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Medical implications
  1. Neal L Benowitz
  1. Division of Clinical Pharmacology and Experimental Therapeutics, University of California at San Francisco, Box 1220, San Francisco, CA 94143-1220, USA
  1. Correspondence to : Neal L Benowitz MD

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In relation to the medical aspects of harm reduction, two medical issues are of concern : (1) Do harm reduction strategies reduce the medical complications of tobacco use? (2) Are the treatments used to promote harm reduction in themselves harmful; which is analogous to the question - does the harm reduction policy cause harm?

I shall deal with these two general issues in the context of four treatment scenarios: (1) nicotine replacement or any other treatment with the goal of reducing cigarette consumption; (2) nicotine maintenance to support tobacco abstinence; (3) over-the-counter nic-otine availability; and (4) physical modification of cigarettes to reduce the adverse health consequences of smoking. I shall discuss efficacy and safety for each strategy.

Cigarette consumption and disease risk

The first general area is nicotine replacement, with a goal of smoking fewer cigarettes. The first question is, does smoking fewer cigarettes substantially reduce the risk of smoking related disease ? Most probably this is the case, with a couple of caveats.

Let us look at the three major diseases that are associated with smoking. Dose-response data on chronic obstructive lung disease are found in the British Physician Study.1 This very large study showed clearly that mortality from chronic lung disease increased as a function of smoking more cigarettes.

Lung cancer data, such as those from a study published by Rosengren, showed a clear dose related increase in lung cancer with a greater number of cigarettes smoked per day.2 The heart disease data are less clear. Different studies have reported different types of results. Some studies have reported roughly linear dose-responses, that is, greater mortality with more cigarettes smoked per day.

In the Wilhelmsen study, there was a relatively flat dose-response for cigarettes per day versus heart disease mortality or odds ratio for heart disease.3 In support of this flat …

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  • Research conducted by NLB and referenced in this report was supported by US Public Health Service Grants DA 02277, DA 01696, and RR-00083.