Tobacco use harm reduction, elimination, and escalation in a large military cohort

Objectives.We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use). Methods. Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months. Results. Among 114 baseline smokers initiating smokeless tobacco use after basicmilitary training,most demonstrated harmescalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is bene?cial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking. Conclusions. When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated bene?ts of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.