In "Tobacco-related disease mortality among men who switched from
cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al
compared mortality rates for smokers who switched to spit tobacco to the
rates for those who quit all forms of tobacco. This is useful
information. However, the fact that the number of smokers in the US has
remained relatively unchanged for the past 20 years tells us that there
are t...
In "Tobacco-related disease mortality among men who switched from
cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al
compared mortality rates for smokers who switched to spit tobacco to the
rates for those who quit all forms of tobacco. This is useful
information. However, the fact that the number of smokers in the US has
remained relatively unchanged for the past 20 years tells us that there
are tens of millions of smokers who cannot or will not overcome their
dependence on nicotine. Thus, it is vital for tobacco policy makers to
establish viable harm-reduction plans. Was there mortality data collected
on the group who continued smoking? If so, it would be very useful for
the authors to publish a follow-up article that compares the mortality
rates for switchers to the rates of those who continued smoking.
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 ha...
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.
In our study in remote Indigenous communities in Arnhem Land we have
now interviewed 305 smokers. Of these, 181 had quit intentions and 37
were trying to quit at the time of interview. The effectiveness of more
intensive support compared with brief advice has not been evaluated in
these populations. However, the need for more intensive support is
highlighted in smokers’ own words, for example:
In our study in remote Indigenous communities in Arnhem Land we have
now interviewed 305 smokers. Of these, 181 had quit intentions and 37
were trying to quit at the time of interview. The effectiveness of more
intensive support compared with brief advice has not been evaluated in
these populations. However, the need for more intensive support is
highlighted in smokers’ own words, for example:
“I’m trying to find a way.”
and
“I can’t do it on my own.”
In our survey, smokers and non-smokers alike called for more
intensive community-based support for smokers to quit, for example:
“… form support groups ….. away from the clinic because they are too
busy doing other djama [work].”
and
“… we need house to house education, every house, clan by clan …”
Our research is trialing interventions that are not limited to quit
support. We agree with Thomas and Johnston that population-level
interventions have been associated with the steepest declines in smoking
prevalence in Australia generally. For Indigenous Australians, especially
those living in remote communities, it is not yet known if such smoking
reduction initiatives can work. High smoking rates that have not changed
in 20 years is evidence that impacts of wider initiatives have not been
felt in remote communities.
We agree with the authors of this letter that closing the gap between
the smoking prevalence in Indigenous and other Australians is possible,
but we do not agree how this is most likely to be achieved.
Many health clinics in remote Indigenous communities in Australia are
better at providing brief advice than is implied by the authors. An audit
of records in 56 health clinics found that 43% of diabetics and 25% th...
We agree with the authors of this letter that closing the gap between
the smoking prevalence in Indigenous and other Australians is possible,
but we do not agree how this is most likely to be achieved.
Many health clinics in remote Indigenous communities in Australia are
better at providing brief advice than is implied by the authors. An audit
of records in 56 health clinics found that 43% of diabetics and 25% those
with no chronic disease had had smoking brief advice in the last six
months (Bailie, R. 2009, pers.comm. 4 August) Nevertheless, more
intensive counseling is only very poorly available, but is only slightly
more effective than brief advice.[1] We agree that it is daft that
nicotine replacement therapy and other cessation pharmacotherapies have
been less available than other medicines regularly dispensed by these
clinics, when they have been shown to be more cost-effective.[2]
However, concentrating on improving cessation services, as they
suggest, will not make much impact on the high prevalence of Indigenous
smoking. The finding that 76% of their sample had quit or attempted to
quit without any interaction with medical cessation services, is not an
indictment of the poor availability of cessation services, but evidence of
Indigenous smokers quitting in ways similar to all other populations: by
themselves, without medical assistance.[3] This figure is unlikely to
change greatly, even with improved access to cessation services.
The absence of cues to quit and the omnipresence of cues to smoke in
these Indigenous communities is not just an impediment to the success of
cessation services. Instead, this is where most of our attention should
now be focused: by improving Indigenous exposure to well-researched
graphic media campaigns, to smokefree public and private spaces, and to
advocacy about the harms of smoking. Increased levels of these
population health activities, and increased taxation (and cigarette
prices), have been associated with the steepest declines in the prevalence
of smoking in the total Australian population,[4] and have the most
potential to quickly reduce Indigenous smoking.
No conflict of interest
References
1. Stead LF, Bergson G, Lancaster T. Physician advice for smoking
cessation. Cochrane Database of Systematic Reviews 2008;Issue 2:Art. No.:
CD000165. DOI: 10.1002/14651858.CD000165.pub3.
2. Bertram MY, Lim SS, Wallace AL, Vos T. Costs and benefits of
smoking cessatioin aids: making a case for public reimbursement of
nicotine replacement therapy in Australia. Tob Control 2007;16:255-260.
3. Chapman S. The inverse impact law of smokign cessation. Lancet
2009;373:702-3.
4. Winstanley M, White V. Trends in the prevalence of smoking. In:
Scollo MM, Winstanley MH, editors. Tobacco in Australia: Facts and issues.
Third Edition. Melbourne: Cancer Council Victoria, 2008. Available at
www.tobaccoinaustralia.org.au (accessed 4 August 2009).
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 tobac...
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
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)
In "Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco" Tob Control 2007; 16: 22-28, Henley, et al compared mortality rates for smokers who switched to spit tobacco to the rates for those who quit all forms of tobacco. This is useful information. However, the fact that the number of smokers in the US has remained relatively unchanged for the past 20 years tells us that there are t...
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 ha...
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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.
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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...
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