Smoking rates in the United States have fallen dramatically over the past several decades, a genuine public health success story, but smoking remains one of the leading causes of preventable death. Convincing the public that smoking was harmful was an easy argument to win: Americans agree that smoking is dangerous. The harder question is what to do for the millions of people who still smoke.
Harm reduction is a well-established principle in public health. Life involves trade-offs, and there are times when choosing a less harmful option is better than insisting on a perfect solution that people might never achieve. Yet one of the clearest opportunities to apply harm reduction has been largely ignored: tobacco.
When non-combustible nicotine products first entered the market, public health leadership and medical organizations reacted with deep skepticism. In some ways, this was understandable. They had invested heavily in building awareness of the harms of smoking and addiction, and largely succeeded in changing public perception. Why would they be distracted by a product that complicates that message and carries its own set of risks?
But health officials' duty was to take seriously the potential harms of non-combustible nicotine products, but also evaluate them against the known severe risks associated with traditional combustible cigarettes. That didn’t happen.
Instead, the medical establishment took a zero-tolerance position that rested on two claims. First, non-combustible nicotine products would act as a gateway to teen cigarette smoking. Second, that there was little evidence that these products would help current smokers move away from combustible tobacco, and so giving even an inch was misguided. Their messaging led many members of the public to become convinced that non-combustible nicotine products were harmful in ways that were equal to, and maybe even worse than, traditional combustible cigarettes.
This was incorrect, but didn’t matter to policymakers, and it distorted how the public, and even some members of the medical community, viewed the risks involved. Nicotine is addictive, and may carry some health risks. But the overwhelming driver of the harms from smoking—cancer, chronic lung disease, heart disease, and countless other smoking-related illnesses—is due to the toxins created when tobacco is burned. That distinction—the risks of nicotine versus the far greater harms from combustible tobacco—was too often lost in the conversation. The result was widespread confusion that left many smokers believing there was little meaningful difference between continuing to smoke cigarettes and switching to a non-combustible nicotine alternative.
Significant restrictions were enacted to discourage the use of any nicotine product with no consideration of a rational middle ground. These actions might have been grounded in legitimate concern at first, but they were communicated to the public with far greater certainty than the evidence actually supported. And more importantly, once the evidence evolved, these same leaders, certain in the rightness of their position, failed to evolve with it.
Over the past decade, the scientific literature has settled in a different place than American public health leadership predicted it would. The feared resurgence in youth cigarette smoking never materialized, and what became clear was that non-combustible alternatives had allowed many adult smokers to reduce or eliminate their use of combustible cigarettes.
This is the essence of harm reduction. Helping even a portion of smokers move from combustible cigarettes is an unquestionable good, even if complete nicotine abstinence is never achieved.
The United Kingdom recognized this years ago and formally incorporated tobacco harm reduction into its public health strategy. The United States did not. Instead, the American medical community continued to overstate theoretical risks of nicotine alternatives that were not borne out by study, and gave little to no attention to the growing body of evidence that harm reduction could benefit adult smokers.
This is beginning to change.
Current public health leadership has signaled a greater willingness to recognize harm reduction as a legitimate approach to addressing nicotine dependence. This is a move that will save lives.
The next chapter in tobacco control will be about supporting the people who benefited least from its initial successes: lower-income Americans, veterans, and people living with serious mental illness. They continue to bear the greatest burden of smoking-related disease. They deserve public health recommendations grounded in the best available evidence.
The harm of refusing harm reduction is not theoretical. Every smoker who continues to use combustible cigarettes because the medical establishment is unwilling to embrace harm reduction represents a missed opportunity to prevent disease. Public health leaders should have the humility to acknowledge that they got this issue wrong—and the courage to follow the evidence now.
