For many people who smoke cigarettes or drink alcohol, abstinence seems impossible. Now doctors and public-health officials are debating whether it's even always necessary.
A number of medical researchers now believe that smokers and alcohol abusers can benefit from "harm reduction" meaning instead of kicking the habit, they can reduce health risks by merely drinking less or switching to a less-hazardous alternative, such as smokeless tobacco. With the success rate of abstinence programs abysmally low about 75% of those who go to 12-step anti-alcohol programs drop out, for example, and only about 20% of those who remain actually stop drinking -- the aim is for smokers or drinkers to "manage" their addictions at a potentially less-harmful level.
The notion already is being promoted to consumers. Vector Group sells Omni brand low-toxin cigarettes. Brown & Williamson is test marketing another low-toxin line called Advance. R.J. Reynolds is test marketing Eclipse, a cigarette that primarily heats tobacco rather than burning it, producing a less-toxic smoke. UST, which makes smokeless tobacco, has asked the Federal Trade Commission for permission to claim its product is less hazardous than cigarettes.
Books such as "Alternatives to Abstinence" and support groups such as Moderation Management (www.moderation.org) promote the idea that drinking less rather than giving up alcohol altogether is an option for some problem drinkers.
But harm reduction has triggered a contentious debate among addiction researchers and public-health officials. The main worry is that such programs will take away the incentive for addicts to quit and that the alternatives being touted still pose unacceptable health risks.
But for smokers who have repeatedly tried to kick the habit and drinkers who can't imagine never again having a glass of wine with dinner, harm reduction has an inherent appeal. It "offers more embraceable lifestyle changes than those imposed by abstinence," says Elizabeth Whelan, president of the American Council on Science and Health which recently hosted a symposium on the subject.
Harm reduction starts with the idea that while abstinence is the ideal, it often isn't realistic. That's why public-health workers distribute clean needles to heroin addicts and promote condom use to curb teen pregnancy.
But applying the philosophy to smoking and alcoholism is proving a tougher sell. Although most doctors agree that scaling down to one pack a day from two packs is a step in the right direction, it isn't yet clear whether smoking fewer cigarettes can lower health risks. In a Mayo Clinic study, participants cut their smoking by 50%, but their blood tests showed a decrease in only two out of five tobacco toxins. An expert panel convened by the Institute of Medicine last year concluded that while such products as low-toxin cigarettes are "potentially beneficial," there's no proof yet that using them will lower health risks.
Some harm-reduction advocates say smokers can better manage their nicotine addiction by switching to smokeless tobacco, which delivers a concentrated hit of nicotine into the body more quickly and for far longer than nicotine patches and gum. Smokeless tobacco can cause oral cancer, but it isn't nearly as lethal as cigarettes, which by some estimates, may eventually kill about half of the people who smoke long term. Smokeless tobacco kills about 1% of those who use it, says Philip Cole, professor emeritus at the University of Alabama School of Public Health in Birmingham.
"The problem is not tobacco, it's smoking," says Dr. Cole, whose university has received research funds from UST. "It's the burning of tobacco and the inhalation of smoke that kills people." Nonetheless, Dr. Cole says he doesn't advocate smokeless tobacco to curb youth smoking, but thinks it should be considered for the middle-age, "inveterate smoker" who simply cannot quit.
A sharp decline in smoking rates in Sweden, where smokeless tobacco is widely used, gives credence to the idea that the product may have a role in helping people stop smoking. Since 1980, smoking among males in Sweden has dropped to 17.1% from 36.3%. At the same time, use of smokeless tobacco or "snus" as it's called there, increased to 18.2% from 16.6%. Clearly, not all the smokers quit by switching to snus, but researchers speculate that the widespread use of smokeless tobacco may have played a role, along with other anti-tobacco efforts such as higher tobacco taxes and marketing restrictions.
But Gregory Connolly, director of the Massachusetts Department of Public Health tobacco-control program, says promoting smokeless tobacco as safer than cigarettes will have unintended consequences and could lead to more smoking. Kids who use smokeless tobacco are three times more likely to smoke, studies show. "We don't have sufficient evidence to assess the amount of reduced harm," Dr. Connolly says.
Harm reduction for problem drinkers is also controversial. Peter Provet, president of the New York addiction-treatment center Odyssey House, says heavy drinkers can't limit themselves to a few drinks and that moderate drinking programs might prevent alcoholics from getting the help they need.
But advocates say most problem drinkers don't get help because they don't want a lifetime of abstinence. A program of moderated drinking will draw in many people who wouldn't otherwise get help, says Sally Satel, staff psychiatrist at the Oasis Drug Treatment Clinic in Washington. "For some people it may be the only method they will accept," Dr. Satel says.
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Updated July 2, 2002