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Start Chewing may be Tobacco Option

The New York Sun By Julia Levy

Harm Reduction To Be Topic At Health Symposium

If all current smokers in America switched from cigarettes to smokeless tobacco products, 80 times fewer people a year could die of tobacco related illnesses within one generation, an Alabama professor says.

So should all those “quit-smoking” ads the government is running with tobacco-settlement money be changed to “start chewing?”

That’s a question at the heart of the discussion of “harm reduction,” which will be the topic of a June 26 symposium in New York sponsored by the American Council on Science and Health, a non-profit organization. Harm reduction strategies aim to reduce the dangers of risky activities like smoking and drinking without imposing strict policies of abstinence. For example, the “safe sex” approach promotes condoms to reduce the likelihood that people will contract sexually transmitted diseases, without eliminating the risk entirely.

“There are some things that we can do that can make things a little better … even though they may not reduce a threat all the way,” explained an assistant professor of risk analysis and decision science at Harvard School of Public Health, Kimberly Thompson.

Proponents of harm reduction acknowledge that quitting smoking and drinking remains the most foolproof way of eliminating the medical risks of cigarettes and alcohol, but they say moderating or altering use could significantly reduce risks and also encourage more people with problems to seek help. Opponents say introducing new products and treatment methods could confuse or mislead patients, and lead to new, unforeseen health risks.

The condom debate has already been had at school boards nationwide, and the question of moderation versus abstinence when it comes to alcohol flared in the summer of 2000, when the director of the Smithers Addiction Treatment and Research Center of St. Luke’s-Roosevelt Hospital Center quit under fire over comments he made suggesting an openness toward the moderation approach. But the cutting edge of the harm-reduction debate may be about tobacco.

A professor emeritus of epidemiology at the University of Alabama at Birmingham, Dr. Philip Cole, said he will tell the symposium about his research showing that if all current smokers in America converted from cigarettes to smokeless tobacco products like snuff or chewing tobacco, annual deaths from tobacco related illnesses would plummet within one generation to 5,000 a year from 400,000 a year.

Dr. Cole said smokeless tobacco products, which he said where “like a teabag placed in the mouth” between the gum and the cheek, can be used as an aid in programs designed to help smokers quit or as permanent substitutes for cigarettes.

But according to the director of the Massachusetts Department of Public Health’s tobacco control program, Dr. Gregory Connolly, who will participate in the symposium, there is no good evidence proving that smokeless tobacco products would reduce the harm to consumers.

He said it is well documented that smoking cigarettes can lead to cardiovascular disease and lung cancer, but he said it is also true that chewing tobacco and other smokeless products can cause health problems, including cardiovascular disease, mouth cancers, lesions of the gums and periodontal disease.

“It’s almost like playing God when you start choosing between a lung cancer and a mouth cancer,” he said.

Dr. Connolly said the Food and Drug Administration has found that some nicotine replacement products like nicotine patches and gums can help people quit, but he said the administration is barred from testing smokeless tobacco products.

He said it would be “reckless” for the government to allow the tobacco industry to market smokeless tobacco products as safer alternatives to cigarettes without conducting tests and acquiring increased regulation authority.

He added that studies like Dr. Cole’s on the merits of smokeless products should be taken “with a very large grain of salt” because “in the real world … there’s no way that we’re going to have 400,000 people transfer from cigarette smoking.”

A fellow at the American Enterprise Institute, a Washington think tank, Dr. Sally Satel, who will participate in the symposium, said alcohol treatment programs should include harm reduction strategies to help people who have drinking problems, but who are not clinically dependent on alcohol, learn how to drink moderately.

“If you want to reduce to risk to zero, then never drink again,” she said. “But I think it’s an option for some people.”

The president of Odyssey House, a drug treatment agency in New York, Peter Provet, who will debate Dr. Satel at the harm reduction symposium, acknowledged, “there is a legitimate frustration in the substance abuse field with how to engage people.” But he said creating a new model of treatment based on a continuum of addiction rather than exclusively treating the most extreme cases of alcoholism would likely have negative medical repercussions.

“While it might help some, it very well could hurt many,” he said.

Mr. Provet said he has three main concerns about using harm reduction techniques to treat problem drinkers.

First, he said the ambiguity of alcoholism diagnosis might lead serious alcoholics to enroll in a harm-reduction program rather than a more appropriate abstinence program like Alcoholics Anonymous.

“You may be putting people into that kind of program who are very serious abusers and who would be using the treatment approach to further their abuse,” he said.

Next, he said the potential introduction of harm-reduction techniques would represent a “seismic shift in the treatment model” for problem drinkers.

“There are millions of people per year who have a dependency on alcohol,” he said. “Once you say in the field there’s this new approach we can teach people to drink moderately… you will add confusion to hundreds of thousands of Americans who are struggling with severe alcoholism.”

Finally, he said given the broad range of social and medical risks associated with alcohol abuse, addiction and dependency, he would rather make a conservative error in diagnosis rather than a liberal error.

“We are not at a place yet diagnostically to determine with few mistakes who has a serious potential versus who has a weak potential to go on to abuse alcohol,” he said. “We need to come at this very conservatively.”

Mr. Provet did not rule out treatments geared toward patients with varying levels of dysfunction in the future, but he said, “We’re just not there yet.”

Ms. Thompson, who will provide background on risk management at the symposium, said she thinks Mr. Provet’s stance is overly pessimistic.

“I don’t think everybody needs to go to Alcoholics Anonymous,” she said. “We need to find a strategy that’s not that extreme, but that’s better for some people.”

The associate director of the American Council on Science and Health, Jeff Stier, said his organization does not have an official stance on harm reduction, but he said the topic should not be excluded from public debate, especially because some studies suggest that harm reduction might be a promising solution to some of the country’s most pressing medical concerns.

“Our position is that this is a concept that ought to see the light of day,” he said.

He said the anti-tobacco movement, of which his organization is a part, should consider promoting harm reduction techniques, even though they have so far been ignored, because available evidence suggests that advising people to change their tobacco use instead of quitting entirely could save lives.

“If you can’t quit smoking, you should try doing other things,” he said. “Chewing tobacco may be one approach that smokers find acceptable that is one way of lowering the risk.”


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