Tobacco and Public Health - TCSC Indonesia

documents and through litigation by State attorneys general in the United States and
elsewhere.
A place for harm reduction?
PREFACE xiii
Much of public health can be viewed as efforts to reduce disease prevalence and severity
by reducing exposures to pathogens, and by treating those exposed. In principle,
this approach could be applied to reduce the death and disability caused by tobacco in
ongoing tobacco users. This has been discussed elsewhere, and in this volume, with
respect to tobacco (Food and Drug Law Institute 1998; Warner et al. 1998; Stratton et al.
2000; Henningfield and Fagerstrom 2001; Warner 2001). It is certainly one of the most
controversial elements among potential strategies for reducing the risk of death and
disease in tobacco users who, despite our best efforts, will be unable to completely
abstain from tobacco. We should not ignore their plight anymore than we should
ignore the plight of the person who has contracted a tobacco-caused disease. After all,
their volitional control over their tobacco use may be little different than their volitional
control over the expression of cancer in their bodies. Furthermore, if we can
reduce their risk of disease despite aspects of their behavior that we cannot control, are
we not better off, both as a global community and as individuals? Here again, I draw
upon my experience with the HIV epidemic in the United States. Before we were even
certain that a virus was the etiological culprit, I, as the nation’s surgeon general, advocated
strategies to reduce the spread of the disease—strategies ranging from the use of
condoms to drug abuse measures, including treatment. Despite our best efforts, we
could not eliminate risky sex or drug abuse, but we were able to reduce the spread of
the disease by reducing the risk of transmission (Bullers 2001).
The problem with harm reduction approaches is that may pose theoretical benefits
to a few individuals, along with real and theoretical risks to many others. This was the
experience with smokeless tobacco products in the United States, in which relatively
few recalcitrant cigarette smokers may have switched from cigarettes to snuff, incurring
theoretical (but as yet uncertain) disease reduction, while, at the same time, a new
epidemic of smokeless tobacco was observed in young boys, who happened to be
athletes (US DHHS 1986). In this domain I concur with the general conclusions of the
Institute of Medicine report, which said, in essence, that although there is great potential
to reduce disease by harm-reduction methods, none have yet been studied adequately
to allow their promotion, and those promoted by tobacco companies, in
particular, carry substantial risks of worsening the total public health picture by undermining
prevention and cessation (Stratton et al. 2000). This is also an area in which
our science needs to be substantially expanded, because, at present, the main body of
knowledge pertaining to the potential health effects of tobacco product design and
ingredient manipulations seems to reside within Big Tobacco. This has been proven an
unreliable source of complete and accurate information. In the future we cannot be
held hostage to such a state of affairs.