Tobacco smoking, harm reduction, and nicotine regulation

The Lancet Early Online Publication, 5 October 2007
The Lancet DOI:10.1016/S0140-6736(07)61482-2
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Tobacco smoking, harm reduction, and nicotine product regulation
Prof John Britton MD a and Richard Edwards MD b
Cigarette smoking is highly addictive, widely prevalent, and very hazardous. Smoking killed 100 million people in the 20th century,1 and is predicted to kill 1 billion in the 21st century.1 Worldwide, there are about 1·1 billion smokers, and there are expected to be 1·6 billion by 2025.2 Half of all smokers will die prematurely, unless they stop smoking.3
In the 50 years since the health risks of smoking first became widely recognised, the political and public health responses to smoking at national and international levels have been grossly inadequate. Although the main components of current recommended tobacco control policy4,5 (panel 1) have changed little from those first proposed in 1962,6 they have still not been widely applied7 and, in any case, achieve a reduction in smoking prevalence of typically about 0·5,8–10 and at best 1·0,11 percentage point per year. Full implementation of these policies might be sufficient to prevent smoking in countries in which the smoking epidemic has yet to take hold, but this is only part of the necessary solution for countries with an established smoking population. In the UK, for example, where 24% of adults still smoke,12 at a reduction rate of 0·5 percentage point per year it would take more than 20 years to reduce the prevalence of smoking by half. Even then, there will be more than 5 million smokers in the UK alone, predominantly from the most socioeconomically disadvantaged sectors of society,13 bearing a vast burden of avoidable morbidity and mortality. In fact most of the 150 million deaths from smoking that are expected over the next 20 years will occur in current smokers who are alive today. Since millions of these are unlikely to stop smoking in the near future, we argue, on the basis of a new report from the Royal College of Physicians,14 that in addition to conventional tobacco control policies, the application of harm reduction principles to nicotine and tobacco use could deliver substantial reductions in the morbidity and mortality currently caused by tobacco consumption. However, achievement of these reductions will require radical structural reform of the way in which nicotine and tobacco products are regulated and used.