Elsevier

Preventive Medicine

Volume 38, Issue 3, March 2004, Pages 309-317
Preventive Medicine

Smokeless tobacco use: harm reduction or induction approach?

https://doi.org/10.1016/j.ypmed.2003.10.006Get rights and content

Abstract

Background: Smokeless tobacco (ST) substitution for cigarettes as a method to reduce harm has been actively debated. Use of ST as a smoking cessation method or as a means to reduce cigarettes has been proposed. The impact of using ST in these ways is relatively unknown.

Method: A review of the different issues and studies related to using smokeless tobacco as a method to reduce tobacco toxin exposure and harm is presented.

Results: The toxicity of the product itself varies by brand of ST and across countries. Of the existing studies, comparisons of consequences between cigarettes and ST show that cigarette smoking produces more negative health effects, is likely to have a higher addiction potential and more severe withdrawal, and leads to a higher rate of relapse than ST use. On the other hand, ST use facilitates the use of cigarettes, which is a deadly tobacco product. Additionally, ST is not a harmless product, and a less harmful product, medicinal nicotine, is available as an effective treatment approach. Furthermore, ST products are not under the same regulatory scrutiny as medicinal nicotine products.

Conclusions: Considerably more research and product regulation is necessary prior to considering smokeless tobacco as a harm reduction method.

Introduction

In recent years, consideration has been given to the use of oral noncombustible or smokeless tobacco (ST) as a harm reduction method for cigarette smokers who are unable or unwilling to quit using tobacco. As defined by the Institute of Medicine report, Clearing the Smoke, Assessing the Science Base for Tobacco Harm Reduction, [1] “a product is harm-reducing if it lowers total tobacco-related mortality and morbidity even though use of that product may involve continued exposure to tobacco-related toxicants.” The use of ST as a harm reduction approach has been fueled by the experiences in Sweden, where the rates of tobacco-related mortality and morbidity have been reduced significantly. These reductions have been attributed to the decreasing prevalence of cigarette smoking resulting from the greater use of snus (oral snuff) among the male tobacco users [2]. Furthermore, several Swedish cohort studies suggest that most smoking cessation by men occurred with the use of ST [3], [4], [5], [6]. However, a similar reduction in smoking prevalence has been observed among females who have not used snus instead of cigarettes. Therefore, the reduction in prevalence may be a result of other significant tobacco control measures that have been implemented in Sweden [7]. Thus, this issue continues to remain controversial among scientists and tobacco control advocates.

The use of ST as a method for reducing tobacco toxin exposure can occur on several levels. ST can be used as a substitute for cigarettes in situations where smoking is not allowed, when inconvenient or to reduce secondhand smoke exposure. Marketing attempts have been made by smokeless tobacco companies aimed at smokers to use smokeless tobacco in situations where they cannot smoke [8] or to switch to ST to reduce secondhand smoke (US Smokeless Tobacco Company, letter submitted to the Food and Trade Commission, 2003). These efforts to capture the market of cigarette smokers may have great economic benefit to the smokeless tobacco companies and lead to great public health harm. For example, this substitution approach would not necessarily lead to lower levels of nicotine or tobacco toxin exposure for the individual. That is, ST would be used in situations where the cigarette smoker would normally not have been able or want to smoke; thereby the use of ST could potentially increase overall exposure. Furthermore, this approach may lead to more harm by increasing the maintenance of smoking [8], although others have argued that use of ST products may eventually increase interest in quitting. Two other reduced exposure methods that are potentially more reasonable include the use of ST as a substitute for cigarette smoking for those who are primarily attempting to cut down on number of cigarettes. Or, ST could be used as a cessation tool, either transitionally towards cessation of all tobacco products or as a long-term substitute for cigarette smoking. The focus of this paper is the use of ST among existing cigarette smokers aimed at the latter two approaches. The pros and cons of using these purported harm reduction approaches need consideration because of the current endeavors of the tobacco industry to position ST as a safer alternative to smoking. In addition, a few members of the scientific and public health community are advocating that switching from cigarette smoking to ST use will have significant public health benefits. This paper will discuss the rationale for considering ST as a harm reduction method, the existing although limited literature that examines the efficacy of this approach, and future research recommendations. Although important, no extensive discussion will be presented as to whether public health will benefit if ST was chosen over cigarette smoking as a primary tobacco product.

Section snippets

Rationale

Several reasons have been given for the use of ST as a harm reduction method [9]. Prominent among these reasons is the fewer negative health consequences associated with ST compared to cigarettes. Estimates have been made that ST poses about 2% of the mortality risk of cigarette smoking [9], [10] and only half of the risk of oral cancer associated with continued cigarette smoking [9]. The average years of life remaining across age groups have been estimated to be the same among quitters of

The effects of smokeless tobacco use on cigarette smoking

In the United States, the rate of ST use among cigarette smokers is lower than cigarette use among ST users. The proportion of current cigarette smokers who report using ST ranges from 2.6% [82] to 4.7% (2000 NHSDA). In a recent study by Tomar [68], about 20% of daily snuff users and 40% of occasional snuff users were smokers. In prior studies, about 22.9% of current ST users were current smokers [82]. Epidemiological data show that a small number of smokers use ST to quit smoking and a

Future research directions

Although there is sufficient rationale to suggest that ST has the potential to be used as a harm reduction method for cigarette smokers, several significant concerns are also evident. Before any recommendations can be made for the use of ST as a means for cigarette reduction and cessation, several scientific issues need to be addressed.

Although ST leads to reduced mortality and morbidity compared to smoking, it is not a safe product and it is addictive. The extent to which this product imposes

Acknowledgements

This review was funded by NIDA/NCI grant P50-DA13333 (DH and CL) and T32 DA07239 (CL) and NCI Contract No. 263-MQ-210254 (ST).

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      These changes have been accompanied by a debate among experts regarding whether smokeless tobacco products offer a “reduced harm” alternative to cigarettes (Hatsukami, Lemmonds, & Tomar, 2004; Savitz, Meyer, Tanzer, Mirvish, & Lewin, 2006). Some experts argue that smokeless tobacco use presents reduced health risks compared to cigarette use and, therefore, smokeless tobacco use should be promoted as an alternative to cigarette, while others argue that smokeless tobacco still presents health risks and, therefore, should not be promoted by public health officials (Gartner, Hall, Chapman, & Freeman, 2007; Hatsukami et al., 2004). The FDA has the authority to determine whether an individual product can be marketed as a modified risk tobacco product based on data submitted for the individual product.

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