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In total there are over 80 papers in this collection, and these have been divided into ten sections. Each of the sections contains papers advocating for harm reduction, as well as papers that provide the evidence base for harm reduction. For many of the sections, there are also articles for “further reading”. To view the documents in each section, as well as a description of the section itself, please click on the links below.
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1. Overviews of harm reduction
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2. Nicotine policy
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3. Regulation of nicotine replacement therapies
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4. The health risks of smokeless tobacco and its role in a harm reduction strategy
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5. Regulation of cigarettes
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6. The failure of light cigarettes
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7. Cigarette reduction
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8. PREPS and other tobacco use
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9. The role of the tobacco industry and funding
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10. Communication and perceptions of relative risk
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1. Overviews of harm reduction
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The rationale behind tobacco harm reduction approaches is that, while dependence on nicotine (the addictive substance in tobacco) underpins most tobacco use, it is not what causes most of the harm. Cigarettes are the dominant global nicotine delivery devices and are highly engineered and sophisticated, yet extremely harmful and largely unregulated. Harm reduction approaches to tobacco use are aimed at reducing the adverse effects of tobacco use for continuing users. This can be achieved through education, promoting reduced consumption as a viable alternative to abstinence, and promoting alternative forms of nicotine delivery which, relatively at least, carry less risks of harm. This section includes papers, book chapters and reports that examine the need for a harm reduction strategy alongside other tobacco control strategies, and what the scope of such a strategy might be.
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2. Nicotine policy
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This section examines the policies that are needed in order to improve the regulation of all nicotine products. These papers discuss how cleaner nicotine products can replace cigarettes as the dominant form of nicotine delivery. In particular, they detail the need for a single coordinated regulatory framework for all nicotine products together.
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3. Regulation of nicotine replacement therapies
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Nicotine replacement products (NRT) are products that are manufactured by the pharmaceutical industry to be used as aids to smoking cessation and are ‘clean’ nicotine delivery devices. They have proven efficacy and currently there are six different types of NRT available in the UK, one of which (the gum) was launched in the UK in 1981. Lengthy experience with these products has demonstrated that they are much less harmful than smoking, although caution is needed with some populations such as pregnant women. However, NRT products are much more tightly regulated than tobacco and their use, until very recently, is mostly restricted to short-term use during a quit attempt.
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4. The health risks of smokeless tobacco and its role in a harm reduction strategy
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Smokeless tobacco products are less harmful than cigarette smoking because they are non-combustible. Nevertheless, there is a wide variety of different smokeless tobacco products on the market around the world and they differ enormously in terms of their use across different populations and contexts, and their harmfulness. Some papers in this section focus on the Swedish case study and “snus” (a smokeless tobacco product manufactured to contain very low levels of many carcinogens). Snus has a long history of widespread use in Sweden, which has a low smoking prevalence and low tobacco related morbidity. Other papers focus on the types of smokeless tobacco that are used in other countries. The potential role of regulated smokeless tobacco products within a harm reduction strategy is also explored.
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5. Regulation of cigarettes
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There will never be a truly “safe” cigarette because the process of combustion, by its very nature, releases a host of toxic smoke components. However, it may be possible to make changes to cigarettes to minimise these harmful components, and regulators and manufacturers would be negligent if they did not utilise all knowledge at their disposal to reduce the harmfulness of cigarettes to the extent that this is feasible. The cigarette is a highly engineered and sophisticated nicotine delivery device and an assessment of the harm and addictiveness of cigarettes will need to be made across a number of dimensions. The articles in this section focus on how the cigarette has changed over the years, and the various attempts that have been made to monitor and regulate them.
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6. The failure of light cigarettes
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Thus far, the most significant attempt to reduce the harmfulness of cigarettes was the “tar reduction” strategy. It is now widely agreed that this strategy has achieved little (if any) public health benefit. Crucially, it failed to take account of the fact that smoking is a predominantly nicotine-seeking behaviour. Additionally, the tobacco industry designed cigarettes to subvert the strategy in a number of ways, including the misleading labelling of lower tar cigarettes as “light” or “mild”. This section includes papers that explain why the tar reduction strategy failed as well as those that make recommendations for future regulation.
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7. Cigarette reduction
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Cigarette reduction has been widely proscribed as a harm reduction measure as, when reducing the number of cigarettes smoked each day, many smokers tended to smoke each individual cigarette more intensively. However, recent evidence has emerged to show that cutting down with the use of nicotine replacement therapy to top up nicotine levels may reduce compensatory smoking and result in increased quitting behaviour.
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8. PREPs and other tobacco use
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In addition to conventional cigarettes, and smokeless tobacco (covered in Section 4), there are other forms of tobacco available. For example, traditional alternatives to cigarettes are pipes and cigars and several tobacco companies have designed (and in some cases marketed) new forms of nicotine delivery – sometimes referred to as Potential Reduced Exposure Products (PREPs). These include, for example, “Eclipse” - a product that heats the tobacco rather than burning it. In the USA, this is being marketed as a safer alternative to conventional cigarettes. The health risks of these alternative tobacco products compared to the conventional cigarette are explored in this section.
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9. The role of the tobacco industry and funding
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This section includes articles which examine the tobacco industry’s knowledge of smoking and toxicity as well as the potential role that the industry can play in tobacco harm reduction in the future. (In addition, the role that the tobacco industry played in subverting lower tar cigarettes is covered in Section 6.)
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10. Communication and perceptions of relative risks
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The attitudes of smokers towards harm reduction products are critically important to their success. This section includes papers which outline and investigate how much smokers understand about the role of nicotine in their tobacco use and the relative risks of smoking cigarettes compared to other forms of tobacco.
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