The products mentioned in the study appear to be selected
specifically selected for their low nicotine content. While the paper
succeeds in adapting existing methodology for traditional tobacco products
to these new classes of smokeless tobacco products, only testing PREPs
containing a low amount of nicotine understates their potential as a
smoking cessation aid.
Star Scientific Inc. (manufacturers of Ariva) pro...
The products mentioned in the study appear to be selected
specifically selected for their low nicotine content. While the paper
succeeds in adapting existing methodology for traditional tobacco products
to these new classes of smokeless tobacco products, only testing PREPs
containing a low amount of nicotine understates their potential as a
smoking cessation aid.
Star Scientific Inc. (manufacturers of Ariva) produces a similar
product, another compressed milled tobacco lozenge, with additional
nicotine. This PREP, Stonewall, is marketed towards "heavy smokers." The
only appreciable difference is that Stonewall is advertised as containing
more nicotine. Considering that the individual participants reported a
mean daily consumption of over 20 cigarettes, one could reasonably
categorize them as heavy smokers.
In addition, the selected pasteurized tobacco sachets (in particular,
Phillip Morris' Marlboro Snus) have been characterized by Foulds and
Furberg as a low-nicotine product (due to a number of factors, ranging
from moisture content to acidity to starting free nicotine content), in
contrast to Swedish snus, which delivers nicotine comparable to a
cigarette. The graphs show that plasma nicotine levels for PREPs were all
much less than own-brand cigarettes, and all PREPs were remarkably
similar. All PREPs delivered half or less of the plasma nicotine levels
the subjects were accustomed to with cigarettes.
Swedish Match AB, the largest player in the Swedish smokeless tobacco
market, has started to export its most popular product line, General Snus,
to American test markets. This product is identical in nicotine content to
the one offered in Sweden. Another brand of snus, Triumph (manufactured by
Swedish Match for Lorillard), essentially a reflavored version of Swedish
Match's General, features the same nicotine content. Neither of the two
products would be difficult to obtain or test. These represent only two
brands of a quickly growing "reduced-harm" tobacco market in America; also
note that many North European smokeless tobacco manufacturers offer a
"sterk" or strong version of their regular product lines, with additional
nicotine.
The authors might find, unsurprisingly, PREPs that deliver more
nicotine will be perceived as more "satisfying" and more effective in
suppressing abstinence symptoms than the selection tested in the study,
perhaps even to the point of being a successful smoking cessation aid.
I am an undergraduate student at The Ohio State University, and I
declare no conflict of interest.
References:
Foulds, J, & Furberg, H (2008). Is low-nicotine marlboro snus
really snus?. Harm Reduction Journal, 5, 9.
Waters, L (2009, June 30). Triumph Snus. Retrieved July 14, 2009,
from Snus Central Web site: http://snuscentral.org/snusnus/mr-unz-
reports/248-triumph-snus-the-latest-on-nicotine-levels-.html
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...
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.
This paper addresses a number of important issues around the costs of
smoking to society, and in particular to the UK National Health Service
(NHS). However there are methodological issues which result in the paper
overestimating the costs of smoking to the NHS. While smoking does
represent a significant cost to the NHS, the estimates provided in this
paper, based as they are on a mixture of very old data and parameters...
This paper addresses a number of important issues around the costs of
smoking to society, and in particular to the UK National Health Service
(NHS). However there are methodological issues which result in the paper
overestimating the costs of smoking to the NHS. While smoking does
represent a significant cost to the NHS, the estimates provided in this
paper, based as they are on a mixture of very old data and parameters
derived indirectly for a broad geographic region of which the UK is just
one part and at that a rather atypical part, are of questionable validity.
The only recent piece of UK information used by the authors refers to
2005/06 total NHS cost. The breakdown of total cost by disease and the
proportion of disease-based costs attributable to smoking are derived
respectively from extremely old NHS sources and from five-year old figures
for a WHO region. In addition the authors assume that a method appropriate
for estimating the burden of disease by age to society is also applicable
to estimating health service use.
There are 2 key elements in this study:
identifying diseases where smoking is a factor and providing
population-attributable fractions (PAFs) for these diseases; and,
the apportionment of NHS costs to these diseases.
We believe that the paper uses questionable data in both these areas.
We use the example of the English NHS to demonstrate this. The paper
suggests that the cost to the NHS in England of smoking was £4.4 billion
at 2005/06 prices. We have recently calculated a figure between £2.7
billion and £3.1 billion at 2006/07 prices using a method which calculates
the appropriate PAFs for England, and using more recent NHS service use
and cost data (ASH 2008).
COSTS
Taking costs first, the paper recognises the limitation of using NHS
cost data by disease category based on the proportion of costs associated
with particular diseases in 1992/93. The authors even go as far as
comparing their figures with the more recent NHS programme budget data,
showing very large differences. But they choose to ignore this. This may
be because they have misunderstood what the programme budget data cover as
they wrongly state that they ‘provide(s) detailed expenditure information
for primary care service…’ In fact although there are some limitations to
the quality of the data, all elements of NHS expenditure are covered
though till now primary care consultation costs are not yet apportioned by
disease.
It is likely that the disease-based pattern of actual NHS costs in
England in 2005/06 was different from that in 1992/93 (the actual data on
which the authors base their study) as there have been changes in patterns
of disease, clinical practice and technology, NHS structures, and overall
spend levels. This is demonstrated by the programme budget data. For
example, in 1992/93 cardiovascular diseases accounted for an estimated
12.1% of costs. Using the Department of Health’s programme budget
estimates of costs by disease – which apportion all hospital costs and
primary prescription costs but not so far primary care consultation costs
– ‘circulation problems’ accounted for 7.9% of 2005/06 NHS costs
(Department of Health, 2006). If we apportion pro rata the separate
category which includes all primary care consultation costs (9% of costs
altogether) across disease-based categories this provides a more directly
comparable figure of 8.9%. This alone reduces the estimated cardiovascular
smoking cost to £1.6 billion rather than the authors’ figure of £2.1
billion. Applying the same approach to cancer and the ‘other medical’
category comprised of respiratory disease and peptic ulcer indicates an
increase of £0.3 billion in cancer costs and a reduction of £0.6 billion
in ‘other medical’ costs. Altogether this amounts to a £0.9 billion
reduction and this alone would bring the cost down to £3.5 billion. The
actual impact is likely to be considerably higher as programme budget
categories include a broader set of ICD codes than in the conventional
disease groups; for example, the program budget category includes all
cancers and tumours. If ICD codes were matched more precisely then the
implied overstatement would be considerably greater.
POPULATION ATTRIBUTABLE FRACTIONS (PAFs)
We also have concerns about the PAFs used by the authors in
calculating costs for the UK/England. Our concern is less with the method
used to estimate the PAFs than with the actual regional PAFs used; they
misrepresent the UK sex and age pattern of exposure to smoking and they
apply to the year 2000 rather than 2005. In estimating deaths due to
smoking for example, rather than deriving UK-specific figures for 2005 to
reflect the sex and age distribution of deaths by disease, the authors
chose to use WHO regional PAFs. Peto et al. using the same method to
estimate PAFs but based on UK data estimated that in the UK in 2000, 21.9%
of male deaths and 16.1% of female deaths were attributable to smoking,
whilst their overall ‘developed’ countries estimate of 22.0% male and
8.1% female deaths signified much lower female relative to male exposure.
(Peto et al. 2006). More recently an estimate for England in 2005 using an
alternative method indicates 22% of all male and 13% of all female deaths
attributable to smoking (Information Centre 2007). The authors’ UK
estimate of 27.2% male and 10.5% female deaths in 2005 based on the male-
female relationship embodied in the regional PAFs appears therefore to
misrepresent the UK.
For costs furthermore the authors indicate that the PAFs for DALYs
used were WHO EUR-A region (very low child and adult mortality) figures
for 2002. However the separate all-age male and female PAFs used in the
paper were in fact for 2000 and based upon the much broader, more varied
and higher mortality ‘Developed’ region. We have attempted to correct for
this by using male and female EUR-A 2000 instead of ‘Developed’ 2000 PAFs
for DALYs, combining them as the authors did using the 2002 DALYs
distribution for EUR-A. This has a significant impact on costs. For
example, for cardiovascular disease, the paper calculates PAFs (using
‘Developed’ 2000) as 32% males, 10% females, 22% combined, whereas based
on EUR-A 2000, the PAFS are 27% male, 8% female, 19% combined. The effect
of this is to reduce the attributable cost by £0.3 billion (using the
paper’s outdated cost proportions), or £0.2 billion using 05/06 disease-
based costs. Assuming 05/06 disease costs and adjusting only the PAF for
cardiovascular disease, the effect is to reduce the overall cost from £4.4
billion to £3.2 billion. However even these figures are based on PAF
figures for year 2000 smoking levels; more recent figures would result in
an even lower estimate of costs.
References
ASH (2008). Beyond Smoking Kills. London: ASH.
Department of Health (2006). Resource accounts 2005-06. London: The
Stationery Office .
Peto R, Lopez AD, Boreham J, Thun M (2006). Mortality from smoking in
developed countries 1950-2000 (2nd edition: updated June 2006).
Information Centre (2007). Statistics on Smoking, England 2007.
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...
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
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...
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)
First, an apology is in order for taking so long to respond to the online discussion surrounding the review by Foulds et al. [1] and the opinion piece by Bates et al. [2]. As we had promised in our earlier reply to Foulds et al. (19 December 2003) and have been reminded by Bates, we are belatedly responding to the specific points raised by Foulds et al. in their e-letter dated 5 December 2003:
First, an apology is in order for taking so long to respond to the online discussion surrounding the review by Foulds et al. [1] and the opinion piece by Bates et al. [2]. As we had promised in our earlier reply to Foulds et al. (19 December 2003) and have been reminded by Bates, we are belatedly responding to the specific points raised by Foulds et al. in their e-letter dated 5 December 2003:
1. “Misrepresentation of our review.” Our commentary did not misrepresent the conclusions reached by Foulds et al. [1]. We cited their direct quote that snus had “...a direct effect on the changes in male smoking and health” and made the observation that their review added little additional evidence to support that conclusion beyond the spotty evidence cited by Bates et al. (and those two papers had several co-authors in common). Yes, we read their 11 journal pages, 8 figures, 2 table, and 66 references, as well as the 8 journal pages Tobacco Control generously devoted to Bates et al. [2]. No one in the mainstream scientific community questions the underlying premise that exclusive use of snus conveys lower risks for death and disease than does exclusive cigarette smoking. The primary question is whether snus was responsible for the decline in smoking in Sweden and related disease patterns. In support of that hypothesis, Foulds et al. cite sales data from Swedish Match, trend data for tobacco use among men and women age 18–70 years that was unadjusted for age, and cross-sectional data from two northern Swedish counties. That evidence for the role of snus in improving public health does, in fact, provide little additional evidence to what was cited by Bates et al. Foulds et al. make much of the sex differences in use of tobacco products in Sweden to support their hypothesis, yet their reliance on crude (unadjusted) patterns actually masks recent trends in tobacco usage in Sweden and undermines their conclusions. In reality, true age-adjusted smoking initiation rates and cessation rates for males and females in Sweden are essentially equal [3].
2. “Selective reporting of findings”. Foulds et al. acknowledge that they omitted several studies because they were from a part of the country where snus usage was low, claiming that “(b)asing conclusions about snus use in Sweden on a study based exclusively in Malmo is like basing conclusions on smoking and smokeless use in the USA on studies in Utah.” Fair enough, although Foulds et al. had fewer concerns with drawing conclusions about the role of snus in Sweden as a whole based on patterns in northern Sweden.
We stand corrected on our statement that “between 1981 and 2001 daily smoking declined more rapidly for 15-16 year old girls (23% to 16%) than boys (13% to 10%), snus use remained rare among girls, and the sex difference in smoking prevalence decreased.” As the figure presented by Foulds et al. in their electronic letter indicates, the rate of decline in smoking among 15–16-year-olds was about the same for boys and girls. However, that pattern, coupled with a high and increasing level of snus usage among adolescent males in Sweden and very low levels of usage among adolescent girls, provides little support for the conclusion reached by Ramstrom and Foulds [4], two of the authors of the 2003 review paper, that use of snus in Sweden is “associated with a reduced risk of becoming a daily smoker.” If that were truly a causal association, we would expect the initiation rate to be declining more rapidly among boys than among girls due to the much greater growth is snus usage among boys, but it is not. Although there was a 10-fold difference in snus usage between 15–16 year-old boys and girls (20% vs. 2%), smoking initiation exhibited a rather constant and much more modest 3–6 percentage point difference during that time period.
Foulds et al. did not respond in their e-letter to broader national trends in Sweden for young males and females that we mentioned in our commentary. We present here more recent data for 16–24-year-olds in Sweden, the age range during which nearly all smoking initiation occurs [3]:
Figure 1. Trends in proportion of persons age 16–24 who used snuff daily or currently smoked (daily or occasionally), by sex. Sweden, 1988–1989 to 2004–2005. Data from Statistics Sweden ULF Surveys.
Secular trends in tobacco use among adolescents and young adults in Sweden (or Norway and the United States, for that matter) do not support a preventive effect of smokeless tobacco use for cigarette smoking. Official national data from Statistics Sweden indicate that daily snuff use among 16-24 year-olds has increased over the past 15 years, from 23.0% in 1988–1989 to 26.5% in 2005 among males and from 0.6% to 3.9% among females (Figure 1). Current smoking (i.e., daily or occasional) in that age group exhibited a flat trend line for males during that time period and a declining trend line for females over the same time period. In 2004–2005, 33.4% of males and 30.2% of females aged 16–24 years in Sweden were current smokers. However, the prevalence of daily smoking was lower for males (9.3%) than for females (13.3%) in that age group. The secular patterns in tobacco use among Swedes aged 16–24 years suggest that snuff may have served as a partial substitute for smoking among males, but had a negligible effect, if any, on smoking initiation rates for either sex.
3. “Tomar et al’s errors in critical appraisal of health effects of snus”. We stand by the original comments regarding the interpretation of the studies by Lewin et al. [5] and Schildt et al. [6]. In the study by Lewin et al., there was an elevated risk for head and neck cancers among an important subgroup (lifetime non-smokers); Foulds et al. only cite the non-significant multivariate relative risk estimate, ignoring that subgroup analysis or the obvious colinearity that occurs in multivariate modeling when nearly all snus users also have a history of smoking. [Since that time that study was published, its lead author, Freddi Lewin, has gone on to a career with Swedish Match]. In contrast, Foulds et al. chose to report only the univariate analyses in Schildt et al., when the multivariate analysis found that neither smoking, alcohol consumption, nor snus were associated with oral cancer. We may be “out on a limb” regarding the carcinogenicity of snus, but we appeared to be joined on that limb by the International Agency for Research on Cancer [7] and the European Commission’s Scientific Committee on Emerging and Newly Identified Health Risks [8].
4. “Birth-cohort patterns relating smoking and snus use.” The birth cohort data presented by Foulds et al. do not support a role for snus in smoking cessation or refute our contention that most snus uptake occurred among young people because they present no data on snus usage. All birth cohorts of men and women experienced declines in daily smoking during that 17-year period; for most birth cohorts the difference between men and women was 2–7 percentage points. Differences were larger for older adults (8–11 percentage points), but women aged 50 years and older began the cohort study with much lower prevalence of smoking. Non-daily smoking remains unreported, even though it accounts for a large proportion of current smoking in Sweden. Most smoking cessation trials would not consider reduction from daily smoking to less than daily smoking as cessation, but perhaps the authors’ clinics and trials use different criteria. The primary point is that evidence such as Figure 1 in the review by Foulds et al., which presents trend data from Swedish Match on consumption of snus and cigarettes, or the cohort data on smoking they posted in their e-letter cannot determine whether the groups taking up snus are necessarily the same ones driving the decline in cigarette consumption; we continue to contend that they largely are not.
5. “Is the sex difference in smoking prevalence due to fewer women in the smoke-free workplace?” We acknowledge that our hypothesis was speculative and lacked direct supporting evidence. However, in their e-letter, Foulds et al. stated: “One thing that doesn’t seem to fit with that is the data on the older age groups presented in the table above. Those aged 50+ in 1980–1 in that (sic) data would mostly have retired from the workforce by 1996–7 and so might be less affected by workplace smoking bans. However, despite that, the sex-difference in cessation is actually stronger in that age group than any other.” That conclusion is not necessarily true; the prevalence of smoking was substantially higher among men age 50 or older than among same-aged women, men were more likely than women to be lost to follow-up by the end of the study, and a greater proportion of men (9.2%) than women (6.2%) died between the second interview and the time of the third follow-up interview [9]. Some of that “sex-difference in cessation” was very likely to have been differential mortality between older men and women, driven heavily by higher smoking-attributable mortality rates among older men. One sure way to quit smoking is to die.
6. “Use of snus as a smoking cessation aid”. Foulds et al. claim that we tried to “brush this important piece of evidence (of snus as a smoking cessation aid) under the carpet.” In fact, in our commentary we stated, “…the large majority of men (71%) and women (97%) who quit smoking did not use snus at their last quit attempt, with modest effectiveness for snus as a cessation strategy in that observational study. That is hardly compelling evidence for snus as "an important explanation" for the decline in smoking in Sweden.” We did not claim that no smokers in Sweden quit smoking by using snus, but we do maintain that the role of snus in reducing smoking has been substantially overstated. When half of the adult population (women) has never used a purported smoking cessation method but still achieved a greater prevalence of complete smoking cessation than the half that has widely adopted that method, it suggests that there are other, more important factors that explain the decline in smoking in Sweden.
7. “This is about Sweden, not the USA.” While that may be true, USA remains the world’s largest market for commercial moist snuff products and reviews such as those by Foulds et al. and an opinion piece such as that of Bates et al. can have significant effects on U.S. tobacco policy, its tobacco industry, and the usage of tobacco products. A great deal has happened since those papers were published six years ago. Nearly the entire moist snuff market in the USA is now controlled by cigarette manufacturers, who are developing and test-marketing new smokeless tobacco products at a furious pace. New products include Marlboro Snus, Camel Snus, and Camel Dissolvables that include Camel Orbs, Strips and Sticks. Those products are largely being positioned as complements to cigarette smoking, not substitutes, and we are likely to see a growth in dual product usage [10]. The primary target audiences in test marketing appear to be young people, not middle-age smokers looking to reduce their risks from smoking. Those companies also continue to heavily promote their traditional moist snuff products to young males, as evidenced by a 12-page advertising insert the January 2009 issue of Playboy magazine.
It remains to be seen whether snus or more traditional U.S. types of moist snuff will be adopted by smokers as substitutes for cigarettes, but so far they have not gained much traction [11]. While it is true that we may have a relatively U.S.-centric focus, we do note that nearly all U.S. states have achieved a lower prevalence of smoking than has Sweden. Even using the more stringent definition of daily smoking among persons age 15 years or older, about one-half of U.S. states have levels of smoking equal to or lower than Sweden's, with relatively little use of moist snuff despite its widespread availability.
8. “Both snus and Swedish tobacco control deserve some of the credit”. We obviously have a different interpretation of the situation in Sweden. Our skepticism and concerns are fueled, in part, by the lack of an evident public health benefit in neighboring Norway, which has seen a skyrocketing prevalence of snus usage among young males with no apparent impact on smoking initiation or cessation rates [3].
Disclosures
Scott Tomar is currently serving as an expert witness for plaintiffs in product liability law suits brought against a smokeless tobacco manufacturer and against a cigarette manufacturer.
Greg Connolly has no conflicts to disclose.
Scott L. Tomar
University of Florida College of Dentistry
Greg N. Connolly
Harvard School of Public Health
References
[1] Foulds J, Ramstrom L, Burke M, Fagerstrom K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control. 2003;12(4):349-59.
[2] Bates C, Fagerstrom K, Jarvis MJ, Kunze M, McNeill A, Ramstrom L. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control. 2003;12(4):360-7.
[3] Tomar SL. Epidemiologic perspectives on smokeless tobacco marketing and population harm. Am J Prev Med. 2007;33(6 Suppl):S387-97.
[4] Ramstrom LM, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control. 2006;15(3):210-4.
[5] Lewin F, Norell SE, Johansson H, Gustavsson P, Wennerberg J, Biorklund A, et al. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer. 1998;82(7):1367-75.
[6] Schildt EB, Eriksson M, Hardell L, Magnuson A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int J Cancer. 1998;77(3):341-6.
[7] International Agency for Research on C. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Vol. 89. Smokeless Tobacco and Related Nitrosamines. Lyon, France: IARC; 2007.
[8] Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR). Health Effects of Smokeless Tobacco Products. Brussels: European Commission, Health & Consumer Protection Directorate-General; 2008.
[9] Rasmussen F, Tynelius P, Kark M. Importance of smoking habits for longitudinal and age-matched changes in body mass index: a cohort study of Swedish men and women. Prev Med. 2003;37(1):1-9.
[10] Carpenter CM, Connolly GN, Ayo-Yusuf OA, Wayne GF. Developing smokeless tobacco products for smokers: an examination of tobacco industry documents. Tob Control. 2009;18(1):54-9.
[11] Zhu SH, 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. 2009 Jan 23.
The authors quote a study by Boffetta et al to support the idea that
second-hand smoking causes disease. The Boffetta study does not support
that claim. Boffetta et al found no significant association between lung
cancer and passive smoking from spouse or workplace. They did find a
significant association with childhood exposure: those so exposed were
less likely to develop lung cancer.
The results of Boffetta et al are...
The authors quote a study by Boffetta et al to support the idea that
second-hand smoking causes disease. The Boffetta study does not support
that claim. Boffetta et al found no significant association between lung
cancer and passive smoking from spouse or workplace. They did find a
significant association with childhood exposure: those so exposed were
less likely to develop lung cancer.
The results of Boffetta et al are the reverse of what your authors claim.
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 th...
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
I thought I would revisit this debate some five years on,
only to find that the promised response (19 December
2003) has not yet been done.
None of the facts have changed much - those that wish
to intervene to prevent smokers choosing tobacco
products that are many times less hazardous still have
the upper hand - not in argument or evidence, but in
dominant public health approach and (in Europe) in the
most...
I thought I would revisit this debate some five years on,
only to find that the promised response (19 December
2003) has not yet been done.
None of the facts have changed much - those that wish
to intervene to prevent smokers choosing tobacco
products that are many times less hazardous still have
the upper hand - not in argument or evidence, but in
dominant public health approach and (in Europe) in the
most extraordinary and perverse legislation.
They might not like the to be labelled appropriately with
the blunt but accurate epithet "quit or die", but that is
the price of taking a position so strongly at odds with
evidence and ethics.
Come on.... it's never too late to put the record straight
and defend your work... or admit you were wrong. I
suspect this contribution will still be on the internet in
100 years time.
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...
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.
The products mentioned in the study appear to be selected specifically selected for their low nicotine content. While the paper succeeds in adapting existing methodology for traditional tobacco products to these new classes of smokeless tobacco products, only testing PREPs containing a low amount of nicotine understates their potential as a smoking cessation aid.
Star Scientific Inc. (manufacturers of Ariva) pro...
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...
This paper addresses a number of important issues around the costs of smoking to society, and in particular to the UK National Health Service (NHS). However there are methodological issues which result in the paper overestimating the costs of smoking to the NHS. While smoking does represent a significant cost to the NHS, the estimates provided in this paper, based as they are on a mixture of very old data and parameters...
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...
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...
First, an apology is in order for taking so long to respond to the online discussion surrounding the review by Foulds et al. [1] and the opinion piece by Bates et al. [2]. As we had promised in our earlier reply to Foulds et al. (19 December 2003) and have been reminded by Bates, we are belatedly responding to the specific points raised by Foulds et al. in their e-letter dated 5 December 2003:
1. “Misrepresentation of...
The authors quote a study by Boffetta et al to support the idea that second-hand smoking causes disease. The Boffetta study does not support that claim. Boffetta et al found no significant association between lung cancer and passive smoking from spouse or workplace. They did find a significant association with childhood exposure: those so exposed were less likely to develop lung cancer. The results of Boffetta et al are...
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 th...
I thought I would revisit this debate some five years on, only to find that the promised response (19 December 2003) has not yet been done.
None of the facts have changed much - those that wish to intervene to prevent smokers choosing tobacco products that are many times less hazardous still have the upper hand - not in argument or evidence, but in dominant public health approach and (in Europe) in the most...
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...
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