Watching this first salvo in the battle over whose nicotine is safer and which side eventually makes the big nicotine maintenance bucks, Big Pharm or Big Oral Tobacco, is sad yet understandable? Even for those few without any financial stake in the debate, imagine the natural frustrations born from having turned the wrong research or policy corner and dedicated two decades of your life to having chosen to fight nicotine addiction by feeding nicotine addicts more nicotine.

We've already watched as half-baked pharmaceutical financed science undertook the intentional destruction of the credibility of earth's most productive means of nicotine dependency recovery. We watched as Big Pharm bought the policy door keys and embarked upon a massive campaign to erase earth's most productive tool from cessation literature around the globe.[1] In exchange for what, the Swedish experience or NRT?

Before throwing in the towel wouldn't a bit of reflection upon where your last campaign took us be in order? You threw out the baby with the bathwater in declaring the life's work, and the daily dependency recovery programs of thousands, to be unscientific. Why grab hold of a shark when drowning, when the water is just five feet deep?

The March 2003 OTC NRT meta-analysis published here in TC found that only 7% succeeded in remaining smoke-free at six months.[2]

A November 2003 persistent NRT use study, also published here in TC, suggests that as many as 7% of gum users may still be chewing nicotine at six months.[3] If true, who actually broke free from nicotine while using it? Unlike the one puff lesson that can eventually flow from repeated attempts at abrupt cessation, we've known since 1993 that the only lesson flowing from repeated NRT use is that the odds of relapse increase to nearly 100%,[4] but that too has been kept a secret from those who needed to know.

Overzealous public health officials must be held accountable for the demise of highly effective community-based abrupt nicotine cessation programs, many of which were achieving 40% midyear nicotine cessation.[5] Imagine a mind so convinced its right that its willing to pervert the term "science based" and use it as a weapon in order to destroy the credibility of superior performance, so that it can claim market share and carry out its own grand insane nicotine weaning experiment.

Now it's almost as if many of those same so called "experts" who so badly damaged worldwide cessation (some of whom have never personally conducted a single cessation clinic program themselves)have given-up on dependency recovery and embarked upon a massive new social experiment to try and transfer their failure to "safer" forms of delivery.

Worldwide cessation is in shambles and now we must watch as those who've made the mess argue whether sloshing nicotine-rich tobacco juices around in the mouth or allowing NRT to at last live up to its name - "replacement" not "cessation" - is the answer to all our problems.

No one here argues with the logic of cleaner delivery but we should all be deeply troubled by the knee-jerk cattle herding tactics and priorities already employed by those now pushing transfer to "safer" delivery. Many teach at institutions whose graduates mold society yet somehow they seem unable to comprehend that, to one degree or another, every graduate of effective community-based recovery programs became recovery teachers themselves. High quality short-term abrupt cessation education, skills development and support programs have now all but vanished, having lost funding and favor after having been declared non science-based, and overrun by those toying with months of weaning.

I submit that all nicotine dependent humans are entirely capable of quitting. I submit that any attempt by science to put a positive spin on any form of nicotine dependency should cast science in the same mold as any other drug pusher, as more humans, not less, will become dependent. I'm not talking about true harm reduction efforts but marketing spin and easy access that will inevitably snare the curiosity and lives of untold thousands of youth.

We need only look to Nicorette's current nicotine gum marketing spin to begin to imagine just how out-of-hand a license to push daily maintenance will quickly become.

Its website asserts that "Once in your brain, nicotine begins working. It stimulates the secretion of neurotransmitters (chemicals in the brain), which appear to enhance awareness and judgment. Nicotine also increases dopamine levels, improving your mood. The substance has also been known to even enhance memory and reduce aggression." ... "Heightened awareness. Enhanced judgment. Better moods. Adrenaline boosts. No wonder cigarette smoking is hard to quit."[5]

Imagine the tactics that will be employed by the tobacco industry once Pandora's box is fully opened. Just one question, why would you again demand the entire world as your stage when any damage could have been limited to small test communities? It's probably a good thing that TC does not require disclosure of financial interests. Profits or science?

[1] Polito, Is cold turkey quitting more productive and effective than NRT? WhyQuit, July 2003 - http://whyquit.com/whyquit/A_Cold_Turkey.html

[2] Hughes, JR, Shiffman, S, et al., A meta-analysis of the efficacy of over-the-counter nicotine replacement . Tobacco Control, March 2003;12:21-27 - http://tc.bmjjournals.com/cgi/content/full/12/1/21

[3] Shiffman S, Hughes JR, et al, Persistent use of nicotine replacement therapy: an analysis of actual purchase patterns in a population based sample, Tobacco Control 2003 November; 12: 310-316 - http://tc.bmjjournals.com/cgi/content/abstract/12/3/310

[4] Tonnesen P, et al., Recycling with nicotine patches in smoking cessation. Addiction. 1993 Apr;88(4):533 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8485431&dopt=Abstract

[5] CDC Sept. 4, 1992 MMWR, Public Health Focus: Effectiveness of Smoking-Control Strategies, United States - http://www.cdc.gov/mmwr/preview/mmwrhtml/00017511.htm

[6] Nicorette website, How smoking affects your body. http://nicorette.quit.com/nicr_internal/nrt1.asp

Kawaldip Sehmi's letter seems to advocate ignorance and a kind of book-burning attitude to understanding this area. But in fact, better knowledge of the science might help his cause.

The paper by Enstrom and Kabat caused problems not because its findings conflicted with the established evidence base, but because it was flawed and the BMJ failed to put its contribution in context with the rest of the large evidence base. In contrast, Jonathan Foulds and his colleagues have done a good job at dispassionately examining and presenting the evidence on snus in Sweden, and the comparison with Enstrom and Kabat is unjustified.

Here are two examples where the developments that flow from this analysis may work to the advantage of the community Kawaldip Sehmi is concerned about (and where his ideas might cause more harm)...

If a regulatory framework was introduced in Europe for smokeless tobacco as part of unbanning snus (and this is what the harm reduction supporters are pressing for), it is likely many of the South Asian imported products would not meet the standard and have to come off the market. There may be a market response that reduced the hazardousness of the range of products available to the S. Asian community - either becase the S. Asian manufacturers would comply, or because other compliant products would enter the market to meet the gap. This would be an improvement on the status quo.

Science might also help re-think the evidence-free campaign to get these other smokeless tobacco products banned - in the UK or in S. Asia. How do the campaigners know that the former smokeless tobacco users would turn to the much higher risk smoking products? How do they know that those that would have started to use smokeless products would not just start to smoke instead? (and this would be a great opportunity for predatory cigarette companies). If they do, then they will be at much higher risk. In taking that gamble, what are the campaigners hoping to achieve through a prohibition and do they mind if some people are at greatly increased risk as a result of their idea? When Sweden joined the EU it was granted an exemption from the ban on oral tobacco - and it is a good thing too, because there would be more Swedish smokers now if the ban had been imposed. From reading Foulds et al's paper even the most extreme flat earth "quit or die" advocates cannot think that the EU's ban should be extended to Sweden - surely! But if not, why not? And if not in Sweden, should that give prohibitionist campaigners pause for thought about their campaigns to achieve this elsewhere? Sweden's experience issn't necessarily applicable everywhere - but it is a reason for caution about banning smokeless tobacco anywhere.

Please let's have less talk of editorial orifices and recognise that Tobacco Control journal and its editor are doing public health a service by shining light on this murky former no-go area and challenging some ill- considered orthodoxies.

The motor racing piece that prominently features tobacco company sponsorship and brand logos in the August issue of Maxim (News Analysis 2003;13:348) is not alone. That same month, a seven page article provided similar exposure for Jordan’s association with B&H in FHM, the leading UK ‘lad mag’ (circulation circa 600,000).

These promotions, of course, reflect standard tobacco industry strategy of circumventing advertising bans through coverage of their sponsorship and promotion of motor racing, and the readership of FHM and Maxim - predominantly young men - fits a traditionally important market.

Of perhaps greater concern is the appearance of an advertisement for Subaru sports cars in the sport section of the UK Sunday paper The Observer, (29 June, 2003). The quarter-page ad, a much more subtle approach than the glossy picture spreads of FHM, featured a photograph of winning driver Petter Solberg’s Subaru World Rally Team (SWRT) car at the 2003 Cyprus Rally and the accompanying caption informed readers that they too could be winners by taking advantage of current prices on a range of Subaru models. What was noteworthy about the ad was the central place and visibility given the State Express 555 livery on the car.

The Advertising Standards Authority (ASA), however, saw no problem with the Subaru promotion, noting in its response to a written complaint: “the advertisement is for Subaru cars and shows a winning rally car that features the sponsor’s branding…. [it] is clearly intended to draw attention to the car and does not place emphasis on tobacco.”

The Observer’s circulation figures generally hover around the 450,000 mark and while not one of the biggest Sunday papers, it could reasonably assumed to have a much broader readership than the monthly men’s magazines mentioned above, not least children and teenagers who leaf through the Sunday papers in their homes.

An important discussion of issues is being missed in a rash of name calling. Let’s back up, recognize our common goals and see if we can discuss issues and skip the personalities. We believe that the letters of Foulds et al and Bates et al badly mangled our comments and took statements out of context. Foulds et al. and Bates et al. obviously feel the same about our article. This issue has precipitated name calling, questioning of integrity, even rather defamatory slogans used to attack those with differing opinions ranging from “quit or die” to “flat earth believers”. Clearly, we disagree on several aspects of the issue, even while agreeing on others (such as the importance of efforts to reduce death and disease in those who continue to use nicotine without undermining prevention and cessation). This core point of agreement is shared by many of us engaged in this debate. It is unfortunate, and frankly very discouraging, that the differences seem to be resulting in more vitriol than are the common values resulting in constructive dialog. Many of the specific comments of Foulds et al. will be addressed in a subsequent response. Here we would like to briefly address some of the main issues. Our commentary takes issue with the position of Bates et al. and Foulds et al. which calls for a role for smokeless tobacco in tobacco control efforts to reduce smoking. We believe that Bates et al. and Foulds et al. overstate the benefits and generality of the Swedish snus experience and that they understate the risks and areas of uncertainty. Not surprisingly, they imply that we have overstated the risks and understated the benefits in our urge for caution and a regulated playing field. As we note in our commentary:

“If there is a role for oral tobacco in a comprehensive effort to reduce the death toll from tobacco use, then its manufacture and marketing must be overseen by an agency with comprehensive regulatory authority. A regulatory agency should be open to all strategies that are scientifically based and that will save lives. However, the decision about what role oral tobacco plays in that overall scheme is a decision that can only be made by an agency that has all of the relevant information.”

The fact that a population of persons using exclusively smokeless tobacco is at overall lower risk of most forms of smoking caused disease is not disputed by us. We do assert that smokeless tobacco has been repeatedly demonstrated to be a deadly addictive product that causes a variety of serious and life-threatening diseases as documented in the Institute of Medicine Report (IOM) (see pages 426-429 and 563-564 for a review of widely accepted oral diseases and attributable cancer). With regard to Swedish smokeless tobacco, at least as marketed in Sweden, we concur with the conclusion of that report on page 167 as follows: “It may be considered that such products could be used as PREPs [potentially reduced exposure products] for persons addicted to nicotine, but these product should undergo testing as PREPs using the guideline and research agenda contained herein.” Neither we nor the IOM Report are ready to accept extant data as sufficient for endorsing smokeless tobacco for harm reduction. Furthermore, we support the general strategies recommended by the IOM Report to develop the data that would enable such and endorsement. We apparently differ from Foulds et al. and Bates et al. in our call for such data. We stand by our position.

Perhaps the most important issue implicit in our concerns about our colleague’s characterizations of the Swedish experience is their explicit or implicit judgment that it is relevant outside of Sweden. Bates et al. do not recite their analysis of the Swedish experience solely for rhetorical purposes or to support its continuation in Sweden. They cite it in support of its application outside of Sweden to greater Europe and beyond. Similarly, because we were asked to provide a commentary for the Tobacco Control issue as Americans, we responded to this analysis with our concerns about the application of the Swedish experience to the United States and elsewhere. We noted that the U.S. Smokeless Tobacco Company (UST) did not cite the Swedish snus experience in its pleadings before the Federal Trade Commission in order to gratuitously commend Sweden: UST was making a pitch to expand its marketing of smokeless tobacco in the United States, armed with government endorsed harm reduction claims which it argued could then be made for all if its products, including those known to be gateways to tobacco use among youth and those that are among the highest in cancer-causing nitrosamines. In fact, neither the Foulds et al. nor Bates et al. reviews noted that outside of Sweden, even Swedish Match products are higher in cancer-causing nitrosamines than they sell in Sweden.

Thus, a fundamental question for all tobacco control experts is as follows: If smokeless tobacco has played any overall positive role in Swedish health, what is the relevance of the experience to other countries? Moreover, what questions should tobacco control leaders consider before endorsing smokeless tobacco as a component of comprehensive tobacco control strategies? We have many questions about the benefits attributable to snus in Sweden. Moreover, we are very concerned about the potential for expanded smokeless tobacco marketing in the absence of comprehensive tobacco and nicotine product regulation, particularly if endorsed by public health advocates, to cause more damage to public health than it will to improve public health. The potential risks are numerous and include: Deadly delays in quitting smoking with the support of smokeless tobacco to manage smoking restrictions. Uptake of smokeless tobacco by persons who would not have otherwise used any tobacco product. Substitution of the most popular high nitrosamine smokeless products in the U.S. and as available most everywhere but Sweden for cigarettes as an alternative to complete tobacco cessation. Graduation from smokeless tobacco use to cigarette smoking as has already been well documented in the United States.

Finally, it is not as if there are no alternatives to reducing smoking prevalence. As demonstrated in California, Florida, Mississippi, and Massachusetts, dramatic reductions in youth smoking initiation and adult smoking prevalence can occur, as compared to surrounding states, without advocating snuff use or trading cigarettes for snuff, but rather on the basis of comprehensive tobacco control efforts.

Other tobacco control experts will need to carefully examine the data, weigh their concerns, and come to their own conclusions. We remain concerned about the place of smokeless tobacco in tobacco control and will continue to insist that that comprehensive tobacco regulation should be the prerequisite for its further consideration.

Scott L. Tomar, University of Florida, Division of Public Health Services and Research, Gainesville, Florida, USA

Greg N. Connolly, Massachusetts Tobacco Control Program, Boston, Massachusetts, USA

Judith Wilkenfeld, Campaign for Tobacco-Free Kids, Washington, DC, USA

Jack E. Henningfield, Pinney Associates, Bethesda, Maryland; and Johns Hopkins University School of Medicine, Baltimore, Maryland, USA