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LETTER |
Correspondence: Requests for reprints should be sent to Gary A. Giovino, PhD, MS, Division of Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263 (e-mail: gary.giovino{at}roswellpark.org).
I contributed to the Institute of Medicine report Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction,1 and I am writing to correct misrepresentations made about it in 2 recent articles in the Journal.2,3 The articles suggest that the report signals a rebirth of "safer cigarettes"2 and that it was primarily about cigarette harm reduction and less hazardous cigarettes.3 However, the report did not endorse any specific class of products. Rather, the Institute of Medicine committee addressed the feasibility of tobacco harm reduction (i.e., minimizing harm and decreasing total morbidity and mortality without completely eliminating tobacco or nicotine exposure) and addressed questions raised by the Food and Drug Administration about individual exposure and disease risk and the public health implications of potential reduced-exposure products (PREPs) that have been marketed.1 The committee specifically warned against the use of the term "safer cigarette" and instead recommended the use of "PREP" to cover both tobacco and pharmaceutical products that might be incorporated into a potential harm reduction strategy.
Tobacco harm reduction does not require that modified cigarettes or cigarette-like products be used instead of conventional cigarettes. The tobacco control community is skeptical about the role of combusted products in harm reduction, while acknowledging a role for medicinal nicotine as a PREP.4–6 The cigarette industry has been misleading the public for decades1,7 and will likely market PREPs that would expose users to far greater concentrations of carcinogens and other toxicants than would medicinal nicotine.1,8 Low-nitrosamine smokeless tobacco, a PREP that is being debated to a considerable extent,9 will likely expose consumers to more carcinogens and other toxicants than medicinal nicotine, but far fewer than conventional or modified cigarettes.1,8 Currently, smokers are inadequately informed about the constituents and risks of various nicotine-delivery devices.10
The committee recommended that a strong research initiative, comprehensive public health surveillance system, and regulatory framework be instituted to minimize the possibility of untoward events (e.g., products that claim to reduce exposure but actually don’t, products that may reduce exposure but don’t reduce harm, reduced-exposure messages that are misinterpreted by consumers to indicate reduced harm, increased initiation and relapse, and decreased quitting). Since the use of PREPs poses greater health risks than no tobacco exposure, the public health community should continue to emphasize prevention (i.e., harm avoidance), cessation (i.e., harm minimization), and protection from environmental tobacco smoke as it considers the role of tobacco harm reduction.
References
1. Stratton K, Shetty P, Wallace R, Bondurant S, eds. Committee to Assess the Science Base for Tobacco Harm Reduction, Institute of Medicine. Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction. Washington, DC: National Academy Press; 2001.
2. Fairchild A, Colgrove J. Out of the ashes: the life, death, and rebirth of the "safer" cigarette in the United States. Am J Public Health. 2004;94:192–204.
3. Gori G. The Institute of Medicine report on smoking: a blueprint for a renewed public health policy. Am J Public Health. 2002;92:945–946.
4. Kozlowski L, Strasser A, Giovino GA, Erickson P, Terza JV. Applying the risk/use equilibrium: use medicinal nicotine now for harm reduction [editorial]. Tob Control. 2001;10:201–203.
5. Warner KE, Martin EG. The US tobacco control community’s view of the future of tobacco harm reduction. Tob Control. 2003;12:383–390.
6. Martin EG, Warner KE, Lantz PM. Tobacco harm reduction: what do the experts think? Tob Control. 2004;13:123–128.
7. Risks Associated With Smoking Cigarettes With Low Machine-Measured Yields of Tar and Nicotine. Bethesda, Md: National Cancer Institute; October 2001. Smoking and Tobacco Control Monograph No. 13. NIH publication 02-5074.
8. Hecht SS. Tobacco carcinogens, their biomarkers and tobacco-induced cancer. Nat Rev Cancer. 2003;3:733–744.[ISI][Medline]
9. Chapman S. Harm reduction. Tob Control. 2003;12:341.
10. Cummings KM, Hyland A, Giovino GA, Hastrup J, Bauer J, Bansal MA. Are smokers adequately informed about the health risks of smoking and medicinal nicotine? Nicotine Tob Res. In press.
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