Friday, January 15, 2010

"Quit or Die" or use harm reduction?

Jim quit smoking when he was in his 30's after receiving a diagnosis of Chronic Obstructive Pulmunary Disease (COPD). He took his doctor's advice and switched from smoking cigarettes to using smokeless tobacco or "chew". Thirty years later Jim is in my Stop Smoking, Stay Quit class to stop his nicotine addiction to smokeless tobacco.

This is an example of "harm reduction". The premise is that some individuals are so addicted to nicotine that they just can't quit, so harm reductionists advocate switching to the use of a less harmful tobacco product. Harm reductionists say a "Quit or Die" approach doesn't work and by using a less harmful form of nicotine is a better way to go. While I do believe that the physical addiction to nicotine can be so strong that it seems impossible to quit, that does mean we should just give up on these individuals? The same concept is used with heroin addicts by replacing heroin with methadone but not every heroin addict uses methodone to quit. There are no easy answers.

But there is a new player in mix and that is e-cigarettes. The US District Court in Washington DC just ruled that the FDA does not have the authority to regulate e-cigarettes as a drug device combination. Instead, e-cigs are a recreational product that promotes the use of nicotine in a less harmful way than by smoking cigarettes. There are many antedotal stories of smokers quitting by using an e-cig but they cannot be advertising as such because then the product would fall under the jusdiction of the Food, Drug, and Cosemtic Act (FDCA). While it would appear that e-cigarettes maybe less harmful because there are less components to the vapor of an e-cigarette than the thousands of chemicals found in tobacco smoke, we don't know for sure since there are no long term studies on e-cigs. Since currently there is no regulation on the manufacture of e-cigs, the public must rely on the integrity of the manufacturer. Are they after your money or to better your health?

Switching from smoking cigarettes to chew tobacco most certainly saved Jim's life, yet now he is dealing with the health effects of 30 years of chewing. Jim has gum disease, tooth loss, and has had both a kidney and a liver transplant. His doctor now wants him to totally quit the use of nicotine since nicotine is excreted through the kidneys into the bladder. Jim wishes that when he stoped smoking that he would had tried to stop using all nicotine products, instead of switching to chew.

I think the debate should end and nicotine be declared a drug/medication. You can't have it both ways--it can't be both a recreational product AND one that is so addictive that some individuals are unable to stop using. As a drug/medication, there may be benefits to the continued use of nicotine, just as there are benefits (as well as risks) to every drug/medication that is used.

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