Re: Tobacco harm reduction: the devil is in the deployment | BMJ
Hastings et al. summarise well the dilemmas associated with tobacco harm reduction, and rightly conclude that the devil is in the deployment.
The use of Nicotine Replacement Therapy (NRT) by smokers for harm reduction outside of established guidelines may already be widespread (1). Certainly locally we have seen a significant increase in NRT use without a corresponding increase in measured quits.
This shouldn't be too surprising, as it has become common knowledge that NRT products have a 97% + failure rate when it comes to smoking cessation. However, it is nice to finally see this acknowledgement coming from a published article in the BMJ. If this doesn't provide the empirical evidence to support a shift towards tobacco harm reduction, away from the old ways of the quit or die orthodoxy, then I don't know what possibly could.
Mr. Furber then goes on to say:
Therefore better management of harm reduction through NICE guidelines (2) is welcome. But the implementation will be difficult and will need to be monitored carefully. In particular the NHS reforms in England potentially create the additional complication of tobacco control being funded by local authorities but much of the financial saving falling to NHS Clinical Commissioning Groups (through reduced NHS activity). Health and Wellbeing Boards will need to quickly develop the maturity to manage this, and ensure they deliver better outcomes for tobacco control.
When addressing this issue of harm reduction via NICE guidelines, I wonder what Mr. Furber means when he stresses for the need for maturity in dealing with such a complex, but necessary subject.
For anyone who has the time to read it in its entirety, the guideline can be seen here.
In the meantime, here are a few excerpts. One of the first things to gnaw at my craw can be seen on the very first page of this 100 page report:
The use of products containing tobacco as a means of ‘harm reduction’ is outside the scope of this guidance. This means that ‘reduced exposure cigarettes’ and ‘smokeless tobacco’ are excluded..
..Outside of the scope of this guidance? I think that I am beginning to understand what Mr. Furber means when he calls for better management in the world of tobacco control...err, I mean tobacco harm reduction.
What's interesting is that also on the very first page of the NICE guideline is the recognition that smoking less can be a means of harm reduction:
This guidance aims to reduce the illnesses and deaths caused by smoking tobacco among people who smoke and those around them. People who smoke can do this by:
• stopping smoking
• cutting down prior to quitting smoking
• smoking less
• abstaining from smoking temporarily.
This is certainly a welcome admission, but what doesn't make sense is the total and utter disregard for reduced exposure tobacco products! 92+% of tobacco users smoke combustible cigarettes. Hence, I repeat, it simply does not make sense to ignore the obvious.
From one side of the mouth they are saying that less smoke is better than more smoke while giving the finger to what will prove to be THE missing piece of the equation (in terms of harm reduction) that has been missing from the conversation for far too long.