Boston Public Health Commission's Facebook Page

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Achieving Smoking Abstinence

I notice that the Commission is promoting the idea of using the patch to quit smoking. True, using nicotine reduction/weaning therapy does double the 3% success rate achieved by going cold turkey, but why is 6% or 7% considered good enough? Success rates using a harm reduction approach are 10 times higher. How can a harm reduction approach be implemented?

The first step is to recognize that while nicotine is the substance that keeps smokers lighting up, it isn't the substance that causes smoking-related diseases. Smoke contains tar, carbon monoxide, particulates, and thousands of chemicals created by the process of combustion. These, not the nicotine, are what cause the cancer, lung disease, and heart disease triggered by smoking.

The next step is to recognize that all addictions are not created equal. There are no laws against driving while under the influence of nicotine because nicotine is not intoxicating. Nicotine doesn’t impair physical reflexes, nor the ability to concentrate, remember, and make sound judgments. In fact it enhances these abilities. That’s one reason why nicotine is so difficult for the majority of tobacco users to give up. Another reason is because nicotine helps to control symptoms of depression and anxiety, which are problems for about 20% of smokers.

The third step is to learn about smoke-free alternatives. Modern smokeless tobacco products can reduce the risk of smoking-related diseases by up to 99%. Decades of research in Sweden on snus, a type of moist tobacco treated to reduce nitrosamines, show that smoking-related lung disease risks are eliminated, and rates of cancer and heart disease are equal to those of former smokers who don’t use any form of tobacco. Swedish snus users have the same life expectancy as those who have become abstinent from all tobacco products. The FDA is considering whether to approve long-term use of approved nicotine products such as the patch, gum, lozenges, and the prescription inhalers. These may prove acceptable as permanent substitutes for smoking, especially if the FDA takes it a step further and permits higher nicotine content in these products. Finally, electronic cigarettes mimic the experience of smoking but remove the hazards of inhaling smoke. Even the “high” dose of e-cigarette liquid contains the same quantity of nitrosamines in a one-day supply as an FDA-approved nicotine patch (about 8 nanograms), while a pack of cigarettes may contain more than 100,000 nanograms.

The fourth step is to compare the success rates of switching to reduced-harm smoke-free alternatives with success rates for the traditional approach of weaning down and off nicotine. When used as directed, FDA-approved nicotine products have a 7% success rate at 6 months, 5% at one year, and dropping to 2% at 20 months. In Sweden, where the public is given truthful information about the relative harm of smoking versus smokeless products, 66% of snus users are former smokers. Surveys of e-cigarette users show success rates range as high as 82% for consumers who are given advice about equipment and supplies and guidance on how to use the devices properly. Keep in mind that these success rates apply to achieving smoking abstinence. There is no additional health benefit to be gained by insisting on nicotine abstinence.

The fifth and final step is for public health experts to provide truthful information about relative risks of various sources of nicotine to smokers and to the general public. Warning labels that state “This product is not a safe alternative to cigarettes” are misleading half-truths. No product could ever be proven 100% safe. But the labels imply that the health risks of this smokeless product are equal to the health risks of smoking. Nothing could be farther from the truth. Stop talking about “tobacco-related diseases” when 99% of these diseases are caused by inhaling smoke. Stop worrying about curing nicotine addiction, when nicotine without the smoke is about as harmful as caffeine. Stop striving for tobacco abstinence and focus on helping smokers achieve abstinence from smoking.