Foulds and Ramström raise important questions regarding a direct comparison of mortality rates among smokers, smokeless tobacco (ST) users, persons with mixed or former use, and non-users. They urge officials from the Centers for Disease Control and Prevention (CDC) and from the American Cancer Society (ACS) to make these comparisons and report the results, so that Americans are fully informed about the health risks related to tobacco use. But there is a simpler and more compelling solution: The CDC must release publicly all data it uses to estimate the relative risks and mortality rates among tobacco users.

Every year the CDC publishes statistics concerning how many Americans smoke, and how many Americans die as a consequence (1,2). These statistics form the raison d’être for current tobacco policies at all levels of American government – and for the massive regulatory scheme currently under consideration by the U.S. Congress.

The data from which the CDC estimates prevalence of tobacco use are publicly available from the National Health Interview Surveys. In stark contrast, the data from which the CDC estimates deaths from tobacco use are not available to researchers outside the agency or its collaborator, the ACS. Instead, the CDC takes a black-box approach of filtering information on mortality through its online program called Smoking- Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) (3).

But SAMMEC is marginally informative, and utterly unsatisfactory. It does not provide any information comparing the mortality experience of smokers and ST users. It cannot even provide simple statistics like the number of deaths among current and former smokers. In 2006 I submitted a request for these data through the SAMMEC web site. I received this unsigned response from the CDC Office on Smoking and Health: “Data are not available for current or former smokers separately.”

The public release by the CDC of data relating to tobacco-related mortality will also place the agency in compliance with the intention of the NIH Data Sharing Policy (4), which states that “data sharing is essential for expedited translation of research results into knowledge, products, and procedures to improve human health.”

Brad Rodu

Professor of Medicine

Endowed Chair, Tobacco Harm Reduction Research

University of Louisville

Competing Interests: Dr. Rodu's research is supported by unrestricted grants from two smokeless tobacco manufacturers to the University of Louisville. More information is available at www.smokersonly.org

References

1. Centers for Disease Control and Prevention 2005: Cigarette smoking among adults – United States, 2004. MMWR 54:1121-1124.

2. Centers for Disease Control and Prevention, 2005: Annual smoking- attributable mortality and years of potential life lost, and productivity losses – United States. MMWR 54:625-628. 1997–2001.

3. Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC). Available at: http://apps.nccd.cdc.gov/sammec/login.asp

4. NIH Data Sharing Policy. Available at: http://grants.nih.gov/grants/policy/data_sharing/

The longstanding tradition of the U.S. military and tobacco industry leaders 'smoking in the good ol' boys room' is well documented by the Smith, Blackmon, Malone "Death at a Discount" research paper!

It is time that the military and other federal politicos become concerned about the health of our military, and drop the montra of tobacco use being a 'right'. Obviously, the lobby of the tobacco industry even infiltrates the Department of Defense offices, too.

While military personnel can buy tobacco products cheaply in base commissaries, they also are readily hooked on snuff and cigarettes whil deployed overseas (a known tactic of the industry since WWI). This acciction to tobacco products spells profits to the industry when our soldiers return, plus significant future health care costs to all.

West Virginia has a documented high prevalence of tobacco addiction in our reserve and active military families. We have made tobacco cessation quitline services available free-of-charge to resident military personnel and their immediate family members through a statewide program called AboutFace. The Federal government and Department of Defense need to do an 'about face' on their view of tobacco use and the military.

Dr Gupta’s letter suggests that the reduction in lung cancer in both Sweden and Connecticut is highly likely to be due to a reduction in smoking in both places. This is entirely unsurprising, and as far as Sweden is concerned is precisely what we suggested in the original paper he referred to:

“There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.” (p349, abstract)1.

The idea that smoking and lung cancer rates may fall to a similar or greater degree in other places is entirely irrelevant to whether or not snus played a role in smoking reduction in Swedish men. Indeed, in the original paper we stated clearly that:

“Both within and outside Sweden, smoking is primarily influenced by factors other than availability of smokeless tobacco (for example, real price of cigarettes, health education, smoke-free air policies, industry marketing, etc).” (p357)1

It is therefore entirely unsurprising that these types of factors will have influenced smoking and lung cancer rates in the United States and every other country, regardless of whether or not snus is available. A key point in our original paper that distinguished Sweden from other countries was that smoking rates WITHIN that country have fallen significantly faster in men than women, and that this appeared to be related to the fact that men in Sweden use snus much more than women. So although these comparisons between one country in Europe and a state in the US are almost entirely irrelevant to the question of the effect of snus use on lung cancer rates in Sweden, the more appropriate comparison (if one wanted to make one) would be of the difference in decline of lung cancer rates between men and women in Sweden as compared to changes in that difference in the US. It is not clear whether the data presented in Dr Gupta’s letter was for men, women or both.

Since the publication of our original paper there have been subsequent publications that have confirmed that in Sweden, men who start using snus are less likely to become daily smokers, that men who smoke and then start using snus are more likely to stop smoking, and that a higher proportion of men than women in Sweden have quit smoking, with the difference largely attributable to snus use2,3. It had previously been suggested that the men who quit smoking in Sweden are not the same ones who start using snus (and that snus use is therefore not involved in men quitting smoking)4. However, studies have now verified that in fact a sizeable proportion (26-29%) of Swedish men who quit smoking use snus as a smoking cessation aid2,5.

It is now crystal clear that their transfer of nicotine dependence onto snus has accelerated the rate of decline of smoking among Swedish men in substantial numbers. That transfer from an extremely harmful form of tobacco use (cigarette smoking) to a much less harmful form (snus) has contributed to a reduction in the rate of smoking-caused diseases in Swedish men.

1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003; 12:349-59. 2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006 Jun;15(3):210-4.Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm 3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob Control.2005; 14:422- 424. 4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59 5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.

Dear Editor

Some tobacco control community members believe that advocating the use of snus, a form of Swedish smokeless tobacco said to be less harmful than cigarettes, would prove an effective harm reduction strategy against tobacco related diseases. One important basis for such a claim is the fact that snus is widely used in Sweden (23% men used snus daily in 2002), where the incidence of cancer caused by tobacco is relatively low, and the observation that the Swedish are switching from smoked tobacco to snus. One way of looking at this claim of harm reduction through the use of snus is to compare tobacco related cancer rates in Sweden to those in the state of Connecticut, where use of any kind of smokeless tobacco including snus has been consistently rare.

The table below provides a comparison of age adjusted incidence rates for Sweden and Connecticut. As the data show, the incidence of tobacco related cancer is much lower in Sweden, about one half that of Connecticut. Trend data for Sweden seemingly provide further supportive evidence to the harm reduction hypothesis, as a dramatic increase in snus use in Sweden (0.4 kg/person in 1970 to 0.9kg/person in 2000) coincides with a decreasing cigarette consumption (1.1kg/person in 1970 to 0.6kg/person in 2000) resulting in a decrease of tobacco related cancer from 97.8 per 100,000 in 1966-1970 to 56.7 per 100,000 in 1993-1997.1,

However, if snus has a harm reduction effect, the incidence of tobacco related cancers should not only decline in Sweden as snus use increases, but it should decrease more in Sweden than in Connecticut, where the consumption of smokeless tobacco has remained <1% over 1990s. However, the data below demonstrate that the ratio of the incidence of tobacco related cancer in Sweden and Connecticut has remained constant at about 0.5 since 1973, and the same ratio for lung cancer has been stable at about 0.4 since1960. Rather than snus causing the decrease in tobacco related cancer in Sweden, these data suggest that another factor was responsible in reducing cancer incidence in both Sweden and Connecticut. That factor is likely to be the decline in cigarette use, which fell in men from about 28% to 15% (Sweden) and 26.7% to 18.7% (Connecticut) from 1985-2003.1,3 During the period of 1970s to 1990s, both populations were exposed to smoking reduction strategies such as increased awareness of health risks, increased prices, a change in social norms regarding tobacco use, etc but both places did not have an increase in snus use. Thus, the data do not seem to support the hypothesis that the decrease in tobacco related cancers in Sweden is due to increasing use of snus.

References

1. Foulds, J., Ramstrom, L., Burke, M., Fogerstrom K. Effect of Smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control, 2003; 12:349–359.

2. Cancer Incidence in Five Continents. Vol. I-VIII. Lyon: International Agency for Research on Cancer.

3. CDC. State System: State Tobacco Activities tracking and evaluation system. Tobacco Use Supplement to the Current Population Survey. 2006. Available at http://apps.nccd.cdc.gov/statesystem/. Accessed January 17, 2007.