the risk depends on the toxicity specific to nicotine, which tends to be confined primarily to reproductive and cardiovascular disorders. Prior studies have examined the use of nicotine replacements with concurrent smoking. These studies have found no major adverse effect even at a very high dose of nicotine patch (Benowitz et al., 1998) or in smokers who have experienced cardiovascular disease (Joseph et al., 1996; Murray et al., 1996; Working Group for the Study of Transdermal Nicotine in Patients with Coronary Artery Disease, 1994).

A second concern is the reduced desire for abstinence as a result of a reduced perception of risk associated with decreased levels of smoking. Individuals who would normally have quit may choose continuing to smoke at lower amounts. Similarly, the desire to quit may also be decreased if the use of nicotine products is encouraged in areas that restrict tobacco use, so that the individual no longer needs to contend with withdrawal symptoms in these situations. A third and related concern is the reduced perception of risk among adolescents and younger adults. If the option of smoking a few cigarettes with reduced health consequences is available, then perhaps a greater number will be more willing to initiate smoking. A fourth concern, which is related to the long-term use of medications, is the potential toxicity that may be associated with chronic use, even though the toxicity is lower than that of tobacco products. An important principle that underlies all of these concerns is that no increase in harm occurs as a result of using a tobacco exposure reduction approach and that a significant and meaningful decrease in actual harm be the outcome.

Several advantages related to the availability of exposure reduction approaches include potentially increasing recruitment into treatment. That is, smokers who are not ready to quit can perhaps be persuaded to begin to reduce their tobacco consumption as a step toward cessation or as a method to reduce harm. This reduction may then reduce mortality and morbidity among individuals who want to continue smoking, and may also reduce environmental tobacco smoke exposure, and eventually facilitate abstinence. Furthermore, the use of medications in situations where smoking may not be allowed (e.g., work environment) may reduce work-related accidents, which have been observed to increase during periods of tobacco withdrawal (Waters et al., 1998).

Use of Pharmacological Agents for Tobacco Exposure Reduction

The use of nicotine replacements for tobacco exposure reduction has been suggested to minimize compensatory smoking behavior when reducing the number of cigarettes smoked (Shiffman et al., 1998). In addition, nicotine replacements are likely to induce minimal harm since it is



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