Tob Control 19:297-305 doi:10.1136/tc.2009.031427
  • Research paper

Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA

  1. Stanton A Glantz3
  1. 1Center for Tobacco Control Research and Education, University of California, San Francisco, USA
  2. 2Division of General Internal Medicine, Department of Medicine, Center for Tobacco Control Research and Education, University of California, San Francisco, USA
  3. 3Division of Cardiology and the Philip R Lee Institute for Health Policy Studies, Department of Medicine, Center for Tobacco Control Research and Education, University of California, San Francisco, USA
  1. Correspondence to Stanton A Glantz, Department of Medicine, Division of Cardiology, Center for Tobacco Control Research and Education, Philip R Lee Institute for Health Policy Studies, University of California San Francisco, Box 1390, 530 Parnassus Avenue, Suite 366, San Francisco, California 94143-1390, USA; glantz{at}
  1. Contributors SAG conceived of the study and programmed the Monte Carlo simulation. ABM refined the decision structure and collected most of the data on transition probabilities and health effects, with some help from SAG and PML. All three authors contributed to analysis and interpretation of the results, drafting the article, and revising it critically for important intellectual content. All authors approved the version to be published.

  • Received 12 May 2009
  • Accepted 26 February 2010
  • Published Online First 27 June 2010


Background Snus (a form of smokeless tobacco) is less dangerous than cigarettes. Some health professionals argue that snus should be promoted as a component of a harm reduction strategy, while others oppose this approach. Major US tobacco companies (RJ Reynolds and Philip Morris) are marketing snus products as cigarette brand line extensions. The population effects of smokeless tobacco promotion will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns.

Objective To quantitatively evaluate the health impact of smokeless tobacco promotion as part of a harm reduction strategy in the US.

Methods A Monte Carlo simulation of a decision tree model of tobacco initiation and use was used to estimate the health effects associated with five different patterns of increased smokeless tobacco use.

Results With cigarette smoking having a health effect of 100, the base case scenario (based on current US prevalence rates) yields a total health effect of 24.2 (5% to 95% interval 21.7 to 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health-concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with a health effect of 30.4 (5% to 95% interval 25.9 to 35.2). The anticipated health effects for additional scenarios with lower rates of smokeless uptake also overlapped with the base case.

Conclusions Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.


  • An earlier version of the material in this paper was presented as a plenary lecture at the 2008 Society for Research on Nicotine and Tobacco, titled ‘Innovative Approaches to Harm Reduction;’ and the same version as an abstract at the 14th World Conference on Smoking or Health.

  • Funding This work was supported by National Cancer Institute Grant CA-61021, the Flight Attendant Medical Research Institute (FAMRI) and the Centers for Disease Control and Prevention. SAG is American Legacy Foundation Distinguished Professor in Tobacco Control. The funding agencies played no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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