KICKING THE HABIT (SORT OF): NEW THEORY LETS SMOKERS SMOKE, ALCOHOLICS DRINK

For many people who smoke cigarettes or drink alcohol, abstinence seems
impossible. Now doctors and public-health officials are debating whether
it's even always necessary.

A number of medical researchers now believe that smokers and alcohol
abusers can benefit from "harm reduction" -- meaning instead of kicking the
habit, they can reduce health risks by merely drinking less or switching to
a less-hazardous alternative, such as smokeless tobacco. With the success
rate of abstinence programs abysmally low -- about 75% of those who go to
12-step anti-alcohol programs drop out, for example, and only about 20% of
those who remain actually stop drinking -- the aim is for smokers or
drinkers to "manage" their addictions at a potentially less-harmful level.

The notion already is being promoted to consumers. Vector Group sells Omni
brand low-toxin cigarettes. Brown & Williamson is test marketing another
low-toxin line called Advance. R.J. Reynolds is test marketing Eclipse, a
cigarette that primarily heats tobacco rather than burning it, producing a
less-toxic smoke. UST, which makes smokeless tobacco, has asked the Federal
Trade Commission for permission to claim its product is less hazardous than
cigarettes.

Books such as "Alternatives to Abstinence" and support groups such as
Moderation Management (www.moderation.org) promote the idea that drinking
less rather than giving up alcohol altogether is an option for some problem
drinkers.

But harm reduction has triggered a contentious debate among addiction
researchers and public-health officials. The main worry is that such
programs will take away the incentive for addicts to quit -- and that the
alternatives being touted still pose unacceptable health risks.

But for smokers who have repeatedly tried to kick the habit and drinkers
who can't imagine never again having a glass of wine with dinner, harm
reduction has an inherent appeal. It "offers more embraceable lifestyle
changes than those imposed by abstinence," says Elizabeth Whelan, president
of the American Council on Science and Health which recently hosted a
symposium on the subject.

Harm reduction starts with the idea that while abstinence is the ideal, it
often isn't realistic. That's why public-health workers distribute clean
needles to heroin addicts and promote condom use to curb teen pregnancy.

But applying the philosophy to smoking and alcoholism is proving a tougher
sell. Although most doctors agree that scaling down to one pack a day from
two packs is a step in the right direction, it isn't yet clear whether
smoking fewer cigarettes can lower health risks. In a Mayo Clinic study,
participants cut their smoking by 50%, but their blood tests showed a
decrease in only two out of five tobacco toxins. An expert panel convened
by the Institute of Medicine last year concluded that while such products
as low-toxin cigarettes are "potentially beneficial," there's no proof yet
that using them will lower health risks.

Some harm-reduction advocates say smokers can better manage their nicotine
addiction by switching to smokeless tobacco, which delivers a concentrated
hit of nicotine into the body more quickly and for far longer than nicotine
patches and gum. Smokeless tobacco can cause oral cancer, but it isn't
nearly as lethal as cigarettes, which by some estimates, may eventually
kill about half of the people who smoke long term. Smokeless tobacco kills
about 1% of those who use it, says Philip Cole, professor emeritus at the
University of Alabama School of Public Health in Birmingham.

"The problem is not tobacco, it's smoking," says Dr. Cole, whose university
has received research funds from UST. "It's the burning of tobacco and the
inhalation of smoke that kills people." Nonetheless, Dr. Cole says he
doesn't advocate smokeless tobacco to curb youth smoking, but thinks it
should be considered for the middle-age, "inveterate smoker" who simply
cannot quit.

A sharp decline in smoking rates in Sweden, where smokeless tobacco is
widely used, gives credence to the idea that the product may have a role in
helping people stop smoking. Since 1980, smoking among males in Sweden has
dropped to 17.1% from 36.3%. At the same time, use of smokeless tobacco or
"snus" as it's called there, increased to 18.2% from 16.6%. Clearly, not
all the smokers quit by switching to snus, but researchers speculate that
the widespread use of smokeless tobacco may have played a role, along with
other anti-tobacco efforts such as higher tobacco taxes and marketing
restrictions.

But Gregory Connolly, director of the Massachusetts Department of Public
Health tobacco-control program, says promoting smokeless tobacco as safer
than cigarettes will have unintended consequences and could lead to more
smoking. Kids who use smokeless tobacco are three times more likely to
smoke, studies show. "We don't have sufficient evidence to assess the
amount of reduced harm," Dr. Connolly says.

Harm reduction for problem drinkers is also controversial. Peter Provet,
president of the New York addiction-treatment center Odyssey House, says
heavy drinkers can't limit themselves to a few drinks and that moderate
drinking programs might prevent alcoholics from getting the help they need.

But advocates say most problem drinkers don't get help because they don't
want a lifetime of abstinence. A program of moderated drinking will draw in
many people who wouldn't otherwise get help, says Sally Satel, staff
psychiatrist at the Oasis Drug Treatment Clinic in Washington. "For some
people it may be the only method they will accept," Dr. Satel says.