Tobacco harm reduction: an alternative cessation strategy for inveterate smokers

According to the Centers for Disease Control and Prevention, about 45 million Americans continue to smoke, even after one of the most intense public health campaigns in history, now over 40 years old. Each year some 438,000 smokers die from smoking-related diseases, including lung and other cancers, cardiovascular disorders and pulmonary diseases. Many smokers are unable--or at least unwilling--to achieve cessation through complete nicotine and tobacco abstinence; they continue smoking despite the very real and obvious adverse health consequences. Conventional smoking cessation policies and programs generally present smokers with two unpleasant alternatives: quit, or die. A third approach to smoking cessation, tobacco harm reduction, involves the use of alternative sources of nicotine, including modern smokeless tobacco products. A substantial body of research, much of it produced over the past decade, establishes the scientific and medical foundation for tobacco harm reduction using smokeless tobacco products. This report provides a description of traditional and modern smokeless tobacco products, and of the prevalence of their use in the United States and Sweden. It reviews the epidemiologic evidence for low health risks associated with smokeless use, both in absolute terms and in comparison to the much higher risks of smoking. The report also describes evidence that smokeless tobacco has served as an effective substitute for cigarettes among Swedish men, who consequently have among the lowest smoking-related mortality rates in the developed world. The report documents the fact that extensive misinformation about ST products is widely available from ostensibly reputable sources, including governmental health agencies and major health organizations. The American Council on Science and Health believes that strong support of tobacco harm reduction is fully consistent with its mission to promote sound science in regulation and in public policy, and to assist consumers in distinguishing real health threats from spurious health claims. As this report documents, there is a strong scientific and medical foundation for tobacco harm reduction, and it shows great potential as a public health strategy to help millions of smokers.

Tobacco use among Swedish schoolchildren

OBJECTIVE

To study the prevalence of snus use and of smoking among Swedish schoolchildren from 1989 to 2003.

DESIGN

Surveys conducted by the Swedish Council for Information on Alcohol and Other Drugs.

SETTING

All of Sweden.

SUBJECTS

84,472 boys and girls age 15-16 years.

MAIN OUTCOME MEASURES

Subjects are classified as non-smokers, occasional smokers, and regular smokers, and into three similar categories for snus use. Tobacco use is reported as sex specific prevalence.

RESULTS

During the period 1989 to 2003, the prevalence of tobacco use declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.

CONCLUSIONS

The high prevalence of snus use in Sweden not only reduces smoking rates among Swedish men, but suppresses smoking among boys as well.

Epidemiologic studies of chrome and cancer mortality: A series of meta-analyses

We used 49 epidemiologic studies based on 84 papers published since 1950 to develop an array of meta-analyses relating exposure to chrome-six compounds with 10 causes of death. Most exposures occurred in occupational settings. Studies were assessed for quality, and for control of smoking or economic status if they related to lung or stomach cancer. There was no excess mortality from all causes combined among chrome-exposed persons. A minimal excess of cancer (SMR=112), overall, was due primarily to an excess of lung cancer (SMR=141) but the SMR was 112 among the better-quality, smoking-controlled studies. The overall SMR for stomach cancer was 113 but it was 82 among the studies that were controlled for economic status. Findings were unremarkable for the six other cancers evaluated: prostate, kidney, and central nervous system cancer and leukemia, Hodgkin's disease and other lymphatohematopoietic cancer. This series of meta-analyses indicates that chrome-six is a weak cause of lung cancer and is not a cause of any of the other seven forms of cancer evaluated.

The decline of smoking in northern Sweden

For decades men in Sweden have smoked at far lower rates than those in comparable countries. Previous studies showed that snus use played a major role in low smoking rates among men in northern Sweden; daily smoking declined from 19% (95% CI 16-22%) in 1986 to 11% (CI 8.9-14%) in 1999. The prevalence of smoking among all men is now 9% (CI 7.0-11%) and only 3% (CI 0.1-5.4%) among men age 25-34 years; the prevalence of exclusive snus use is 27% (CI 24-30%) and 34% (CI 27-42%) respectively. Combined smoking and snus use, an unstable and transient category, was under 5% in all surveys and was 2.2% (CI 1.4-3.4%) by 2004. For the first time snus use is also associated with a decrease in smoking prevalence among women. These patterns of tobacco use have implications for all smoking-dominated societies.

Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study

OBJECTIVE

To explore the effect of smoking and smokeless tobacco, 'snus', on the risk of type 2 diabetes.

DESIGN

Population-based cross-sectional and prospective follow-up study in northern Sweden.

SUBJECTS

A total of 3384 men, aged 25-74 years, who participated in the MONICA study in 1986, 1990, 1994 or 1999, 1170 of whom had an oral glucose tolerance test. In 1999, 1757 men from previous cohorts returned for re-examination. Main outcome measures. We compared the prevalence of type 2 diabetes or pathological glucose tolerance (PGT) amongst tobacco users to that of nonusers at entry into the study and at follow-up, using odds ratios.

RESULTS

Compared with never users, the age-adjusted risk of prevalent clinically diagnosed diabetes for ever smokers was 1.88 (CI 1.17-3.0) and for smokers 1.74 (0.94-3.2). Corresponding odds ratios for snus users were 1.34 (0.65-2.7) and 1.18 (0.48-2.9). We found no increased risk of prevalent PGT in snus users or smokers. Former smokers and snus users had an insignificantly increased risk for PGT. Compared with nonusers, the age-adjusted risk of developing clinically diagnosed diabetes during follow-up was 4.63 (1.37-16) in consistent exclusive smokers, 3.20 (1.16-8.8) in ex-smokers and no cases in consistent snus users. The risk of PGT during follow-up was not increased in consistent tobacco users but evident, although not statistically significant, in those who quit snus during the follow-up period, 1.85 (0.60-5.7). Adjustment for physical activity and alcohol consumption did not change the major findings.

CONCLUSIONS

The risk of diabetes for snus users was not significantly increased. Smoking was associated with prevalent and incident cases of diabetes. Ex-tobacco users tended towards more PGT.

The burden of mortality from smoking: comparing Sweden with other countries in the European Union

We describe the mortality currently attributable to smoking in the European Union (EU), and the change that would result if all EU countries had the smoking prevalence of Sweden. Almost 500,000 smoking-attributable deaths occur annually among men in the EU; about 200,000 would be avoided at Swedish smoking rates. In contrast, only 1100 deaths would be avoided if EU women smoked at Swedish rates. The low smoking-related mortality among Swedish men probably is due to their use of snus (Swedish smokeless tobacco).

The influence of smoking and smokeless tobacco use on weight amongst men

OBJECTIVE

To explore the effect of tobacco use (smoking and smokeless tobacco) and cessation on body weight.

DESIGN

Cross-sectional and prospective follow-up study.

SETTING

Northern Sweden.

SUBJECTS

A total of 2993 men aged 25-64 years who participated in the northern Sweden MONICA study in 1986, 1990 or 1994, 1650 of whom were followed up in 1999.

MAIN OUTCOME MEASURES

The prevalence of overweight [body mass index (BMI) >/= 27] amongst tobacco users was compared with nonusers at entry into the study. The average annual percentage weight gain amongst men was also determined according to tobacco use both at entry and at follow-up, and the development of overweight amongst tobacco-use groups was reported using standardized incidence ratios.

RESULTS

Smokers who quit tobacco during the follow-up period gained significantly more weight than smokers who switched to snus (annual gain 0.96% vs. 0.51%, P < 0.05). At entry, ex-smokers had higher prevalence of overweight than nonusers of tobacco [prevalence ratio (PR) = 1.24, 95% confidence interval (CI) = 1.10-1.40]. Snus users had slightly higher prevalence of overweight at entry (PR = 1.20, CI = 1.01-1.42). Snus users who quit gained more weight than nonusers (0.70% vs. 0.44%, P < 0.05) or those who continued to use snus (0.42%).

CONCLUSIONS

Cessation of tobacco, either cigarettes or snus, leads to significantly increased weight gain. However, snus use may play a role in lowering the weight gain following smoking cessation.

Alcohol-containing mouthwash and oropharyngeal cancer: a review of the epidemiology

BACKGROUND

There has been concern that the use of alcohol-containing mouthwash may increase the risk of developing oropharyngeal cancer, or OPC. The authors examine the epidemiologic literature relating to this issue.

TYPES OF STUDIES REVIEWED

The authors identified all nine English-language epidemiologic studies of OPC that made reference to mouthwash. The findings and major strengths and limitations of each study are described. In addition, the authors reanalyzed data from one of the studies.

RESULTS

The results of six of the studies reviewed are negative and provide no support for the hypothesis that use of alcohol-containing mouthwash increases the risk of OPC. One of the three studies with positive results was a case series and included a follow-up case-control study, the results of which were negative. The authors reanalyzed the study with the most positive results. This analysis found that the study results were just as positive for nonmucosal cancers developing in the mouth as they were for the usual type of OPC. The authors concluded that this study's positive finding resulted from recall bias.

CLINICAL IMPLICATIONS

It is unlikely that the use of mouthwashes that contain alcohol increases the risk of developing OPC.

Evolving patterns of tobacco use in northern Sweden

BACKGROUND AND OBJECTIVES

Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999.

DESIGN

This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999.

RESULTS

Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05).

CONCLUSIONS

The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.

Impact of smokeless tobacco use on smoking in northern Sweden

BACKGROUND AND OBJECTIVES

For many years Swedish men have had the world's lowest rates of smoking and smoking-related mortality. Despite these facts, a thorough analysis of tobacco use patterns in Sweden has not been performed. The purpose of this study was to examine the prevalence and interaction of cigarette smoking and use of Swedish moist snuff (snus) in the population of northern Sweden.

DESIGN

The study cohort of 2998 men and 3092 women aged 25-64 was derived from the northern Sweden MONICA study, consisting of population-based surveys in 1986, 1990, 1994 and 1999. Detailed information on tobacco use was used to develop prevalence data, and the prevalence ratio was used to compare rates amongst various subgroups.

RESULTS

Amongst men ever-tobacco use was stable in all survey years at about 65%, but the prevalence of smoking declined from 23% in 1986 to 14% in 1999, whilst snus use increased from 22% to 30%. In women the prevalence of smoking was more stable in the first three surveys (approximately 27%) but was 22% in 1999, when snus use was 6%. In all years men showed higher prevalence of ex-smoking than women. A dominant factor was a history of snus (PR = 6.18, CI = 4.96-7.70), which was more prevalent at younger ages.

CONCLUSIONS

The recent transition from smoking to snus use amongst men, and incipiently amongst women, in northern Sweden is remarkable and relevant to the global discussion on strategies to reduce smoking.

Smokeless tobacco use and cancer of the upper respiratory tract

The most recent epidemiologic review of the cancer risks associated with smokeless tobacco use appeared in 1986, when 10 studies were available. This review describes 21 published studies, 20 of which are of the case-control type. We characterize each study according to the specific anatomic sites and according to the type of smokeless tobacco products for which it provides relative risks of cancer. The use of moist snuff and chewing tobacco imposes minimal risks for cancers of the oral cavity and other upper respiratory sites, with relative risks ranging from 0.6 to 1.7. The use of dry snuff imposes higher risks, ranging from 4 to 13, and the risks from smokeless tobacco, unspecified as to type, are intermediate, from 1.5 to 2.8. The strengths and limitations of the studies and implications for future research are discussed.

Impact of the American anti-smoking campaign on lung cancer mortality

Customary statistics on smoking practices are limited because they do not correlate well with the frequency of smoking-related diseases. Our study developed outcome measures based on lung cancer mortality and used them to assess the anti-smoking campaign. Changes in mortality from lung cancer were used to assess significant smoking among 5-year birth cohorts of white men born from 1901 to 1942. We used each cohort's lung cancer mortality rate at ages 40-44 to indicate its earlier smoking. A lung cancer mortality ratio was developed to describe each cohort's continued smoking from ages 40-44 to 55-59. These ratios were then compared with the durations of the cohorts' exposure to the anti-smoking campaign that began in 1965. Lung cancer mortality in white men ages 40-44 peaked in 1970 and declined continuously thereafter, indicating that the anti-smoking campaign promptly reduced significant smoking among younger men. However, the lung cancer mortality ratio indicates that only half of smokers in the specified birth cohorts were able to quit by ages 55-59, despite receiving ever more intense anti-smoking messages. The anti-smoking campaign produced moderate benefits among younger white male smokers but fewer benefits among older smokers because of the existence of a large number of inveterate smokers.

Aggressive osteoblastoma of the mandible closely simulating calcifying epithelial odontogenic tumor. Report of two cases with unusual histopathologic findings

Aggressive osteoblastoma is a rare bone-forming neoplasm composed of prominent epithelioid cells that demonstrate locally invasive growth with a high rate of recurrence but no metastatic potential. Clinical, radiographic and pathologic features of mandibular aggressive osteoblastoma in a 21-year-old African-American male and a 12-year-old Caucasian female are presented. Both tumors were resected with wide surgical margins and neither patient had adjuvant radiation or chemotherapy. The patients showed no evidence of local recurrence or distant spread either clinically or radiographically after two years of follow-up. These tumors were composed of solid sheets of pleomorphic epithelioid cells, eosinophilic amorphous osteoid with foci of calcification, which closely simulated amyloid. Differentiation of this tumor from histologically similar calcifying epithelial odontogenic tumor and low-grade osteosarcoma proved difficult. Immunohistochemical study with osteocalcin confirmed the osteoblastic nature of these epithelioid cells.

Case-control study of intracranial tumors among employees at a petrochemical research facility

This case-control study evaluated the relation between potential exposure to chemical and physical agents and the occurrence of intracranial tumors among employees at a petrochemical research facility. Cases were employees with glioma (n = 6) or benign intracranial tumors (n = 6). Controls (n = 119) were individually matched to cases on gender and birth year, and they were alive and did not have an intracranial tumor at the case's diagnosis date. Exposure information came from interviews with subjects or surrogates and from corporate records on agents used in research projects. Analyses computed matched odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for self-reported exposure to 15 agents and project-based estimates of exposure to 29 agents. For gliomas, the OR was elevated for self-reported exposure to ionizing radiation (OR, 15.7; CI, 1.4 to 179.4), n-hexane (OR, infinity; CI, 1.4 to infinity), organometallics (OR, 9.4; CI, 1.5 to 59.7), and amines other than nitrosamines (OR, 6.0; CI, 1.0 to 35.7). The OR also was elevated for project-based potential use of ionizing radiation (OR, 9.6; CI, 1.7 to 55.2) and for potential use of n-hexane lasting at least 4 years (OR, 16.2; CI, 1.1 to 227.6). For benign intracranial tumors, the OR was elevated only for self-reported exposure to ionizing radiation (OR, 5.4; CI, 1.7 to 43.1) and other amines (OR, 5.2; CI, 0.9 to 29.5). Occupational exposure may have contributed to the glioma excess, but the specific causal agents remain unknown. The study indicated that benign intracranial tumors were unlikely to be work-related.

Cancer and benign tumor incidence among employees in a polymers research complex

The detection of several intracranial tumors among employees in one building complex (C500) at a petrochemical research facility prompted investigation of a possible workplace cause. This retrospective follow-up study included 1847 subjects, of whom 1735 had worked in C500. Medical records, death certificates, and Illinois State Cancer Registry data confirmed self-reported cancers and tumors. Analyses compared the subjects' cancer and benign intracranial tumor incidence rates with national general population rates. C500 employees had 15% fewer than expected total cancers (92 observed/108 expected; standardized incidence ratio [SIR], 85; 95% confidence interval [95% CI], 69 to 104). An excess of brain cancer (6/2.0; SIR, 302; 95% CI, 111 to 657) was concentrated among white men who had 10 or more years since hire and 5 or more years of C500 employment (4/0.7; SIR, 602; 95% CI, 165 to 1552) and who had worked in a particular building of C500 (5/0.7; SIR, 735; 95% CI, 239 to 1716). An excess of benign intracranial tumors (6/1.6; SIR, 385; 95% CI, 142 to 839) was not restricted to a single type of tumor and was not concentrated in any particular building. Occupational exposure may have caused the increased rate of brain cancer but is a less likely explanation for the elevated rate of benign intracranial tumors.

Mortality among employees at a petrochemical research facility

BACKGROUND

This retrospective follow-up study evaluated mortality during 1970-1996 among 6,956 employees at a petrochemical research facility in Illinois.

METHODS

Standardized mortality ratios (SMRs) compared employees' mortality rates with those of the Illinois general population. Poisson regression procedures estimated rate ratios for various subject subgroups compared to other facility employees.

RESULTS

Subjects had 267 observed/524 expected deaths (SMR = 51) from all causes combined and a large deficit of deaths from all cancers (76/136, SMR = 56) and from most other major diseases. Other results included fewer than expected brain cancers (1/4.0, SMR = 25) and a slight increase in colorectal cancer (20/14, SMR = 139) that was concentrated in white male scientists employed for one of the three main companies at the facility (SMR = 295, RR = 2.6).

CONCLUSIONS

The deficit of brain cancer deaths contrasts with an excess incidence seen in a companion study. Subjects' generally favorable mortality experience probably reflects socioeconomic advantages of employees relative to the Illinois general population.

Cancer incidence among employees at a petrochemical research facility

This investigation evaluated cancer incidence among workers at a petrochemical research facility in Illinois. A cluster of brain cancer and other intracranial tumors had occurred at the facility before the study began. The subjects were 5641 people who had worked at the facility from 1970 through 1996 and who had lived in Illinois at any time between 1986 and 1997. Data on cancer cases came primarily from the Illinois State Cancer Registry. Analyses compared the 1986-to-1997 cancer incidence rates of employees with Illinois general population rates. Subjects had 18% fewer than expected total cancers (125 observed/153 expected cases; standardized incidence ratio [SIR], 82; 95% confidence interval [CI], 68 to 98), which was primarily attributed to a large deficit of lung cancer (10/26; SIR, 39; CI, 19 to 72). Brain cancer was increased in the overall study group (6/2.7; SIR, 222; CI, 81 to 484). This excess was restricted to white men who were scientists or technicians for one of the three companies at the facility (6/0.8; SIR, 750; CI, 275 to 1633); all cases in this group had worked in the "500 building complex" (6/0.6; SIR, 968; CI, 355 to 2106). Subjects also had an increased incidence of thyroid cancer (7/2.6; SIR, 265; CI, 106 to 546) that was not concentrated in particular occupational or building groups. The brain cancer incidence patterns indicated that an unidentified occupational exposure might have been responsible for the excess. Chance, socioeconomic factors leading to better case detection in facility employees than in the general population, and confounding by potential nonoccupational risk factors are plausible explanations of the observed increase in thyroid cancer.

The fifty-year decline of cancer in America

PURPOSE

From 1950 to 1990, the overall cancer mortality rate increased steadily in the United States, a trend which ran counter to declining mortality from other major diseases. The purpose of this study was to assess the impact of lung cancer on all-cancer mortality over the past 50 years.

METHODS

Data from the National Centers for Health Statistics were used to develop mortality rates for all forms of cancer combined, lung cancer, and other-cancer (all-cancer minus lung cancer) from 1950 to 1998.

RESULTS

When lung cancer is excluded, mortality from all other forms of cancer combined declined continuously from 1950 to 1998, dropping 25% during this period. The decline in other-cancer mortality was approximately 0.4% annually from 1950 to 1990 but accelerated to 0.9% per year from 1990 to 1996 and to 2.2% per year from 1996 to 1998.

CONCLUSION

The long-term decline is likely due primarily to improvements in medical care, including screening, diagnosis, and treatment.

Mortality among employees at a petrochemical research facility

BACKGROUND

This retrospective follow-up study evaluated mortality during 1970-1996 among 6,956 employees at a petrochemical research facility in Illinois.

METHODS

Standardized mortality ratios (SMRs) compared employees' mortality rates with those of the Illinois general population. Poisson regression procedures estimated rate ratios for various subject subgroups compared to other facility employees.

RESULTS

Subjects had 267 observed/524 expected deaths (SMR = 51) from all causes combined and a large deficit of deaths from all cancers (76/136, SMR = 56) and from most other major diseases. Other results included fewer than expected brain cancers (1/4.0, SMR = 25) and a slight increase in colorectal cancer (20/14, SMR = 139) that was concentrated in white male scientists employed for one of the three main companies at the facility (SMR = 295, RR = 2.6).

CONCLUSIONS

The deficit of brain cancer deaths contrasts with an excess incidence seen in a companion study. Subjects' generally favorable mortality experience probably reflects socioeconomic advantages of employees relative to the Illinois general population.

Case-series investigation of intracranial neoplasms at a petrochemical research facility

BACKGROUND

From 1970 through 1997, 17 intracranial neoplasms were identified among 6,800 employees of a petrochemical research facility. This investigation describes the case-series.

METHODS

The intracranial neoplasms were identified by self reports and record linkages, and were confirmed by medical records and a pathology review. Standardized incidence ratios (SIRs) compare observed and expected numbers of cases according to certain work characteristics.

RESULTS

Overall, there were 17 observed and 10.5 expected intracranial neoplasms, including 11/4.7 benign intracranial tumors and 6/5.9 brain cancers. All brain cancers occurred among male research scientists or technicians. Four had worked at some time on the same floor of one building (SIR=12.6, 95% CI=3.4-32.1), and several had worked on a research project with at least one other brain cancer case. The benign intracranial neoplasm cases did not have common building assignments or work activities.

CONCLUSIONS

The occurrence pattern of brain cancers, but not that of benign tumors, suggests a possible occupational etiology.

Caliber-persistent labial artery. A common vascular anomaly

Sixteen cases of caliber-persistent labial artery of the lips have been reported to date in the English literature. Six of these were clinically misdiagnosed as squamous cell carcinoma and treated with wedge resection. To date, we have seen 187 cases clinically and an additional 23 cases through our surgical oral pathology services. Careful clinical observation usually reveals a soft linear or papular bluish elevation above the labial mucosal surface. The unique feature is pulsation--not simply pulsation toward and away from the observer, which can be caused by an underlying artery, but lateral pulsation, which only an artery can exhibit. All but 2 of our 187 clinical cases were asymptomatic. To the best of our knowledge, this is the first report of caliber-persistent labial artery of the upper lip. The upper:lower lip ratio for the clinical cases was almost 2:1. Three times as many lower lip as upper lip lesions were biopsied. Males and females were almost equally affected (clinical cases, 76:86; histopathologic cases, 9:13). Although a vascular term (artery, hemangioma, phlebolith, varix, vascular malformation) was used on the biopsy form in one half of the clinical differential diagnoses, none of the clinical histories mentioned pulsation. In contrast to the cases of Miko et al. in 1980 and 1983, none of our cases manifested itself as an ulcer, nor was carcinoma ever mentioned in the clinical differential diagnosis. The purpose of this article is to familiarize clinicians and pathologists with the clinical and histopathologic features of this seldom reported but common vascular anomaly. Clinicians should carefully look for lateral pulsation in lip mucosal papules so as to avoid unnecessary surgery and intraoperative arterial bleeding. Pathologists should recognize that a relatively large-caliber superficial artery in a lip biopsy may not be an incidental finding but rather the clinical lesion that was biopsied.