摘要：From 1964 through the early 1980s, both federal and voluntary agencies endorsed the concept of “safer” cigarettes. Beginning in the mid-1980s, several factors, including revelations of tobacco industry malfeasance, the development of nicotine replacement therapy, and the reconceptualization of smoking as a chronic disease, led to “safer” cigarettes being discredited. In the past few years, some public health professionals have begun to reconsider the viability of developing such products. The issue before us is stark: will a commitment to limiting the toll exacted by smoking preclude the tolerance of a product that while not safe may possibly be safer? PUBLIC HEALTH AND MEDICAL professionals are currently divided over the idea of “safer” tobacco products. In 2001, the Institute of Medicine (IOM) released a report opening the door for endorsement of such products as a feasible component of a harm reduction strategy. 1 On its heels came a National Cancer Institute (NCI) report that fueled enthusiasm for an approach embracing cessation. The NCI’s stance was decidedly hostile to “safer” cigarettes, raising provocative questions about the place of harm reduction within tobacco control. Harm reduction represents an approach to risky behavior that places priority on minimizing damage rather than eliminating the behavior itself. Two related criticisms are most commonly made by its opponents. The first is that harm reduction “sends the wrong message” to society that drug use is acceptable and thereby undermines other messages that would reduce harm to a greater extent. As a corollary, critics charge that harm reduction activities encourage the initiation or continuation of potentially risky behaviors, and thereby perpetuate rather than attenuate harm. Thus, while individual harms may be reduced by efforts to make use safer, this reduction may be accompanied and even outweighed by an aggregate rise in harm. These are the same concerns that have animated debate over “safer” cigarettes. For example, compensatory smoking behavior has been widely observed in the form of smokers who inhale more deeply and frequently, smoke closer to the butt, and plug the filter holes of low-tar, low-nicotine cigarettes to ingest a greater amount of nicotine. Many public health professionals have similarly claimed that the availability of allegedly safer filtered or low-tar cigarettes could provide a disincentive for otherwise motivated smokers to quit their habit; it could encourage others who might otherwise have been deterred from smoking because of health concerns to begin, and it could make relapse more likely. 2 In the cases of both illicit substance use and smoking, the place of abstinence within a harm reduction framework has been the subject of some debate. One source, commenting on “the irrelevance of abstinence,” declared, “Although harm reduction is not inconsistent with the long-term goal of abstinence, harm reduction accepts the fact that the user will continue to use drugs while in a drug program or in the community.” 3 But in the case of smoking, abstinence can have 2 meanings: abstinence from nicotine, the addicting agent in cigarette tobacco, and abstinence from cigarettes. Thus, it is the role of the so-called “safer” cigarette within the history of smoking and harm reduction for which we must account. While we discuss nicotine replacement therapies such as nicotine gum and the patch, which have come to fit comfortably within both the harm reduction and chronic disease models, we focus in this historical analysis primarily on “safer” cigarettes such as those with filters, lower yields of tar, and the newer smokeless alternatives. We argue that while an array of factors has shaped the history of the “safer” cigarette, it is the current understanding of the industry’s past deceptions and continuing avoidance of the moral implications of the sale of products that cause the enormous suffering and death of millions that makes reconsideration of “safer” cigarettes challenging.
