By Todd Seavey
Posted: Monday, July 1, 2002

ARTICLES
Publication Date: July 1, 2002

n a world where so many things are categorized as all-good or all-bad, the concept of "harm reduction" — ameliorating certain health risks when it is impractical or undesirable to eliminate them entirely — remains controversial among public health experts, noted Dr. Elizabeth M. Whelan, president of the American Council on Science and Health, as she introduced the group's harm reduction symposium on June 26 in New York City.

ACSH advisor Dr. Kimberly M. Thompson framed the topic by describing the broader topic of risk management and the costs and benefits associated with risk evaluation, costs and benefits often obscured by sensational media reports, which typically fail to put health risks in perspective by comparing them to familiar, "everyday" risks. Thompson is an associate professor of risk analysis and decision science at the Harvard School of Public Health.

The symposium was centered on two point/counterpoint sessions, one about tobacco and one about alcohol. (See Dr. Whelan's article on "chaw" as an alternative to smoking.)

The Smokeless Tobacco Controversy

In the first, Dr. Greg Connolly of the Massachusetts Department of Health criticized harm reduction efforts aimed at getting inveterate tobacco users to switch from smoking (which causes lung cancer and other health problems) to smokeless tobacco of the sort carried between cheek and gum (which is far less dangerous despite a risk of oral cancer). Connolly contends that the primary effect of encouraging smokeless tobacco use would simply be to create new, young users of tobacco who might in time switch to smoking. He describes smokeless tobacco as a "gateway drug" and said that encouraging use of something that causes oral cancer defies the first principle of the Hippocratic Oath: "do no harm."

Dr. Phil Cole, professor emeritus of the department of epidemiology at the University of Alabama at Birmingham School of Public Health, countered that some 50% of smokers arguably die prematurely from their habit while only about one half of one percent of smokeless tobacco users are killed by their habit. He pointed to Sweden as an example of a country that has seen an encouraging decline in smoking due in part to increased use of smokeless tobacco. Is it a coincidence, asked Cole, that the country with the lowest smoking rate has the highest rate of smokeless tobacco use?

Connolly attributed Sweden's smoking decline instead to anti-tobacco public service announcements and other anti-smoking efforts there. He dismissed Cole's analysis, telling him, "You're not a doctor."

Moderate Alcohol Consumption?

In the session on alcohol, Dr. Peter Provet, president of the Odyssey House treatment center, urged abstinence as the best method of dealing with problem drinkers, saying that holding out the possibility of moderate alcohol consumption to people with alcohol problems was not only bad policy but a threat to the entire alcohol-abuse tradition, which depends in part on a consistent, frequently-reinforced message of abstinence. "We shouldn't jump to a new model," he said, noting that "people who stay in long-term, residential [abstinence-based] treatment have a very high success rate."

Dr. Sally Satel, a W.H. Brady Fellow with the American Enterprise Institute and staff psychiatrist at the Oasis Clinic in Washington, D.C., countered that many people who are problem drinkers but are not full-blown alcoholics "will just not go to a program that calls them 'alcoholics'." They might, however, be willing to participate in a more low-key program that merely taught them moderation. Abstinence may be an unrealistically high hurdle for some, and "the counselor becomes very hostile, often, when the patient rejects it." She notes that many of the people who seek "moderation management" programs are not people who would otherwise have gone to AA but rather people who would otherwise have done nothing about their drinking problems. Satel acknowledged that moderation sounds like an imperfect solution but thinks it is a more realistic one for some drinkers. Satel said Alcoholics Anonymous participants have a 75% dropout rate and that participants in abstinence-based programs in general have about a 60-80% relapse rate. She said that when people say moderation is a bad idea, "remember to ask them: compared to what?"

Harm Reduction Precedents and Prospects

"The drugs are still winning bigtime, and the picture is quite dismal," said Dr. George Lundberg during his keynote speech at the end of the symposium. Lundberg is the editor of the Medscape General Medicine website, editor-in-chief emeritus of Medscape, former editor of the Journal of the American Medical Association, and an ACSH advisor.

Though there is still debate over how best to foster harm reduction among smokers and drinkers, Lundberg noted other examples of harm reduction in action, such as providing clean needles to people unlikely to stop their intravenous drug use, condoms to teens likely to have sex, and low-fat diet suggestions to chronically overweight people. "That's harm reduction," he said. Relying on abstinence alone is unrealistic, and he noted the failure of drug prohibition: "Doesn't work, never has, never will in a free society."

Lundberg noted the speed with which young nicotine users can become addicted and recommended that in their case we still do all we can to eliminate use and encourage them to abstain entirely. For adults who have long smoked and will likely never give up the habit, though, he endorsed alternative nicotine-delivery mechanisms (since nicotine itself is not known to be very dangerous) that eliminate the need for smoking, which causes lung cancer and numerous other ailments: "I don't care how you give it to them. I'd like to give 'em the spike," said Lundberg, "just so they don't ignite it."

For the young, who are newly experimenting with potentially addictive substances, Lundberg said social norms may be the most important incentive toward good behavior. For long-term, hardcore addicts, though, he recommended harm reduction methods: non-smoking delivery of nicotine in the case of smokers and complete avoidance of alcohol in the case of full-blown alcoholics. The debate over the best treatments continues, though, and Lundberg said we must continue to ask, "How can we build incentives to get people to do the right thing?"

 

Responses: August 16, 2002 I recently read the published study on this debate and wanted to add my opinions. I have been smoking off and on, more on than off, since I turned eighteen. In the past six years, I have tried quitting cold turkey, patches, and nicotine gum, with little success. I recently was turned on to chaw because a friend of mine was chewing Skoal's new Berry Blend and I thought it smelled so good. I have since purchased more cans, and on average one lasts me seven to eight days, whereas I smoke almost a pack a day when I buy cigarettes. I can throw in a chew for a half hour or more, and get a nice slow nicotine fix and not need another for hours on end. In that same half hour, I could smoke two to three cigarettes, maybe more depending on my activitiy. If I'm at a bar drinking, I chain smoke. My friend that turned me onto "dipping" routinely goes out drinking with me and hardly ever smokes. When we leave, he pops in a chew for the ride home. I find his control refreshing and am seriously considering turning to chaw for my sole nicotine fix. Honestly, I feel it makes sense. It's safer for others, I can be more discreet about it, and if I ever need a fix I can take it places that I couldn't take cigarettes. I appreciate the information and agree that while it is naive to assume that a smokeless society is just around the corner, and agree that quitting outright is in my best interests, smokeless tobacco does seem to be a safer and more pleasant alternative than cigarettes. I would support campaigns promoting chaw as a safer, albeit not riskless, alternative to tobacco. Sincerely, Lincoln Douglas