The most recent Surgeon Generals Report on Smoking and Health calls for new approaches to control tobacco use and a recent article in The Atlantic, The Nicotine Fix, describes the landscape for Harm Reduction very well. http://www.theatlantic.com/features/archive/2014/11/the-nicotine-fix/382666/

Missing from any of the public discussion of smoking is the question of self-medication. The prevalence of tobacco use among patients with mental illness is almost double that of the general population. Nicotine is an antidepressant. In addition, research has shown that people with Schizophrenia, Attention Deficit Hyperactivity Disorder and Obsessive Compulsive Disorder have improved cognition and Schizophrenics had reduced hallucinations. It is certainly understandable why these smokers are reluctant to quit.

Appropriate diagnosis and treatment of people with mental illness needs to part of any solution to the tobacco control problem. Some anti-depressant medications have been approved for use in smoking cessation, so why not treat two conditions with one drug? A harm reduction approach would also recognize that current medications may be inadequate to completely treat mental illness and that nicotine substitution by lifelong use of nicotine patches or gum may help support a patient to maintain abstinence from smoking.

Many people smoke to prevent symptoms of nicotine withdrawal, with a few added puffs for mood modulation in times of stress. While we debate the regulation of electronic cigarettes, let us acknowledge that anyone using these devices is reducing the harm to themselves. Let us also promote the use of nicotine in safer forms. The British National Health Service has done just that.

What is truly required is a more public discussion of tobacco control. Our number one public health problem, one for which we have evidence-based solutions, has faded from general awareness. Why has that happened?