Is harm reduction a suitable outcome for historically hard‐to‐treat smokers

Commentary on Guillaumier et al. (2020):

Organizational change interventions to promote smoking cessation among those with co‐occurring alcohol and substance use disorders may not yield measurable impact. In a climate of limited resources and overburdened clinicians, addressing smoking in this population is a challenge but may be well‐suited for tobacco harm reduction to minimize tobacco‐related risks.

Guillaumier et al. [1] study the impact of an organizational change intervention on smoking outcomes among patients enrolled in alcohol and other drug (AOD) treatment. Their premise, that changes in health behavior in this population should be driven by organizational change, is compelling, and stands in contrast to the myriad approaches that target patients or providers individually and may not be sustainable within an organization. The study hypothesized that if smoking cessation is integrated into AOD treatment with sufficient resources and training, benefits (i.e. smoking cessation) will extend to the individual. Yet, this sophisticated, cluster‐randomized controlled trial failed to demonstrate differences in smoking abstinence rates or quit attempts between patients enrolled in the experimental and control treatment programs. Although a reduction in cigarettes per day was found for patients in the intervention clinics, numerical differences were minor (15 versus 16) and were not sustained. These inconclusive results could leave the reader with a sense of defeat. On the contrary, we believe there is opportunity amidst this challenge.

The reality is that smokers enrolled in AOD treatment smoke at disproportionately high rates [2] and while many endorse interest in quitting [3], access to smoking cessation treatment is low and few achieve cessation from tobacco during their treatment episode [4, 5]. Further, smoking can be perceived as helpful among those navigating sobriety [6] or less harmful compared to the substance that led them to treatment [7]. These longstanding barriers among the AOD treatment population seem almost intractable. With all things considered, where do we go from here?

It may be tempting to consider more intensive treatments as the answer. After all, as tobacco cessation researchers, our goals are to inform treatment through science to maximize cessation success and minimize tobacco‐related harm. As we have seen in the literature, however, integrating any amount of smoking cessation into AOD treatment is difficult. Many programs are operating on limited budgets, with overworked clinicians who may feel unequipped to deliver evidence‐based cessation support, and patients who are trying to manage often times complicated lives, chronic stressors and the burden of continued sobriety. It may be unrealistic that more intense treatments (i.e. more of the same but at greater cost) will have a different impact.

Harm reduction strategies may have particular relevance in this population. These strategies could include, but are not limited to, (i) smoking reduction; (ii) reduced‐risk tobacco alternatives; or (iii) medication sampling strategies. Tobacco harm reduction remains a controversial topic [8] but is worth considering as a necessary step and catalyst toward greater self‐efficacy, motivation, empowerment and eventually cessation [9, 10].

First, reduced smoking may not only be a step toward improved health [11], but has also been shown to promote eventual cessation among recalcitrant smokers [12–15]. Although many smokers may be deterred by abstinence‐only goals, reduction is a gradual, softer message that may appeal to more smokers who are not yet ready to quit but could still lead to eventual quitting. Second, a rapidly evolving landscape of tobacco products offers newer reduced‐harm alternatives for smokers [16]. Similar to smoking reduction, these products offer the potential for reduced harm (i.e. decreased toxicant exposure), and could promote downstream abstinence [17]. Future work should assess the potential benefit of reduced‐harm alternatives, while ensuring that switching does not result in added harm or exacerbated nicotine dependence. Finally, the low‐burden practice of medication sampling (e.g. providing a 2‐week starter pack of nicotine replacement therapy) without intensive co‐occurring counseling has been shown to increase quit attempts and abstinence with little training required [18]. Although it is not harm reduction per se, medication sampling is an example of a pragmatic strategy that could catalyze cessation behavior, even among unmotivated smokers. There are many other harm reduction strategies that could be explored, such as corrective and accurate messaging around reduced‐harm products [10] or harm reduction paired with smoking bans at treatment centers, in homes, etc. that may further promote eventual cessation.

Tobacco harm reduction for smokers in AOD treatment may leave some with feelings of unease, given that any message other than cessation may be undermining to public health and perceived as an unfair lowering of cessation expectations among a historically hard‐to‐treat population. We disagree and believe that harm reduction is a complement and very often a catalyst to cessation, and never a substitute for it. Harm reduction for smokers in AOD treatment is not giving up on these patients, because they deserve the same chances to achieve tobacco cessation and improved health as all others, but rather it is a means of respecting their autonomy and meeting them where they are in their motivation and perceived ability to quit smoking. Harm reduction strategies in this population may be a more realistic and pragmatic approach to minimize the risks associated with continued tobacco use.