In Response: Dr. Mirvish raises several timely and controversial issues that continue to be the focus of many vigorous discussions in the tobacco control community, often under the rubric of “harm reduction.” In 2006, WHO adopted the theme for World No Tobacco Day: “Tobacco: deadly in any form or disguise,” which supports the principle that there is no safe cigarette or smokeless tobacco—snus or otherwise. Currently, a WHO expert group, of which Dr. Hecht is a member, is in the process of finalizing a scholarly report that provides recommendations for “upper limits” for nitrosamines in combusted tobacco products. This document will provide guidance for countries interested and able to pursue tobacco product regulation. Basically, such product regulation looks to limit the morbidity and mortality of persistent use of a tobacco product. Current recommendations for public health policy are intended to be based on scientific evidence (1). The proposed recommendations for such upper limits are based on the precautionary premise resulting from data that currently exist that less must be better. We should never forget, however, “first, do no harm.” It is not known whether a recommended individual level of any specific constituent will result in decreased morbidity or mortality. Thus, product regulation recommendations must be couched in terms exemplified by the precautionary principle.
In addition, there is no assurance that the tobacco industry will voluntarily solely market low-nitrosamine smokeless (or combusted) tobacco products. Product regulation by the appropriate agency in every country, such as the pending legislative effort in the United States, is necessary to attempt to assess and control the claims that the tobacco industry will be pursuing with ostensibly “safer” tobacco products. As concluded by the Institute of Medicine, the risk of reduced-harm products must be evaluated also at the population level where their introduction could delay quitting, reduce cessation, and increase initiation (2).
The suggestion that reduced nitrate fertilizer be used by tobacco farmers is scientifically reasonable, but perhaps difficult to implement. The majority of countries in the world grow tobacco, and many of the tobacco farmers are quite poor, with little concern about the nitrate content versus the cost of the fertilizer. Reducing the use of nitrate fertilizer will need to be a requirement by the tobacco industries or regulated within the evolving policies emanating from the Framework Convention for Tobacco Control.
Bottom line: Rather than recommending low-nitrosamine tobacco products as the method to reduce harm as Dr. Mirvish suggests, users should quit smoking and the use of smokeless tobacco. We can apply the precautionary principle and regulate the levels of nitrosamines, but there are no data to support that this reduction will reduce harm—yet. Funding for a safer cigarette should come from the tobacco industry, with federal oversight, not from the limited resources available for tobacco control and cancer research. The scientific community and regulatory agencies will need to evaluate any new evidence presented by the tobacco industry in support of claims for any purported “reduced-harm” tobacco products.
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