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tobacco Harm Reduction

I (Dr. Nitzkin) have been active in the tobacco control arena since the early 1970’s. While working in Miami, Rochester, New York and New Orleans I have actively promoted tobacco-related health education activities, smoke-free legislation and smoking cessation programs.


My current involvement in tobacco harm reduction began in February 2007, when the FDA tobacco control bill was introduced into Congress. At that time I was co-Chair of the Tobacco Control Task Force of the American Association of Public Health Physicians (AAPHP).  Rather than simply sign on as a supporter of the bill, I and my fellow co-Chair downloaded and read through the entire then 165-page bill. This was done in hopes of generating a strong endorsement referencing specific sections of the bill.


We were shocked at what we saw. The bill was laced with technical inaccuracies and appeared to be written by lobbyists from Altria (the maker of Marlboro cigarettes) and the big-pharma manufacturers of nicotine replacement therapy pharmaceuticals (gums, patches, etc.). The bill gives a free pass to cigarettes while placing seemingly impossible barriers to introduction of any new tobacco-related product and to claims that any product might be less hazardous than cigarettes. Public health measures and restrictions on marketing were limited to provisions already in place from the 1990 Master Settlement Agreement.


Rather than endorse the bill, AAPHP endorsed FDA regulation of tobacco products in principle and recommended a long list of amendments to strengthen the bill from a public health perspective. ( We were then advised by Rep. Waxman’s office that the bill had been negotiated in secret between Altria and Campaign for Tobacco-Free Kids and that no amendments would be considered to strengthen it from a public health perspective because any such amendment might induce Altria to pull its support from the bill.


In response to that, we did a fresh review of tobacco-related scientific literature to determine what set of policies would likely be most effective in reducing tobacco-related addiction, illness and death in the United States. It was that review that drew our attention to tobacco harm reduction (THR) as the most promising policy option. All of this was before either of us was aware of e-cigarettes and their potential as a THR modality.


After five years of limited tobacco-related research and advocacy at personal expense, I sought a sponsor that would enable me to engage in more substantial work in this arena.


Verbal inquiries to the CDC office was met with a response to the effect that they are totally committed to the goal of a tobacco-free society, and, because of that, they would not offer any support to consideration of adding a THR component to current tobacco control programming.


Shortly thereafter, I received an inquiry from the R Street Institute.


R Street is a right-of-center moderately libertarian Washington-DC based think tank that respects the role of government in regulating industry to protect health and the environment, but strongly opposes undue governmental interference with market forces. R Street designated tobacco harm reduction as one of their priority issues after FDA attempted to remove e-cigarettes from the market by declaring them to be an unapproved drug-device combination subject to the provisions of the drug law (i.e. the Sotera lawsuit). Thus began my affiliation with the R Street Institute.


Then and now, my role within R Street has been defined in terms of advising them as to their policy stance on tobacco-related issues. My role as a spokesperson is limited to issues and positions that I have recommended to them for adoption. These issues and positions currently stand as follows:


  1. Smoking (mainly but not entirely cigarettes) is the major source of tobacco-related addiction, illness and death in the USA and world-wide. Therefore we should do all within our power to reduce the consumption of these deadly products.

  2. Dishonesty in any form is to be condemned.  This includes misleading statements by both tobacco industry and public health authorities. The misleading statements by public health authorities include the inaccurate warnings now mandated for all smokeless tobacco products, statements to the effect that e-cigarettes may be as harmful as cigarettes and misrepresentation of the pharmaceutical smoking cessation products as “highly effective,” given the fact that they fail about 90% of smokers who use them under the best of study conditions when results are measured at 6 to 12 months.

  3. THR means informing smokers who are unable or unwilling to quit that they could substantially reduce their risk of tobacco-related illness and death by switching to a much lower risk nicotine delivery product such as an e-cigarette, a smokeless tobacco product or even one of the pharmaceutical nicotine products if used long term in a harm reduction mode. THR is a free-market initiative. In this context it represents harnessing private sector resources to reduce tobacco-related addiction, illness and death. THR is recommended as an addition to current anti-smoking efforts, with regulation imposed to assure quality if manufacture and prevent predatory marketing by rouge and irresponsible manufacturers and vendors.

  4. FDA, in their actions to date, has been part of the problem from a public health perspective, not part of the solution. Their continuing efforts to simply remove e-cigarettes from the market by imposing requirements no manufacturer could possibly meet in the context of a pre-market application needs to be replaced with honest and scientifically sound policies, regulations and public communications. Given the dysfunctional wording of the FDA tobacco law, Congressional action may be required to amend the law.

  5. Tobacco harm reduction, in general, and e-cigarettes as a harm reduction modality offer the greatest promise of reducing cigarette use and future tobacco-related addiction, illness and death

  6. Experience, especially with e-cigarettes has shown that this can be done without recruiting significant numbers teens and other non-smokers to nicotine use. In fact, a strong case can be made for the recent record reductions in teen and adult smoking in the USA and UK being due to smokers switching to e-cigarettes and potential smokers being diverted away from smoking through experimentation with e-cigarettes, many of which are and have been nicotine-free.

  7. THR is recommended as an addition to, not a replacement for other tobacco control measures.


As always, if evolving scientific literature, surveillance data and real-life experience challenge or otherwise conflict with any of the stances noted above, R Street understands that I reserve the right to amend my position on any or all of these issues.


I have never received financial support from any tobacco, e-cigarette or pharmaceutical enterprise. I have never received financial support from the CDC Office on Smoking and Health.


As is the custom with Washington-DC think tanks, R Street does not disclose their sponsors other than noting that they do not accept government funding. Most of their work and most of their support comes from liability insurance entities. While it is likely that they receive some support from one or more of the big-tobacco cigarette companies, none of the support they accept from any donor comes with strings attached. Policy statements I have generated have been very strongly anti-cigarette, and, to the extent this issue has been addressed, against the e-cigarette products manufactured by the big-tobacco cigarette companies as inferior in effectiveness to the more sophisticated vape-shop products. By virtue of the manner in which my role within R Street has been defined, I have felt comfortable in accepting both logistic and financial support from R Street to enable me to continue work in the tobacco policy arena.


A list of the presentations I have made and policy papers I have generated while affiliated with the R Street Institute can be found at

updated March 30, 2016

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