George D. Lundberg, MD  

Disclosures

September 18, 2017

Hello and welcome. I am Dr George Lundberg and this is At Large at Medscape.

September is "be kind to addicts" month. Addiction is no laughing matter. Once chemical addiction is well established, it is probably lifelong. Thus, prevention is the key. Maximum education, parental and societal authority, law, and culture should make an effort to delay the introduction of potentially addicting substances into American youth as long as possible. The more mature a brain becomes, the less likely it will respond to exposure with lifelong addiction.

But for the already addicted, whether the drug is ethyl alcohol, nicotine, opiates, or opioids, harm reduction should be the goal of therapy. These dictates are not religious, philosophical, or ideological; they are scientific clinical medicine and public health.

Today I want to focus on tobacco smoking and nicotine addiction.

An American tipping point looms for supporting harm reduction with tobacco. All of us, together, should double down on our efforts to prevent the premature deaths of some 40,000 US smokers a month, or 480,000 US deaths each year from smoking-related illness.[1]

I hate the tobacco industry and its knowingly murder-for-profit actions. Of course, lifelong abstinence from nicotine is the preferred route. But that approach fails for many and we collectively seem to say, "Quit smoking or die," while offering no other practical options. But now we can do better. We know how to be tough against the tobacco addiction industry and also kind to the addicted victims and their loved ones. Two "simple" steps can take us two giant leaps forward.

Giant Leaps Forward

First: Pass federal legislation or state legislation in all 50 states, making the growing, manufacture, advertising, marketing, sale, possession, and use of tobacco for smoking illegal in the United States of America.

Wow! Seriously.

Second: Recognize that for the highly addicted nicotine addicts, their addiction, if incurable, can be safely sustained by legal provision of nicotine via other methods that do not include tobacco combustion. US Food and Drug Administration (FDA)-approved prescription products such as nicotine patches and gum suffice for some nicotine-dependent individuals. But other products provide the opportunity for the great leap forward.

I have twice published on these pages in favor of the use of e-cigarettes by nicotine addicts (with various public health safeguards against use or accidental overdose by children) as a reasonable means of reducing harm.[2,3] I reaffirm that position today.

But another major player in the harm-reduction field should be given serious consideration in the United States and, most likely, a fast track into mainstream use. The supporting research is voluminous, the public health success revolutionary. Quick disclosure: I am 100% genetically Swedish, although born in the USA, and I happen to believe that the modern Swedes do a lot of things really well.

A moist form of smokeless tobacco in a pouch that is placed under the upper lip and called "snus" has been in common use in Sweden for several decades. Its widespread acceptance and use is credited by many as the key reason why adult daily tobacco smoking rates in Sweden are now 5%, by far the lowest in Europe, which averages 30%.[4] That rate is vastly superior to the comparatively favorable US rates of 15%, a number that trended dramatically downward from the 1960s rate of 42% but then slowed in the 2000s. This Swedish success was achieved by strategically shifting the confirmed nicotine addicts away from inhaling combustion products and toward the oral nicotine delivery pouches.

Snus and e-cigarettes provide two kind methods to greatly reduce harm for those recalcitrant American nicotine addicts who otherwise would continue to inhale tobacco smoke with all of its toxic elements. They offer nicotine fixes without the killing poisons, a clear winner for kindness.

Let's do it. Let's beat Big Tobacco. Legislators, FDA, show even more compassion for smokers, please. With drug addicts, let's be redemptive, not punitive.

That is my opinion. I am Dr George Lundberg, at large at Medscape.

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