of health promotion, and is the one endorsed by organizations like the American Cancer Society and the National Cancer Institute.

The second approach is to ask, if we can’t get the person to quit smoking, is there a way to reduce the health risks they face? The answer is yes, though the alternative is quite controversial. Cigarette smokers are addicted to nicotine. The drug from any source will feed the smoker’s addiction. Cigarettes are familiar and provide a drug dosage which will satisfy the habit of most smokers. On the other hand, people could also obtain nicotine from smokeless tobacco. There are some health advocates who believe that providing smokeless tobacco as a stop gap measure, until such time as the person is able to break the nicotine addiction fully, is a much safer alternative to smoking. While I subscribe to that approach, it is certainly health promotion heresy for many people.

We have told everyone for decades that all tobacco-cigarettes, chewing tobacco, snuff, and cigars are hazardous to health, and that there is no safe tobacco consumption. All of this is correct. However, the various forms of tobacco are not equally hazardous. It turns out that cigarettes are many times more deadly than smokeless tobacco. The risk of smokeless is not zero, but it is far, far less than smoking cigarettes. Therefore, if a smoker can supply their nicotine habit with smokeless, that is a positive step. To discourage that step, giving the person only the option of continued smoking when they can’t quit entirely, is not a health promoting message. Of course over the long run it is still a worthwhile goal to eventually get rid of all tobacco, but until that time comes, people are much safer with smokeless than with cigarette tobacco.

There is one huge chink in the armor of this logic, and that is, What will the tobacco companies do with a health promotion endorsement? We have seen big tobacco trade on the false health claims of filters and low tar cigarettes. They are not to be trusted. It is one thing to offer smokeless hope to a confirmed smoker. It is another to publicly broadcast health claims about these products. Related to this issue is how do we prevent the tobacco companies from slyly though ingeniously marketing these products to kids? If you don’t think this will happen, you are smoking something else.

We are faced with a dilemma. I believe offering smokeless tobacco is a health promotion tool for many severely addicted smokers. This substitution for cigarettes will benefit those smokers and society-at-large. However, I don’t want to see smokeless marketed to teens or even for adults to add smokeless on top of cigarettes. We don’t really know how to negotiate this treacherous territory, but if the regulatory challenges can be solved, this is a way to significantly decrease the human toll of tobacco in our communities.