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Applying the risk/use equilibrium: use medicinal nicotine now for harm reduction
  1. Department of Biobehavioral Health
  2. †Department of Economics
  3. The Pennsylvania State University
  4. *Roswell Park Cancer Institute
  5. Department of Cancer Prevention, Epidemiology, and Biostatistics
  6. Pennsylvania, USA
  1. Lynn T Kozlowski, PhD, Department of Biobehavioral Health, The Pennsylvania State University, 315 East Health and Human Development, University Park, PA 16802, USA; ltk1{at}

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Both the recent Institute of Medicine (IOM) report1 and the article by Henningfield and Fagerstrom2 in this issue ofTobacco Control consider the value of adding harm reduction products to the main public health strategies for dealing with tobacco use—prevention, cessation, and protection of non-smokers from tobacco smoke pollution.3 4 Harm reducing products are those that lower total tobacco caused morbidity and mortality, even though these products might involve continued exposure to one or more tobacco related toxicants. The IOM committee developed a testing strategy to assess which products (tobacco or pharmaceutical) are truly harm reducing, along with surveillance and regulatory principles for the protection of public health. Henningfield and Fagerstrom2 discussed the possible benefits from an uncontrolled harm reduction “intervention” in Sweden involving Snus (Swedish moist snuff) and to some extent nicotine replacement pharmaceuticals or medicinal nicotine (MN).

It will take years, if ever, before any battery of IOM-type tests will be in place. Given the probability of legal and political battles, the final form of testing and regulation may be far from adequate, leading to further decades of the promotion of ostensibly reduced risk products falsely reassuring tobacco users. Cigarette smoking remains the single leading preventable cause of death in most developed countries5 and a major cause of current and future deaths in developing countries.6 For health, non-smokers should never start smoking, and current smokers should become former smokers as soon as possible. Harm reduction, if done well, offers additional promise. Once it was hoped that lower tar cigarettes would have harm reducing properties and be good for the public's health,7but, on current evidence, they have been a public health disaster.8-11

Strongly prefer harm reduction products with the largest effects to those with small effects

One harm reduction strategy is to alter cigarettes to try to reduce or eliminate toxic ingredients. Such altered …

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