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The most powerful means to reduce the diseases caused by tobacco use are to prevent the initiation of use and to help users to achieve complete and lasting abstinence. For tobacco users who are unwilling or unable to completely give up their tobacco use, the possibility is increasingly being considered that such persons might be able to reduce their risk of disease and premature mortality by reducing their exposure to tobacco toxins. This conclusion may seem obvious, and various expert panels have repeatedly issued guidance based on these observations.1-5 Nonetheless, this public health strategy has been controversial because the purveyors of tobacco products have generally used the guidance as a tool to undermine public health efforts to prevent the initiation of tobacco use and facilitate cessation in those who use the products.2 6-9Furthermore, even in cigarette smokers who have switched to cigarettes advertised as “low tar” or “light” the health benefits to those persons, if any have been small.2 10 11
In the USA, smokeless tobacco products such as snuff and chewing tobacco might have been predicted to lessen overall tobacco attributable mortality to the extent that they provided an alternative source of tobacco delivered nicotine for persons who could not abstain from cigarette smoking. Unfortunately, smokeless tobacco products appear to have actually fuelled the public health problem caused by tobacco use by serving as entrées for youth to develop nicotine dependence and frequently to progress to cigarette smoking.12 13 Youth smokeless tobacco consumption escalated greatly in the 1970s and 1980s, fuelled by development of what the industry termed “starter products”, and aggressive marketing to youth following an industry described “graduation strategy” based on the nicotine delivery potential of the products.14 15 Smokeless tobacco marketing contributed to the initiation of tobacco use in a …