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Re: Promoting Snus Will Save Lives in the USA

Zhu, et al., when comparing tobacco-related behaviors in the U.S. and Sweden concluded that “promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programs may not result in any positive population effect on smoking cessation.” [1]

We believe that this conclusion is too pessimistic.

Promotion of snus in the U.S., as a low-risk alternative for smokers unable or unwilling to quit has great potential to substantially reduce tobacco-related illness and death. Snus and selected other smokeless nicotine delivery products can eliminate all risks from fire, second hand smoke, all pulmonary disease, most cardiac disease and most cancer attributable to smoking. These products are up to 1000 times less hazardous than cigarettes.[2,3] Thus, if large numbers of smokers replace some or all of their cigarettes with low-risk alternatives, a substantial reduction in tobacco-related illnesses and death will occur. This will be true even if large numbers of non-smokers initiate use of these smokeless products.

Zhu et al. concede that “…in the U.S., smokeless tobacco has not been promoted as a safer alternative to cigarettes.” But the American environment is even worse: current federal tobacco policy incorrectly labels a smokeless tobacco product as “not a safe substitute for cigarettes,” which has left most Americans – even healthcare professionals – with the misimpression that smokeless products are as hazardous as cigarettes.[4,5]

The popularity of “light” and “low tar” cigarettes in the U.S. has clearly demonstrated that large numbers of American smokers will switch to products that appear to be of lower risk, if encouraged to do so. While the implied health claims for “light” and “low tar” cigarettes were fraudulent, the well established differences in risk between cigarettes and smokeless tobacco products are not.[6]

One of the more intriguing findings in the Zhu paper is that “men quit smokeless tobacco products at three times the rate of quitting cigarettes (38.8% vs. 11.6%, p<0.001).”[1] This raises the possibility that encouraging American smokers to switch to smokeless products will increase the number that eventually quit all use of tobacco and nicotine.

Many opposed to such an approach claim that “conventional nicotine- replacement therapies…have been tested extensively and shown…to be effective.”[7] Such statements, however, rarely show the quit rates. One recently published study boasts that nicotine gum more than doubles the quit rate. The data show 6-month quit rates of 2.1% in controls and 5.9% in study subjects.[8] The authors fail to mention that the therapy failed for 94% of study subjects. We need to do much better than that if we are to achieve substantial reductions in tobacco-related illness and death.

Zhu et al. acknowledge – then gloss over – the fact that the rate of tobacco-related illness and death are far lower in Sweden, where snus is popular, than in the U.S., where cigarettes are dominant. Data from the World Health Organization and the International Agency for Research on Cancer show that lung cancer rates among both Swedish men and women were well under half the rates for their American counterparts from 1980 to 2002.[9] But the data reveal another amazing fact: since 1989 lung cancer among Swedish men has been lower than that among American women. This is evidence that snus use suppresses smoking, with the important context that per capita nicotine consumption is nearly identical in both countries.[10] Furthermore, the Swedish government neither promotes snus for harm reduction nor vilifies it as “not a safe substitute for cigarettes.”

The time has come for American legislators and public health leaders to educate smokers as to the differences in risk profiles between cigarettes and other tobacco products. This will empower smokers who are unable or unwilling to quit to reduce their risk of tobacco-related illness, even while locked into their nicotine addiction. The potential public health benefit is substantial.

Those opposed to such an approach theorize that smokeless tobacco manufacturers “will inevitably target susceptible adolescents,”[7] creating users who may then transition to cigarettes. They also point out that there is no empirical evidence that such a policy (helpful information to smokers) will generate the projected public health benefits. Whether or not such a program results in increases in teen tobacco use will depend entirely on how it is framed and how it is placed in the context of other tobacco control efforts. As to the projected public health benefits, there will be no way to know for sure without implementing the policy, then carefully tracking the results. A national program in the U.S. that includes helpful health education, effective regulation, and robust surveillance and research programs should be able to make the mid-course corrections needed to assure optimal outcomes from a public health perspective.

A piece of legislation was introduced into the recently concluded 110th U.S. Congress. The bill (HR1108/S625) was known as the “Family Smoking Prevention and Tobacco Control Act.” Unfortunately, this bill, as seen by the American Association of Public Health Physicians, is a total failure with regard to the desired health education. It also fails to effectively regulate tobacco products and strongly favors currently marketed cigarettes. We hope it will be possible to amend the bill in the current Congress so that it will provide the needed health education, effective regulation, surveillance and research.[11]

The relative safety of snus and the latest generation of alternative smokeless nicotine delivery products is not a children’s issue. The eight million Americans who will die from smoking-related illnesses in the next twenty years are now 35 years of age and older. Preventing youth access to tobacco is vitally important, but should not be used as an excuse to condemn smoking parents and grandparents to premature death, especially within socially and economically disadvantaged sub-populations. If implemented as an addition to otherwise effective tobacco control programming, the helpful information to smokers should not significantly increase the numbers of teens initiating tobacco use.[11]

Conflict of Interest

Dr. Nitzkin has never sought nor secured any financial or other support from any tobacco-related enterprise. Dr. Rodu is supported by unrestricted grants from smokeless tobacco manufacturers (US Smokeless Tobacco Company and Swedish Match AB) to the University of Louisville. The terms of the grants assure that the sponsors are unaware of this work, and thus had no scientific input or other influence with respect to its design, analysis, interpretation or preparation of the manuscript.

References

1. Zhu S-H, Wang JB, Hartman A, et al. Quitting cigarettes completely or switching to smokeless tobacco: do U.S. data replicate the Swedish results. Tob Control 2008; in press.

2. Royal College of Physicians of London. Protecting smokers, saving lives: the case for a tobacco and nicotine authority. London, England, 2002. Available at: http://www.rcplondon.ac.uk/pubs/books/protsmokers/index.asp (Accessed February 5, 2009).

3. Nitzkin JL, Rodu B. The case for harm reduction for control of tobacco-related illness and death. Resolution and White Paper, Adopted by the American Association of Public Health Physicians, October 26, 2008. Open access, available at: http://www.aaphp.org/special/joelstobac/20081026HarmReductionResolutionAsPassedl.pdf (Accessed February 5, 2009).

4. O’Connor RJ, Hyland A, Giovono G, et al. Smoker awareness of and beliefs about supposedly less harmful tobacco products. Am J Prev Med 2005;29:85-90.

5. O’Connor RJ, McNeill A, Borland R, et al. Smokers’ beliefs about the relative safety of other tobacco products: findings from the ITC Collaboration. Nicotine Tob Res 2007;9:1033-1042.

6. Rodu B, Godshall WT. Tobacco harm reduction: an alternative cessation strategy for inveterate smokers. Harm Reduction J 2006;3:37. Open access, available at: http://www.harmreductionjournal.com/content/3/1/37 (Accessed February 5, 2009).

7. Smokeless tobacco: harm reduction debatable. CA: Cancer J Clin 2008;58:4-6.

8. Shiffman S, Ferguson SG, Strahs KR. Quitting by gradual smoking reduction using nicotine gum: a randomized controlled trial. Am J Prev Med 2009;36:96-104.

9. World Health Organization Mortality Database. Accessed through the Descriptive Epidemiology Group, Biostatistics and Epidemiology Cluster, International Agency for Research on Cancer, Lyon, France at: http://www-dep.iarc.fr/

10. Fagerström K. The nicotine market: an attempt to estimate the nicotine intake from various sources and the total nicotine consumption in some countries. Nicotine Tob Res 2005;7:343-350.

11. Analysis and Recommendations for Amendment of FDA/Tobacco Bill. American Association of Public Health Physicians, November 5, 2008. Open access, available at: http://www.aaphp.org/special/2009/20081105_AnalRcommendFDATobcBill.pdf (Accessed February 5, 2009).

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Re: Response to Nitskin and Rodu's Comments

Nitzkin and Rodu raise several interesting points about harm reduction and how they would like to see the current FDA bill (HR1108/S625) be improved [1]. However, the purpose of Zhu et al.’s paper is not to advocate for or against harm reduction. It is simply to examine whether current US data replicate the Swedish results [2].

If large numbers of US smokers could be induced to switch to smokeless tobacco, that would certainly help to increase the population smoking cessation rate. However, our study shows that very little switching has occurred in the US population, unlike the Swedish population. Smokeless tobacco has been promoted in both countries for a long time, without a focus on relative risk. In light of these findings, we sound a cautionary note. Tobacco control policymakers face difficult choices, and our hope is that these new results might be helpful.

Nitzkin and Rodu’s arguments for the merits of harm reduction are well known because there has been so much debate on this topic. Some are convinced of such arguments while others are not [3,4]. Our paper aims to inject empirical data into what sometime seems like an endless logical exercise without new information. The debate is often filled with hypothetical scenarios on how things might work this or that way. Some of these hypotheses may turn out to be correct. Our paper does not say that the hypotheses for harm reduction are wrong. It simply says that new results from the US are quite different from the Swedish results and do not support the idea that promoting smokeless tobacco necessarily leads to increased smoking cessation on a population level. We believe that the field needs more such empirical research.

That research can be misused, however, as in Nitzkin and Rodu’s extrapolation of our finding that US men quit smokeless tobacco products at three times the rate of quitting cigarettes. They suggest that this means that “encouraging American smokers to switch to smokeless products will increase the number that eventually quit all use of tobacco and nicotine.” They ignore our larger finding that US smokers are not switching to smokeless in the first place, and they fail to understand that the differential quit rates suggest that, mathematically speaking, US men tend to quit smokeless before quitting cigarettes. Are Nitzkin and Rodu necessarily wrong, then, in suggesting such a hopeful scenario? We would not say that. One can easily imagine various scenarios in which smokeless tobacco helps smokers quit cigarettes or even all forms of tobacco. But however enticing those scenarios may be, the US data do not yet support them.

1. Nitzkin JL, Rodu B. Promoting snus will save lives in the USA. Tob Control eLetter published online February 6, 2009.

2. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson JT et al. Quitting cigarettes completely or switching to smokeless: do U.S. data replicate the Swedish results? Tob Control; in press.

3. Rodu B, Godshal WT. Tobacco harm reduction: an alternative cessation strategy for inveterate smokers. Harm Reduction J 2006;3:37. Open access, available at: http://www.harmreductionjournal.com/content/3/1/37 (Accessed February 10, 2009).

4. Tomar SL, Fox BJ, Severson HH. Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking? Int J Environ Res. Pub Health 2009, 6(1), 10-24; doi:10.3390/ijerph6010010

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Re: Evidence From Zhu et al. That American Smokers Have Switched to Smokeless Tobacco

Zhu et al. reported that 0.3% of men who were exclusive current smokers in 2002 became smokeless tobacco users at follow-up in 2003 (1). Similarly, they reported that 1.7% of men who were former smokers of one year or less duration and 0.3% of men who were former smokers for a longer time were smokeless tobacco users in 2003.

These percentages are quite small, prompting the first author to issue a statement in a press release that the research confirms that the effects of smokeless tobacco use on smoking among Swedish men are unique to Sweden (2). However, the study did not provide population estimates for the American percentages.

Using SPSS statistical software with Complex Samples (Version 15.0 for Windows), I developed U.S. population estimates from the 2002 NHIS for the number of male exclusive current and former smokers in that year, from which I estimated the number who had switched to smokeless tobacco in 2003 as follows:

From exclusive current smokers in 2002: 70,416

From former smokers (<= 1 year): 52,058

From former smokers (> 1 year): 68,165

Total 190,639

Some might believe that 190,000 current or former smokers who became smokeless tobacco users in this one-year period is an insignificant number. But it is consistent with the results of a recent study using the 2000 National Health Interview Survey (3), in which 261,000 American men had used smokeless tobacco to quit smoking. In that study switching to ST compared very favorably with pharmaceutical nicotine, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. Taken together, these results are proof of the concept that smokeless tobacco is a viable cessation option for smokers in the U.S.

As long as American smokers are misinformed about the comparative risks of ST and cigarettes, most will not consider trying to switch, or will do so only reluctantly. A social and public health environment that honestly informs smokers about comparative risks would provide many more smokers with the opportunity to lead longer and healthier lives.

Conflict of Interest

Dr. Rodu is supported by unrestricted grants from smokeless tobacco manufacturers (US Smokeless Tobacco Company and Swedish Match AB) to the University of Louisville. The terms of the grants assure that the sponsors are unaware of this work, and thus had no scientific input or other influence with respect to its design, analysis, interpretation or preparation of the manuscript.

References

1. Zhu S-H, Wang JB, Hartman A, et al. Quitting cigarettes completely or switching to smokeless tobacco: do U.S. data replicate the Swedish results. Tob Control 2008; in press.

2. UC San Diego News Center, available at: http://ucsdnews.ucsd.edu/newsrel/health/01-09SmokelessTobacco.asp (Accessed February 17, 2009)

3. Rodu B, Phillips CV. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey. Harm Reduction Journal 5: 18, 2008 (Open Access, available at http://www.harmreductionjournal.com/content/pdf/1477-7517-5-18.pdf

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Re: Response to Zhu et al. (1, 2)

The authors of this paper (1), the responders (3), and most everyone else agree that smoking is high risk, and that the use of smokeless tobacco is fairly low risk. In any other area, the obvious conclusion would be to encourage smokers to switch to the lower risk alternative.

However, what follows instead is a strange and yet quite common argument that because many smokers might not switch, this alternative should not be promoted. Whether or not most people will actually use a low-risk alternative has never been a necessary precondition for promoting or introducing it. Effectively, the authors suggest that because tobacco harm reduction currently only saves the lives of a few thousand American smokers per year, it should not be encouraged.

But this study actually tells us nothing about how many more might be saved. Zhu et al. argue that their paper adds needed empirical data to the discussion, but in fact they have merely measured something that is not interesting or useful to know, and have confirmed something that no one would ever doubt: They discovered that when a population of smokers does not know that there is a low-risk alternative, then it is likely that few of them will switch to it. Presumably no one would fail to predict that, and reporting it says nothing about the potential benefits of promoting harm reduction.

The authors acknowledge that smokers are unaware of the comparative risks of tobacco use, and to their credit, point out that this shortfall is something that the public health community must still address. However, the authors mislead somewhat by stating that a reason that switching may not have occurred at higher rates might be due to the fact that despite its general availability, smokeless tobacco has not been promoted as a safer alternative, when it is more the case that smokeless tobacco has been actively discouraged as an alternative for smokers. Yes, smokers can buy smokeless tobacco instead, but they do not know there is good reason to do so. The lack of knowledge is the result of a concerted (and successful) disinformation campaign by anti-tobacco extremists to convince people that there are no low-risk nicotine products. Whatever the present paper's empirical findings about historical switching rates, such findings tell us almost nothing about how many smokers would switch if they knew the truth.

If someone was interested in producing actual useful empirical information, rather than just contributing to anti-harm-reduction rhetoric, the most useful experiment would be to education a population about the comparative risk and then observe how many smokers make the switch. If few switched, then the authors' claims would actually be supported. (Though their policy conclusions would still not be supported: It would still be ethically mandated, as well as beneficial to some extent, to tell smokers the truth about alternatives and encourage them to switch, even if most of them chose not to do so.)

Perhaps the only interesting question that arises from this analysis is why Swedish smokers switched to smokeless tobacco. Though a much larger portion of Swedes know the truth than do Americans, many still incorrectly think the risks from snus are similar to those from smoking. Part of the explanation for the popularity of smokeless tobacco is certainly cultural (or, put another way, an historical accident, an economic "path dependence" resulting from social phenomena that trace back about four decades). But part of the explanation is that, despite the widespread lack of knowledge, Swedes are not being actively bombarded by so much disinformation that it drowns out the truth. An American who tries to learn the truth must learn to ignore the disinformation coming from the U.S. national government, other government entities, and most major self-styled health organizations, including some that are respectable sources of advice in other areas (4), and sort through to the rare accurate information that is available (e.g., 5, 6,7). (Nitzkin and Rodu address this point well (2)). Moreover, an American who learns the truth in spite of the disinformation and then wants to tell others needs to then convince the others that most of the authorities they normally trust are lying, making it quite difficult to spread the truth once it is learned.

Despite being largely an historical accident, the Swedish experience with tobacco harm reduction is still a great public health triumph. Zhu et al. admit that tobacco harm reduction seems effective in Sweden but are loathe to generalize or to suggest that we should even try to pursue such triumph elsewhere. Extending their reasoning, consider this: In 1984, in the United States roughly 14% of individuals used seatbelts (8), which is less than half the prevalence in Sweden more than a decade earlier (9). The general knowledge about the usefulness of seatbelts was similar in the two countries, so there was clearly some cultural difference that resulted in Americans adopting the restraints at a lower rate. Following Zhu et al.'s logic, we should have just conceded that Americans are culturally uninterested in using seatbelts, and that the Swedish success could not be generalized.

Fortunately for the tens of thousands of Americans who have been saved by seatbelts over the last few decades, in public health (in contrast to anti-tobacco activism), we generally see success at reducing harm as something to pursue and emulate rather than to dismiss as too foreign to work.

Conflict of Interest

The authors' research is partially supported by an unrestricted (completely hands-off) grant to the University of Alberta from U.S. Smokeless Tobacco Company. Dr. Phillips has consulted for U.S. Smokeless Tobacco Company in the context of product liability litigation. Dr. Phillips is also a member of British American Tobacco's External Science Panel that deals with developing reduced harm products.

References

1. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson JT et al. Quitting cigarettes completely or switching to smokeless: do U.S. data replicate the Swedish results? Tob Control; in press.

2. Zhu et al. Response to Nitzkin & Rodu's comments. Tob Contol eLetter published online February 11, 2009.

3. Nitzkin JL, Rodu B. Promoting snus will save lives in the USA. Tob Control eLetter published online February 6, 2009.

4. Phillips C, Wang C & Guenzel B. You might as well smoke: the misleading and harmful public message about smokeless tobacco. 2005. BMC Public Health 5:31.

5. Phillips C. Tobaccoharmreduction.org. (At: http://www.tobaccoharmreduction.org)

6. Rodu B & Godshall WT. 2006. Tobacco harm reduction: an alternative cessation strategy for inveterate smokers. Harm Reduction Journal 3:37.

7. Royal College of Physicians. 2007. Harm reduction in nicotine addiction: Helping people who can't quit. (Available at: http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234)

8. Presidential Initiative for Increasing Seat Belt Use Nationwide: Recommendations from the Secretary of Transportation. April 16, 1997. http://www.nhtsa.dot.gov/people/injury/airbags/Archive- 04/PresBelt/fullreport.html

9. Phaner G & Hane M. 1979. Seat Belts: Opinion Effects of Law Induced Use. Journal of Applied Psychology 64(2):205-212.

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Re: Response to Rodu’s and Bergen & Phillips’ Comments

Rodu is correct in stating that because the U.S. population is so large, even a small percentage of cigarette smokers switching to smokeless would mean many thousands of people [1]. However, he has done only half the math- the other half is that exclusive smokeless users also switch to cigarettes. In fact, it is easy to see from Table 2 in Zhu et al. that the number switching from smokeless to cigarettes is much greater than the number of smokers switching to smokeless [2]. The reason is that the rate of switching from smokeless to cigarettes is more than 10 times higher than the rate of switching from cigarettes to smokeless. One can use the CPS 2002-2003 longitudinal sample with the proper population weights and find that 120,266 people switched from smokeless to cigarettes, whereas only 53,850 switched from cigarettes to smokeless. Someone else could use these numbers to suggest that if more people use smokeless, more will use cigarettes (although that is not the interpretation in Zhu et al.). That is why it is important not to selectively choose numbers from Zhu et al. and ignore the larger context [3].

Bergen and Phillips dismiss our empirical results as “not interesting or useful to know” [4], and then they reiterate the well known arguments for harm reduction. It is true that our results do not support Bergen and Phillips’ position. Our paper strives to address pertinent arguments from both sides of the harm reduction debate. After examining possible explanations (socio-cultural, price, and product differences) for the difference between the Swedish results and those that we found in the U.S., we raise a cautionary note in our conclusion. Readers can judge for themselves whether our paper is an anti-harm reduction opinion piece or a careful empirical analysis. Interested readers with no access to the PDF file for our paper can request a copy by sending an email to szhu@ucsd.edu.

Conflict of Interest: None to declare

1. Rodu B. Evidence from Zhu et al. that American smokers have switched to smokeless tobacco. Tob Control eLetter published online February 20, 2009. http://tobaccocontrol.bmj.com/cgi/eletters/tc.2008.028209v1#2853

2. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson T, et al. Quitting cigarettes completely or switching to smokeless: Do U.S. data replicate the Swedish results? Tob Control. Published Online First: 23 January 2009. doi:10.1136/tc.2008.028209

3. Zhu, S-H. Gamst, A. Response to Nitzkin and Rodu. Tob Control eLetter published online February 11, 2009. http://tobaccocontrol.bmj.com/cgi/eletters/tc.2008.028209v1#2837

4. Bergen P, Phillips CV. Response to Zhu et al. Tob Control eLetter published online February 20, 2009. http://tobaccocontrol.bmj.com/cgi/eletters/tc.2008.028209v1#2862

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Re: Response to Zhu February 24 e-letter

This note is in response to the latest communication from Zhu, relative to whether a harm reduction component to tobacco control programming in the United States would yield public health benefits. Zhu is very skeptical. Nitzkin and Rodu are certain such a benefit would accrue. In his latest posting, Zhu suggests that Rodu “only did half the math” -- and suggested that one can read anything one wants into the available data. (1) I (Nitzkin) strongly disagree with Zhu’s latest suggestion.

Zhu is correct about the low number of American Smokers switching from smokeless tobacco (ST) to cigarettes and the higher number switching from ST to cigarettes. What he does not address is why. These switch rates are clearly attributable to the fact that 87% of American smokers incorrectly believe that smokeless products are as hazardous as cigarettes. (2,3,4) American smokers are very health conscious -- 85% now use light or low tar cigarette products (5) -- so they have proven their interest in safer ways to use tobacco. American tobacco policies, codified by the 1986 Comprehensive Smokeless Tobacco Health Education Act, have purposely misled the American public into believing that ST products are as hazardous as cigarettes. The law requires that ST products be labeled “not a safe substitute for cigarettes.” This technically correct but misleading statement has been spectacularly successful.

If we, as an American society, are to enjoy the health benefits that a harm reduction component to tobacco control programming can provide – a better than 99% reduction in tobacco-related illness and death by switching from cigarettes to one of a number of low risk smokeless products (6,7,8)– then we must eliminate this misleading statement from the ST product packages and educate the public about the relative risks of combustible versus non-combusted products.

Zhu’s assertion that a harm reduction approach would be unlikely to result in a population-level health benefit ignores the possibility that simply telling the truth to health conscious but inveterate American smokers might dramatically increase the numbers of smokers switching to the lowest risk ST products and dramatically decrease the numbers that switch back to cigarettes. In fact, some of the participants in the recent dialogue on harm reduction (David Levy, Gary Giovino, David Sweanor and Ken Warner) were authors of, and participants Dorothy Hatsukami and Jack Henningfield were expert panelists for, a published study estimating that appropriate marketing of ST as a cigarette substitute would result in a 10% decline in American smoking prevalence, or about 4 million fewer smokers (9).

While Zhu takes no stand on the currently proposed FDA/Tobacco bill, many who are opposed to any consideration of a harm reduction approach have taken his concluding statement as support for the bill.

It is important to note that the current FDA/Tobacco Bill, if passed in its current form, will continue to misinform American inveterate smokers that ST is just as dangerous. By that means, the currently proposed legislation will continue to deny these American smokers the benefits that switching to low risk ST could provide.

The implications of these research findings are substantial. The Tobacco Control Task Force (TCTF) of the American Association of Public Health Physicians has estimated that adding a harm reduction component to the currently proposed FDA/Tobacco bill could save as many as 4 million of the eight million current American smokers who will otherwise die of at tobacco-related illness over the next twenty years. The TCTF could not envision any other feasible policy initiative that could generate a public health benefit of this magnitude. (10) The time has come to shed our longstanding biases against harm reduction and convert these research findings into tobacco control policy and programming.

1. Xhu S-H. A Response to Nitzkin and Rodu. Tobc Control E-letter published on line February 24, 2009 http://tobaccocontrol.bmj.com/cgi/eletters/tc.2008.028209v1

2. CONNOR RJ, HYLAND A, GIOVINO G, FONG GT, CUMMINGS KM. Smoker awareness of and beliefs about supposedly less harmful tobacco products. Am J Prev Med 2005; 29: 85-90.

3. CUMMINGS KM. Informing Consumers about the Relative Health Risks of Different Nicotine Delivery Products, presented at the National Conference on Tobacco or Health, New Orleans, LA, 2001.

4. O’CONNOR RJ, MCNEILL A, BORLAND R, et al. Smokers’ beliefs about the relative safety of other tobacco products: findings from the ITC Collaboration. Nic & Tob Res 2007; 9: 1033-42.

5. ZELLER M, HATSUKAMI D, BACKINGER C et al: The strategic dialogue on tobacco harm reduction: A vision and blueprint for action in the United States. Tobacco Control Online: 24 February 2009 http://tobaccocontrol.bmj.com/cgi/content/abstract/tc.2008.027318v1 (Accessed March 7, 2009)

6. Royal College of Physicians of London. Protecting Smokers, Saving Lives. London, 2002. Available at: http://www.rcplondon.ac.uk/pubs/books/protsmokers/index.asp (Accessed January 6, 2009)

7. LEVY DT, MUMFORD EA, CUMMINGS KM, et al. The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev 2004; 13: 2035-42.

8. PHILLIPS CV, RABIU D, RODU B. Calculating the comparative mortality risk from smokeless tobacco versus smoking. Congress of Epidemiology, 2006.

9. LEVY DT, MUMFORD EA, CUMMINGS KM, et al. The potential impact of a low-nitrosamine smokeless tobacco product on cigarette smoking in the United States: Estimates of a panel of experts. Addictive Behaviors 2006; 31; 1190–1200.

10. NITZKIN J: Projections of Alternative Approaches to Federal Legislation re Tobacco Control. Published Online 3 March 2009 http://www.aaphp.org/special/2009/20090303TobcAlternativeProjections.pdf (Accessed March 7, 2009)

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Re: Response to Nitzkin March 24 eletter

We appreciate Dr. Nitzkin’s desire to improve the current FDA bill. Our paper clearly stated that smokers are generally uninformed about the relative risk of various tobacco products and that is an issue that the public health community still must address (1). However, it is important not to equate providing accurate risk information with promoting the use of specific tobacco products. Nitzkin does not seem to make this distinction very clearly (2, 3).

The chief aim of our paper is to provide empirical analysis of available data to increase understanding of what has happened in the U.S. People differ in their predictions of what the overall population effect on smoking cessation will be if smokeless tobacco products are promoted for harm reduction. We believe results reported in Zhu et al. justify the cautionary note in our conclusion (1).

1. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson T, et al. Quitting cigarettes completely or switching to smokeless: Do U.S. data replicate the Swedish results? Tob Control. 2009;18:82-87. doi:10.1136/tc.2008.028209 http://tobaccocontrol.bmj.com/cgi/content/full/18/2/82

2. Nitzkin JL, Rodu B. Promoting snus will save lives in the USA. Tob Control eLetter published online February 6, 2009.

3. Nitzkin JL. Response to Zhu February 24 e-letter. Tob Control, eLetter published online March 24, 2009 http://tobaccocontrol.bmj.com/cgi/eletters/18/2/82#2891

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Re: Potential utility of switching to smokeless tobacco

The study by Zhu et al. "Quitting Cigarettes Completely or Switching to Smokeless Tobacco:Do U.S. Data Replicate the Swedish Results?" has raised a number interesting questions. [1] However, the conclusions of the study need further scrutiny in addition to the previously published comments.

The main conclusion “The Swedish results are not replicated in the U.S.” is certainly true, but not very interesting since it just lays down something very obvious. Sweden’s last 50 years’ development of increasing snus use is built on quite old Swedish traditions and could not possibly have been replicated in a country where Swedish type moist oral smokeless tobacco has not until recently been available altogether and misleading pieces of discouraging information have dominated over evidence-based statements regarding the characteristics of the product.[2]

The statement “Both male and female U.S. smokers appear to have higher quit rates for smoking than have their Swedish counterparts, despite greater use of smokeless tobacco in Sweden.” has very little support in the study, at the same time as there is evidence of the opposite in other scientific sources. The Zhu et al. study reports that 11.6 % of the men who were smoking at baseline declared that they were not smoking at the end of the observation period. But this does not mean that there has been a 11.6 % rate of sustained smoking cessation. It just means that 11.6 % of the initial smokers have started quit attempts that have remained successful up till the end of the observation period. But, it must be assumed that a number of these attempters will relapse, particularly those who started their quit attempt in the later part of the observation period. This assumption is further supported by the observation that a 11.6 % decrease of smoking from 2002 to 2003 appears to deviate from the actual US pattern. The nationwide Behavioural Risk Factor Surveillance Survey, BRFSS, reports a decrease in male prevalence of smoking of just 4.6 % from 2002 to 2003.[3] Further, none of these figures tell us anything about quit rate (ratio between Former Smokers and Ever Smokers). However, from BRFSS data it can also be calculated that in 2003 quit rates in the U.S. population were 0.53 for men and 0.51 for women. Swedish data representing variables defined exactly as these BRFSS data are not available in published sources but present in the more comprehensive database of FSI, The Research Group for Societal and Information Studies. From these data it can be calculated that corresponding Swedish quit rates are 0.63 for men and 0.54 for women. So, Swedish quit rates are markedly higher than those in the U.S. as far as men are concerned and slightly higher for women. Further, the pattern of differences in quit rates between countries and genders is consistent with the corresponding patterns of differences in snus use. A large population study in Sweden has demonstrated that: 1) the gender difference is absent both in the subgroup with snus use and in the subgroup without snus use, and 2) in each gender the quit rates are substantially higher in those with than in those without snus use. [4] These observations, and findings from other Swedish population-based studies, [5, 6, 7] do suggest that the inter-country differences in quit rates may be associated with the use of snus in Sweden. The above statement by Zhu et al. is not consistent with actual evidence.

The statement “Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programs may not result in any positive population effect on smoking cessation.” would be true if promotion of smokeless tobacco were seen as a priori unable to achieve actual use of smokeless tobacco for smoking cessation purposes. But, the relevant question is whether or not actual use of smokeless tobacco for smoking cessation purposes can yield a positive population effect on smoking cessation. As pointed out above, Swedish population studies have consistently found a positive association between snus use and increased smoking cessation, particularly in men. These findings are also recognized by various international expert reviews. [8, 9 (p. 109), 10] Similar patterns have been demonstrated in Norwegian population studies. [11,12] A recent US population study suggests that also in the U.S. there are signs that use of smokeless tobacco for smoking cessation purposes are emerging and have higher success rates than those using NRT, just as found in Sweden and Norway. [13] All of these findings come from population-based studies and do then apply to the population level. They also come from countries with ongoing tobacco control programs. These programs do then appear to have taken advantage by being supplemented by the use of smokeless tobacco. Consequently, the above statement by Zhu et al is severely weakened by relevant evidence that is actually available.

After noticing that that the Swedish results have not yet been replicated in the U.S., it is natural to look into a possible future. In that respect Zhu et al. appear to be too pessimistic. Norway has already come quite a bit and, as mentioned above, there are emerging signs of progress in the U.S. as well, and this development may be accelerated if evidence-based public information is strengthened. It should thereby be kept in mind that, according to the Swedish experience, snus can both be an effective temporary aid towards total freedom from nicotine, and, a low -toxicity form for continued nicotine intake for the largely neglected group of smokers who can’t quit using nicotine. Their situation has recently been discussed in a British expert report. [14] For these smokers, quitting nicotine completely is no option. Why not then promote the other option, switching to low-toxicity smokeless tobacco. From health point of view this may be almost as beneficial as quitting completely. [15, 16] This potential utility of switching to smokeless tobacco may eventually, if promoted in a responsible manner, save lives in the U.S. just as in Sweden.

Lars Ramstrom PhD Director Institute for Tobacco Studies Stockholm, Sweden

Email: lars.ramstrom@tobaccostudies.com

Conflict of interest. Owner of shares in Pfizer Inc. Never any funding from tobacco industry sources.

References

1. Zhu S-H et al. Quitting cigarettes completely or switching to smokeless tobacco: Do U.S. data replicate the Swedish results. Tob. Control published online 23 Jan 2009; doi:10.1136/tc.2008.028209.

2. Phillips CV et al. You might as well smoke; the misleading and harmful public message about smokeless tobacco. BMC Public Health. 2005 Apr 5;5:31.

3.National Center for Chronic Disease Prevention and Health Promotion, Behavioral Risk Factor Surveillance System. Prevalence and Trends Data, Nationwide (States and DC) – 2003. (Available at: http://apps.nccd.cdc.gov/brfss/page.asp?cat=&yr=2003&state=UB# accessed June 13, 2009.)

4. Ramström L et al. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob. Control, 2006 Jun;15(3):210-4.

5. Furberg H et al. Cigarettes and oral snuff use in Sweden: Prevalence and transitions. Addiction 2006:101;1509-1515.

6. Rodu B et al. Evolving patterns of tobacco use in northern Sweden. Journal of Internal Medicine 2003;253:660-665.

7. Furberg H et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob. Control, 2005 Dec;14(6):422-4.

8. Tobacco Advisory Group of the Royal College of Physicians. Ending tobacco smoking in Britain: Radical strategies for prevention and harm reduction in nicotine addiction. Royal College of Physicians, London, 2008.

9. SCENIHR, Scientific Committee on Emerging and Newly Identified Health Risks. Health Effects of Smokeless Tobacco Products. Brussels: European Commission; 2008. (Available at: http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_013.pdf, accessed June 13, 2009).

10.The European Respiratory Society. Tobacco Smoking: Harm Reduction Strategies - An ERS Research Seminar. Brussels, 2006.

11. Lund K E. The role of snus in the decline of smoking in Norway. Presentation at the 14th World Conference on Tobacco or Health, Mumbai, India, 2009.

12. Scheffels J. Snus as a strategy for smoking cessation. Presentation at the 14th World Conference on Tobacco or Health, Mumbai, India, 2009.

13. Rodu B et al. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey. Harm Reduction Journal 2008, 5:18 doi:10.1186/1477-7517-5-18.

14. Tobacco Advisory Group of the Royal College of Physicians. Harm reduction in nicotine addiction: Helping people who can't quit. Royal College of Physicians, London, 2007.

15. Levy DT et al. The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev 2004; 13: 2035-42.

16. Gartner CE et al. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet, 2007; 369: 2010- 2014.

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Re: Response to Ramstrom

If we understand him correctly, Ramstrom considered our findings on what has happened in the U.S. too obvious to be interesting. It is obvious because, for over 50 years, Sweden has had a particular smokeless tobacco product, snus, that the US did not have [1]. He apparently considered the history of U.S smokeless tobacco use (which is over 100 years) of no significance and he was confident that the U.S. smokeless tobacco products cannot possibly work to help American smokers quit cigarettes. We did not approach the problem with that perspective. That is why we conducted the study. In our paper, we have considered product difference as part of the explanation in the discussion section [2]. But logic requires us not to attribute the different results between the U.S and Sweden to a single factor when there are so many other contributing factors, including significant cultural differences between the two countries. The way that Ramstrom placed all his confidence in a single factor explanation without making an effort to rule out other strong alternative explanations strikes us as rather unscientific.

Ramstrom also did not like our caution that a significant increase in population smoking cessation may not come from promoting smokeless tobacco in places like the U.S. We believe that the results found in our study justify caution in prediction. The results do not suggest that it will be impossible to increase population smoking cessation rates by promoting smokeless tobacco use. They do suggest that it would require a much more aggressive marketing campaign to get more Americans to use smokeless tobacco than simply getting rid of misinformation about the relative risks of smokeless tobacco and cigarettes. An aggressive promotion of smokeless tobacco products, especially if it comes from both the public health community and the tobacco industry, could change the landscape of tobacco control in a rather unpredictable manner. In many countries nowadays, the tobacco control activities and people’s attitude toward tobacco use are very different from those of Sweden’s in the 1970’s, when snus started to be used by more Swedish men. In fact, we do not even know whether the observed effects of snus on smoking cessation in Sweden were mainly due to the large price differential between cigarettes and snus, which had nothing to with snus being perceived as safer [2]. Again, Ramstrom’s confidence in predicting the future with such limited information seems unfounded.

We welcome Ramstrom’s attempt to present empirical data to compare quitting among current smokers in Sweden and the U.S. It is difficult to find two surveys from two countries that are directly comparable, so some estimation is necessary at this point. However, we have difficulty following his method of analysis because he switched between quit ratio and annual quit rate in his comments. The former is an accumulative rate of former smokers among ever smokers, typically obtained in cross- sectional surveys and not adjusted for population change over time when they are reported from different surveys (for example, if there is a sudden influx of young smokers from year 1 to year 2, the quit ratio of the population can actually go down if analyzed using cross-sectional surveys). The latter is confined to the same cohort of smokers for a particular year, and in our case is followed up longitudinally in 12 months. Ramstrom computed the quit ratio using two cross-sectional surveys and he believed that he has proved the annual quit rates for Swedish men are higher than those of their American counterparts and that this is attributable to the fact that Swedish men used snus. This really doesn’t work. One cannot directly deduce an annual quit rate from the quit ratio in this manner. Since this issue is technically subtle it would be preferable if Ramstrom could present his detailed calculations with a description of the data sets used for calculation as a regular research article. The e-letters format, which does not use a regular peer review process, is not conducive to careful examination of the methodology used. We have tried, but we cannot judge from Ramstrom's comments how he decided that the annual quit rate for the time period considered was higher for Swedish than for U.S male smokers. Our statement that U.S. smokers appear to have higher quit rate is based on the fact that the 6-month abstinence rates are 7.6% and 6.6% for U.S. males and females, respectively, which compared favorably to Rodu et al.’s report of 6.0% and 4.1% for Swedish male and female smokers. These results were reported on page 85 in Zhu et al.’s study [2]. The rates reported in the Rodu et al. study included those who had quit for a long time as well as those who had just quit at the time of the survey [3]. Given that the relapse rate between 6 and 12 months is low, it seems reasonable that the 12-month abstinence rate in the U.S. would not be too much lower than those reported. In any case, we would certainly welcome any empirical analysis that can shed light on this issue. It would be a nice change from continuing this route of debate based on preference of how optimistic or pessimistic one is in predicting the future.

Conflict of Interest: None declared.

Reference:

1. Ramstrom LM. Potential utility of switching to smokeless tobacco. Tob Control eLetter published online June 18, 2009 http://tobaccocontrol.bmj.com/cgi/eletters/18/2/82#2899

2. Zhu S-H, Wang JB, Hartman A, Zhuang Y, Gamst A, Gibson T, et al. Quitting cigarettes completely or switching to smokeless: Do U.S. data replicate the Swedish results? Tob Control. 2009;18:82-87. doi:10.1136/tc.2008.028209 http://tobaccocontrol.bmj.com/cgi/content/full/18/2/82

3. Rodu B, Stegmayr B, Nasic S, et al.. Evolving patterns of tobacco use in northern Sweden. J Intern Med 2003;253:660–665

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Re: Re: Response to Ramstrom

The authors’ response to my comments fails to disqualify my criticism. A large part of their response consists of a misinterpretation of some of my points. This appears to be due to confusion about terminology. Unfortunately, terminology practices are not as perfectly unequivocal as would be desirable. If the authors had been well enough familiar with the international scientific literature in this field, they should have noticed that the phrase “quit rate” is used with different meaning in different settings. An instructive note on the terminology situation is found in the pertinent WHO guidelines [1]. After defining “prevalence of cessation”, the guidelines say (I quote from page 80): <<Other terms, such as the “quit rate”, the “quit index”, or the “quit ratio”, have also been used to describe this or a similar measure.>>

I had questioned the validity of the authors’ indication of rate of quitting during one year in their study, since the possibility of remaining relapses was not considered. This can have inflated the registered rate of quitting, and the likelihood of such a risk appears to be strengthened by my observation that in the same period the nationwide decrease in smoking prevalence (mainly due to cessation of smoking) was quite a bit lower.

I had also questioned an entirely different part of the original article, the comparison between cessation practices in the US and in Sweden. While the authors had no real basis at all for such a comparison, I just presented easily understandable evidence in terms of figures for “prevalence of cessation” in these two countries. When I thereby used the denominator phrase “quit rate” (cf above), I started with a perfectly clear, explicit definition of the meaning that I attached to that phrase (ratio between ex-smokers and ever-smokers), so there is no justification for the kind of misinterpretation brought forward in the authors’ response.

In their response the authors say: “The way that Ramstrom placed all his confidence in a single factor explanation without making an effort to rule out other strong alternative explanations strikes us as rather unscientific.” But there is no ground whatsoever for this statement, neither in my comments, nor in any other publication of mine. I have always been very careful to point out that the effect snus use in Sweden is just one of several factors contributing to the Swedish success in reducing smoking and smoking-related diseases. The authors’ procedure to groundlessly attribute a blameworthy opinion/behaviour to a counterpart in a scientific discussion, that is indeed �unscientific’.

As I said in the introduction to my original comments, the Zhu et al article did raise a number of interesting questions. And, beside the weaknesses that I have looked at, it did contain good points as well. But, I still find the final conclusion too pessimistic as far as the possibly positive role of low-toxicity smokeless tobacco is concerned.

Reference:

World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. World Health Organization. Geneva, 1998. ISBN 92 4 154508 9.