You might as well smoke; the misleading and harmful public message about smokeless tobacco

Newspaper coverage of snus in an emerging Norwegian snus market 2002-2011: A content analysis

Background

In a context where snus is a legal product, its advertising is prohibited and its prevalence of use has been on the rise among adolescents and young adults, the aim of this article is to identify the extent of snus coverage in Norwegian newspapers and the themes and values communicated about snus therein from 2002 to 2011.

Aim and methods

All major Norwegian newspapers were scanned for articles with “snus” (and relevant connectors) in headings, ingresses, and/or pictures/captions as search criteria. Using the Retriever media monitoring service as a database, the search returned 943 unique articles, which were subjected to quantitative content analysis.

Results

The number of articles per year increases over the period, while their average length decreases slightly. Thematically, the greatest attention is on the extent of “snus use” (occurring in 52.7% of the articles), and then more equally divided between “tobacco policy” (24.5%), “economy/markets” (29.1%), and “health” (28.7%). A total of 48.6% of the articles are “neutral/mixed” in respect of framing, 28.1% are “negative,” and only 20.7% are “positive” in tone. Articles about tobacco policy are more often negative, while articles on economic factors are more often positive. Articles on health are usually negatively focused, or neutral/mixed.

Conclusion

The slight predominance of negative and/or neutral/mixed articles indicates that the newspaper coverage does not glamorize the snus product. However, the sheer amount of (and growth in) articles over time, as well as positive articles available for selective exposure and perception, may nevertheless have contributed to a normalization of snus use.

Implications

Little is known about media coverage of smokeless tobacco and whether editorial mass media glamorize or criticize its use. This study shows that the extent of snus coverage in Norwegian newspapers has increased over time, but also that the framing of Norwegian newspaper coverage of snus has mainly been neutral/mixed or negative toward snus and its use.

Cigarette and Smokeless Tobacco Perception Differences of Rural Male Youth

Objectives

Compare cigarette and smokeless tobacco (ST) perceptions within a youth population where ST use is common.

Methods

Male baseball players (N = 594) at 36 rural high schools in California rated separately 20 potential risks or benefits associated with cigarettes or ST, along with global harm ratings. Informed by principal components analysis, 3 composite categories were created: oral/rule-breaking risks (eg, mouth cancer, getting in trouble), systemic risks (eg, heart attack), and benefits (eg, relaxation). Standardized composite scores and harm ratings were compared by product and by tobacco use status.

Results

Cigarettes were perceived as likely to impart oral/rule-breaking risks and systemic risks, unlikely to cause benefits, and as very harmful overall. ST was perceived similarly as cigarettes regarding oral/rule-breaking risks, but less likely to cause systemic risks, and more beneficial. Most participants rated cigarettes as more harmful than ST. Similar patterns existed in all tobacco use groups, including non-users and dual-users.

Conclusions

In this population, cigarettes were perceived as very harmful. ST was perceived similarly to cigarettes only for some risks and as less harmful overall. Communication for rural adolescents should consider multifaceted aspects of ST risk.

Perceived Relative Harm of Selected Cigarettes and Non-Cigarette Tobacco Products-A Study of Young People from a Socio-Economically Disadvantaged Rural Area in Poland

The perceived health risk of recently introduced nicotine and tobacco products may influence both their uptake and continued use. The aim of the study was to assess how adolescents rate relative harmfulness of slim and menthol cigarettes, water pipes, e-cigarettes, and smokeless tobacco compared to regular cigarettes. Cross-sectional survey data from students aged 13-19 years from Piotrkowski district, Poland were analyzed. Among the sample of 4050 students, 3552 respondents completed anonymous, confidential, self-administered questionnaire adapted from the Global Youth Tobacco Survey (GYTS). The study results indicate that the students perceived slim cigarettes and menthol cigarettes as less harmful, which is in line with the message created by tobacco companies. On the other hand, less popular products such as water pipes and smokeless tobacco were considered as more harmful. The current study indicates insufficient and misleading perception of harmfulness of different tobacco/nicotine products available on the Polish market. Simultaneously, there is insufficient countrywide public health education in this matter. Preventive measures are necessary to discourage young people from smoking uptake and to ensure that potential consumers can, based on objective data, make informed decisions about cigarettes and non-cigarette tobacco products.

Tobacco use and associated factors among Adults in Uganda: Findings from a nationwide survey

Background

Tobacco use and the exposure to tobacco smoke is one of the most preventable causes of death and disability globally. The risk is even higher among daily tobacco users. The World Health Organization (WHO) has recommended that surveillance of major risk factors for Non Communicable Diseases (NCDs) such as tobacco use is imperative to predict the future burden of NCDs, identify interventions to reduce future burden and monitor emerging patterns and trends. In 2014 the first Uganda nation-wide NCD risk factor survey was carried out to estimate the prevalence of major NCD risk factors. We analyzed data from this survey to estimate the prevalence of daily tobacco use and associated risk factors.

Methods

A nationally representative sample was drawn stratified by the four regions of the country. The WHO’s STEPwise tool was used to collect data on demographic and behavioral characteristics including tobacco use, physical and biochemical measurements. Tobacco use was divided into three categories; daily tobacco use, daily smoked tobacco use and daily smokeless tobacco use. Weighted logistic regression analysis was used to identify factors associated with daily tobacco use.

Results

Of the 3983 participants, 9.2 % (366) were daily tobacco users, 7.4 % (294) were daily smoked tobacco users and 2.9 % (115) were daily smokeless tobacco users. Male participants were more likely to be daily tobacco users compared with female participants AOR 5.51 [3.81–7.95]. Compared with participants aged 18–29 years, those aged 30–49 years were more likely to be daily tobacco users AOR 2.47 [1.54–3.94] as were those aged 50–69 years AOR 2.82 [1.68–4.74]. Compared with participants without any education, those with primary education were less likely to be daily tobacco users AOR 0.43 [0.29–0.65], as were those with secondary education AOR 0.21 [0.14–0.33] and those with university level of education AOR 0.23 [0.11–0.48]. Compared with participants in the central region, those in the eastern region were more likely to be daily tobacco users AOR 2.14 [1.33–3.45] as were those in the northern region AOR 4.31 [2.79–6.45] and those in the western region AOR 1.87 [1.18–2.97]. Participants who were underweight were more likely to be daily tobacco users compared with people with normal BMI AOR 2.19 [1.48–3.24].

Conclusions

In agreement with previous surveys on tobacco use, there is a high prevalence of tobacco use in Uganda with almost 1 in every 10 Ugandans using tobacco products daily. Being older, male, having no formal education, residing in the east, north and western regions and having low BMI were significantly associated with daily tobacco use. This information provides a useful benchmark to the National Tobacco Control Program for the designing of public health interventions for the control and prevention of tobacco use in Uganda.

Electronic supplementary material

The online version of this article (doi:10.1186/s12971-016-0093-8) contains supplementary material, which is available to authorized users.

Ethical considerations of e-cigarette use for tobacco harm reduction

Due to their similarity to tobacco cigarettes, electronic cigarettes (e-cigarettes) could play an important role in tobacco harm reduction. However, the public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear. We identified the major ethical considerations surrounding the use of e-cigarettes for tobacco harm reduction, including product safety, efficacy for smoking cessation and reduction, use among non-smokers, use among youth, marketing and advertisement, use in public places, renormalization of a smoking culture, and market ownership. Overall, the safety profile of e-cigarettes is unlikely to warrant serious public health concerns, particularly given the known adverse health effects associated with tobacco cigarettes. As a result, it is unlikely that the population-level harms resulting from e-cigarette uptake among non-smokers would overshadow the public health gains obtained from tobacco harm reduction among current smokers. While the existence of a gateway effect for youth remains uncertain, e-cigarette use in this population should be discouraged. Similarly, marketing and advertisement should remain aligned with the degree of known product risk and should be targeted to current smokers. Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.

Interviews with smokers about smokeless tobacco products, risk messages and news articles

BACKGROUND

Smokeless tobacco (SLT) products and their communication have been topics of discussion in harm reduction debates, but little is known about smokers' perceptions of existing SLT risk messages. This study aimed to explore smokers' perceptions of SLT and snus products and news stories with different risk messages about them.

METHODS

We conducted interviews with 30 smokers assigned to read 1 of 3 constructed news stories about SLT and snus with different messages about their risks relative to cigarettes: (1) a 'favourable' version (describing SLT/snus as a 'safer' smoking alternative); (2) a 'cautious' version (describing SLT/snus as having various risks); and (3) a 'mixed' version (both stating SLT risks and potential reduced-risk benefits).

RESULTS

Smokers felt somewhat more informed about snus after article reading and largely found quoted sources to be credible. Though some exposed to favourable SLT/snus messages appeared to modify their beliefs about the products' acceptability and risks, many were left unchanged given pre-existing SLT risk perceptions influenced by prior SLT warnings, observed effects in known users, and concerns about SLT's mode of use. Willingness to use/not use snus in the future was also influenced by non-risk-related factors (eg, preference for smoking rituals). Many referenced e-cigarettes as being safer and more attractive smoking alternatives.

CONCLUSIONS

Exposure to reduced-risk SLT information may have some impact on smokers' SLT perceptions and interest, but this might be limited by a variety of negative SLT beliefs and growth of other smoking alternatives. Future research should explore SLT risk message effects with larger samples and different study designs.

Gateway Effects: Why the Cited Evidence Does Not Support Their Existence for Low-Risk Tobacco Products (and What Evidence Would)

It is often claimed that low-risk drugs still create harm because of "gateway effects", in which they cause the use of a high-risk alternative. Such claims are popular among opponents of tobacco harm reduction, claiming that low-risk tobacco products (e.g., e-cigarettes, smokeless tobacco) cause people to start smoking, sometimes backed by empirical studies that ostensibly support the claim. However, these studies consistently ignore the obvious alternative causal pathways, particularly that observed associations might represent causation in the opposite direction (smoking causes people to seek low-risk alternatives) or confounding (the same individual characteristics increase the chance of using any tobacco product). Due to these complications, any useful analysis must deal with simultaneity and confounding by common cause. In practice, existing analyses seem almost as if they were designed to provide teaching examples about drawing simplistic and unsupported causal conclusions from observed associations. The present analysis examines what evidence and research strategies would be needed to empirically detect such a gateway effect, if there were one, explaining key methodological concepts including causation and confounding, examining the logic of the claim, identifying potentially useful data, and debunking common fallacies on both sides of the argument, as well as presenting an extended example of proper empirical testing. The analysis demonstrates that none of the empirical studies to date that are purported to show a gateway effect from tobacco harm reduction products actually does so. The observations and approaches can be generalized to other cases where observed association of individual characteristics in cross-sectional data could result from any of several causal relationships.

Public education about the relative harm of tobacco products: an intervention for tobacco control professionals

BACKGROUND

In the USA, new regulations require the collection of information on tobacco constituents by brand and variety and publication of this information in a way not likely to be misconstrued by consumers. Understanding of such information becomes increasingly important as new tobacco products are marketed and modifications are made to reduce the toxicity of some products. This pilot study assessed the current knowledge of tobacco control professionals regarding the relative harmfulness of several tobacco products, and evaluated an online educational intervention aimed at improving understanding of variations in nicotine and tobacco-specific N-nitrosamines (TSNAs).

METHODS

Fifty-two tobacco control professionals participated in an online intervention which presented and discussed the results of constituent analyses of Camel Snus and Marlboro Snus compared to several conventional smokeless tobacco products. Comparisons with cigarettes were also discussed. Pre- and post-intervention questions assessed understanding of the concepts.

RESULTS

Pre-intervention responses demonstrated that 31% did not know that cigarettes are more harmful than smokeless tobacco, 67% did not know that smokeless products higher in nicotine are likely to be more effective substitutes for cigarettes, 52% did not know TSNAs are the major carcinogens in tobacco and 81% did not know new snus products tend to be lower in TSNAs than conventional spit tobacco. After intervention participation, knowledge increased on all points except one where pretest results were 100% correct.

CONCLUSIONS

Public education campaigns are urgently needed for tobacco control professionals and consumers to increase awareness and understanding of the continuum of risk among tobacco products.

Smokeless Tobacco Risk Comparison and Other Debate Messages in the News

OBJECTIVES

Public health professionals have debated the use of smokeless tobacco (SLT) over cigarettes for harm reduction. This article describes SLT and cigarette risk comparisons and other SLT "debate" messages potentially reaching the public through news stories.

METHODS

We conducted a content analysis of SLT-related 2006-10 articles from top newspapers and selected news wires.

RESULTS

About 16% of articles (N = 677) referred to SLT as less harmful than smoking, attributing these messages to public health professionals as frequently as to tobacco company representatives. About 29% of articles included an "anti" SLT message, including variously phrased warnings that SLT is not a safe smoking alternative, or other potential consequences such as youth uptake.

CONCLUSION

Professionals should begin developing and using more consistent messages about SLT's risks.

Intention to switch to smokeless tobacco use among South African smokers: results from the 2007 South African Social Attitudes Survey

Background

Some smokeless tobacco products (SLT) have been shown to be associated with only a fraction of the risks of cigarettes. This study assessed South African smokers’ interest in switching to a hypothetical reduced harm SLT product.

Methods

The 2007 South African Social Attitudes Survey was analysed for 678 exclusive cigarette smokers. Respondents were asked about their perceptions about relative harm of snuff compared to cigarettes, and their interest in switching to snuff if informed it was 99% less harmful than cigarettes.

Results

About 49.7% of exclusive cigarette smokers believed that snuff was equally as harmful as cigarettes; 12.9% thought snuff was more harmful; 5.7% thought snuff was less harmful; while 31.8% did not know if there was a difference in harm between snuff and cigarettes. Approximately 24.2% of exclusive cigarette smokers indicated interest in switching to snuff, with significantly greater interest observed among those exposed to 100% smoke-free work environment. Interest in switching was highest (34.7%) among smokers who believed a priori that using snuff was more harmful than cigarettes, and lowest (14.5%) among those who did not know if there was a difference in harm. In a multi-variable adjusted logistic regression model, this latter group remained less likely to be interested in harm reduction switching (adjusted odds ratio = 0.42; 95% CI: 0.19–0.91).

Conclusion

About a quarter of smokers indicated interest in harm reduction switching to snuff. SLT products have a potential role in reducing the harm from smoking in South Africa, but only if they are not used to circumvent smoke-free laws that have been associated with reduced smoking.

A fresh look at tobacco harm reduction: the case for the electronic cigarette

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

A content analysis of smokeless tobacco coverage in U.S. newspapers and news wires

INTRODUCTION

Research attention on smokeless tobacco (SLT) has focused on SLT use, health risks, harm-reduction potential, and risk perceptions, but few studies have examined mediated communications about SLT. This study aims to contribute to the literature by providing the first description of SLT coverage in the news, an important communication channel given its ability to educate and shape public opinion about tobacco issues.

METHODS

A content analysis was conducted on SLT-related news and opinion articles between 2006 and 2010 from top circulating national and state newspapers and select news wires. Articles were coded for the main SLT topic, SLT risk references, and slant of opinion articles.

RESULTS

SLT was discussed in news/feature articles (n = 677) in terms of business (28%), new products, product regulation and harm reduction (19%), prevention/cessation (11.4%), taxation (10.2%), profiles/trends in use (9%), bans (8.1%), and tobacco industry promotional activities (4.9%). Health risk references (i.e., addictiveness, carcinogenicity, and specific health effects including oral cancer) were found in 40% of articles, though frequency differed by article topic. Although the majority of opinion articles (n = 176) conveyed an anti-SLT slant (64%), 25.6% were pro-SLT.

CONCLUSIONS

SLT topics of both national and local importance are covered in the news. Public health professionals can participate in SLT coverage by sending in press releases about new study findings, events, or resources and by submitting opinion pieces to share views or respond to previous coverage. Research on SLT news should continue given its potential to shape the public's SLT knowledge and opinions.

Tobacco harm reduction: opportunity and opposition

Purpose

This paper aims to provide a brief summary of the effectiveness and efficacy of tobacco harm reduction (THR). THR is the substitution for cigarettes of low‐risk alternatives, including Swedish or American‐style smokeless tobacco, pharmaceutical nicotine products, and electronic cigarettes. The paper then very briefly summarizes the current social and political situation regarding THR.

Design/methodology/approach

This paper is a review of the evidence.

Findings

The risk from smoke‐free tobacco/nicotine products is so low as to be unmeasurable. For most smokers, adopting THR is a lower risk option than to trying to become nicotine abstinent. THR products have been widely adopted in some populations, providing great public health benefits. There is currently an explosion of interest in electronic cigarettes. However, THR is a threat to the business model of the tobacco control industry, and so they are fighting hard to discourage it. Because they cannot admit their real motives for discouraging THR, anti‐THR activism is an entirely dishonest enterprise.

Practical implications

Tobacco harm reduction is the greatest untapped public health initiative in the developed world. It is more promising than further attempts to promote tobacco/nicotine abstinence. The future inevitably includes a large portion of the population using low‐risk tobacco/nicotine, but anti‐THR efforts might keep people smoking in the short run.

Originality/value

While most of the content of this paper is well known to experts on THR, many ostensible experts on health, as well as other opinion leaders and policy makers, are unaware of the truth.

Retailers' knowledge of tobacco harm reduction following the introduction of a new brand of smokeless tobacco

BACKGROUND

Tobacco retailers are potential public health partners for tobacco harm reduction (THR). THR is the substitution of highly reduced-risk nicotine products, such as smokeless tobacco (ST) or pharmaceutical nicotine, for cigarettes. The introduction of a Swedish-style ST product, du Maurier snus (dMS) (Imperial Tobacco Canada Limited), which was marketed as a THR product, provided a unique opportunity to assess retailers' knowledge. This study examined retailers' knowledge of THR and compliance with recommendations regarding tobacco sales to young adults.

METHODS

Male researchers, who may have looked younger than 18 years old, visited 60 stores in Edmonton that sold dMS. The researchers asked the retailers questions about dMS and its health risks relative to those from other tobacco products. They also attempted to purchase dMS to ascertain whether retailers would ask for identification to verify that they were at least 18 years old.

RESULTS

Overall, the retailers were only moderately knowledgeable about THR and the differences between dMS and other tobacco products. About half of the retailers correctly indicated that snus is safer than cigarettes; half of whom knew it is safer because it is smoke-free. Fifty percent incorrectly believed that snus causes oral cancer. Less than fifty percent indicated that dMS differs from chewing tobacco because it is in pouches and is used without spitting or chewing (making it more promising for THR). Most (90%) of the retailers asked the researchers for identification when selling dMS.

CONCLUSION

Tobacco retailers are potentially important sources of information about THR, particularly since there are restrictions on the promotion of all tobacco products (regardless of the actual health risks) in Canada. This study found that many retailers in Edmonton do not know the relative health risks of different tobacco products and are therefore unable to pass on accurate information to smokers.

Survey of smokers' reasons for not switching to safer sources of nicotine and their willingness to do so in the future

Despite the well-known risks of smoking, policy, social pressure, and accessible cessation programs, tens of millions of North American adults continue smoking rather than quitting or switching to less harmful non-combustion nicotine products. We surveyed people smoking in public in Edmonton, Canada (n = 242, year = 2007) to investigate smokers' reasons for resisting switching to low-risk nicotine sources. 43% had used low-risk products (mostly pharmaceutical nicotine). 75% indicated willingness to consider switching to low-risk products. Smokers cited similar reasons for not switching to smokeless tobacco and pharmaceutical nicotine, largely based on misinformation. Accurate risk information may lead many to try low-risk nicotine products.

Chemical and toxicological characterization of commercial smokeless tobacco products available on the Canadian market

Some health experts are recommending that smokers who refuse to quit or refuse to use nicotine replacement therapy (NRT) such as nicotine-containing chewing gum switch to certain types of smokeless tobacco products (STP) such as Swedish snus. Other health experts disagree citing the uncertainty in the composition of commercially available STP, the lack of governmental regulations to ensure that STP advertised to meet certain standards (i.e., GothiaTek) do actually meet such standards, and the uncertainty that any STP can provide as safe as alternative to smoking as NRT. One reason for uncertainty is the dearth of detailed chemical and toxicological information on contemporary STP. Unlike the situation with cigarettes, there are few standardized methods for analytical and toxicological studies of STP. Consequently, the objective for this work was to characterize several types of STP available on the Canadian market using the modifications of the Official Health Canada chemical and toxicological methods developed for cigarettes. Moist snuff samples tested had TSNA and B[a]P levels somewhat above the GothiaTek standard while samples of Swedish snus, low-moisture snuff, and US-style chewing tobacco did not. Use of in vitro assays to assess STP toxicity was of limited utility in distinguishing product types.

Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey

BACKGROUND

Although smokeless tobacco (ST) use has played a major role in the low smoking prevalence among Swedish men, there is little information at the population level about ST as a smoking cessation aid in the U.S.

METHODS

We used the 2000 National Health Interview Survey to derive population estimates for the number of smokers who had tried twelve methods in their most recent quit attempt, and for the numbers and proportions who were former or current smokers at the time of the survey.

RESULTS

An estimated 359,000 men switched to smokeless tobacco in their most recent quit attempt. This method had the highest proportion of successes among those attempting it (73%), representing 261,000 successful quitters (switchers). In comparison, the nicotine patch was used by an estimated 2.9 million men in their most recent quit attempt, and almost one million (35%) were former smokers at the time of the survey. Of the 964,000 men using nicotine gum, about 323,000 (34%) became former smokers. Of the 98,000 men who used the nicotine inhaler, 27,000 quit successfully (28%). None of the estimated 14,000 men who tried the nicotine nasal spray became former smokers. Forty-two percent of switchers also reported quitting smoking all at once, which was higher than among former smokers who used medications (8-19%). Although 40% of switchers quit smoking less than 5 years before the survey, 21% quit over 20 years earlier. Forty-six percent of switchers were current ST users at the time of the survey.

CONCLUSION

Switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. The results of this study show that tobacco harm reduction is a viable cessation option for American smokers.

Should Australia lift its ban on low nitrosamine smokeless tobacco products?

In Australia, 2.9 million people continue to smoke daily, and tobacco still accounts for 8% of disease burden. Tobacco harm-reduction strategies, such as the use of Swedish snus, have been suggested as a way to further reduce this disease burden. In Australia, the most dangerous tobacco products (cigarettes) are the least regulated, while oral tobacco products, including snus, cannot be sold legally. Recent epidemiological modelling indicates that there are only small differences in life expectancy between smokers who quit and those who switch to snus. There is a case on public health and ethical grounds for allowing inveterate smokers who want to reduce their health risks to access snus. At a minimum, the recent increase in tax on smokeless tobacco should be reversed, and the ban on the commercial importation and supply of low nitrosamine smokeless tobacco should be reconsidered in light of the epidemiological evidence on its potential to reduce tobacco-related disease in smokers.

Effect of smokeless tobacco product marketing and use on population harm from tobacco use policy perspective for tobacco-risk reduction

This article presents policy perspectives on the marketing of smokeless tobacco products to reduce population harm from tobacco use. Despite consensus that smokeless tobacco products as sold in the United States are less dangerous than cigarettes, there is no consensus on how to proceed. Diverse factions have different policy concerns. While the tobacco industry is exempted from U.S. Food and Drug Administration (FDA) oversight, the pharmaceutical industry whose nicotine replacement therapy (NRT) medicines compete with smokeless tobacco as noncombustible nicotine-delivery systems are regulated by the FDA. Some public health experts support smokeless tobacco use to reduce population harm from tobacco; other public health experts oppose promoting smokeless tobacco for harm reduction. Adult consumers can freely purchase currently-marketed smokeless tobacco products and even more-deadly cigarettes. Concerns with and advantages of smokeless tobacco products are discussed. In that noncombustible medicinal nicotine-delivery systems have been proven to be effective smoking-cessation aids, smokeless tobacco, as another source of psychoactive doses of nicotine, could be used similarly, in a dose-response fashion as a smoking-cessation aid (consistent with FDA principles for evaluating generic versions of drugs). Price measures should be used on tobacco products to make costs to consumers proportional to product health risks (which would make smokeless tobacco much cheaper than cigarettes), and smokeless tobacco should be encouraged as an option for smoking cessation in adult smokers, particularly for those who have failed to stop smoking using NRT or other methods.

Introducing oral tobacco for tobacco harm reduction: what are the main obstacles?

With the number of smokers worldwide currently on the rise, the regular failure of smokers to give up their tobacco addiction, the direct role of smoke (and, to a much lesser extent, nicotine) in most tobacco-related diseases, and the availability of less toxic (but still addictive) oral tobacco products, the use of oral tobacco in lieu of smoking for tobacco harm reduction (HR) merits assessment.

Instead of focusing on the activity itself, HR focuses on the risks related to the activity. Currently, tobacco HR is controversial, generally not discussed, and consequently, poorly evaluated.

In this paper, we try to pinpoint some of the main reasons for this lack of interest or reluctance to carry out or fund this type of research. In this paper we deal with the following issues: the status of nicotine in society, the reluctance of the mainstream anti-tobacco lobby toward the HR approach, the absence of smokers from the debate, the lack of information disseminated to the general population and politicians, the need to protect young people, the role of physicians, the future of HR research, and the role of tobacco companies.

Warning: Anti-tobacco activism may be hazardous to epidemiologic science

This commentary accompanies two articles submitted to Epidemiologic Perspectives & Innovations in response to a call for papers about threats to epidemiology or epidemiologists from organized political interests. Contrary to our expectations, we received no submissions that described threats from industry or government; all were about threats from anti-tobacco activists. The two we published, by James E. Enstrom and Michael Siegel, both deal with the issue of environmental tobacco smoke. This commentary adds a third story of attacks on legitimate science by anti-tobacco activists, the author's own experience. These stories suggest a willingness of influential anti-tobacco activists, including academics, to hurt legitimate scientists and turn epidemiology into junk science in order to further their agendas. The willingness of epidemiologists to embrace such anti-scientific influences bodes ill for the field's reputation as a legitimate science.

Should the health community promote smokeless tobacco (snus) as a harm reduction measure?

The tobacco control community is divided on whether or not to inform the public that using oral, smokeless tobacco (Swedish snus) is less hazardous to health than smoking tobacco. Proponents of "harm reduction" point to the Swedish experience. Snus seems to be widely used as an alternative to cigarettes in Sweden, say these proponents, contributing to the low overall prevalence of smoking and smoking-related disease. Harm reduction proponents thus argue that the health community should actively inform inveterate cigarette smokers of the benefits of switching to snus. However, critics of harm reduction say that snus has its own risks, that no form of tobacco should ever be promoted, and that Sweden's experience is likely to be specific to that culture and not transferable to other settings. Critics also remain deeply suspicious that the tobacco industry will use snus marketing as a "gateway" to promote cigarettes. In the interests of promoting debate, the authors (who are collaborators on a research project on the future of tobacco control) have agreed to outline the strongest arguments for and against promoting Swedish snus as a form of harm reduction.

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.

Deconstructing anti-harm-reduction metaphors; mortality risk from falls and other traumatic injuries compared to smokeless tobacco use

Anti-harm-reduction advocates sometimes resort to pseudo-analogies to ridicule harm reduction. Those opposed to the use of smokeless tobacco as an alternative to smoking sometimes suggest that the substitution would be like jumping from a 3 story building rather than 10 story, or like shooting yourself in the foot rather than the head. These metaphors are grossly inappropriate for several reasons, notably including the fact that they are misleading about the actual risk levels. Based on the available literature on mortality from falls, we estimate that smoking presents a mortality risk similar to a fall of about 4 stories, while mortality risk from smokeless tobacco is no worse than that from an almost certainly non-fatal fall from less than 2 stories. Other metaphors are similarly misleading. These metaphors, like other false and misleading anti-harm-reduction statements are inherently unethical attempts to prevent people from learning accurate health information. Moreover, they implicitly provide bad advice about health behavior priorities and are intended to persuade people to stick with a behavior that is more dangerous than an available alternative. Finally, the metaphors exhibit a flippant tone that seems inappropriate for a serious discussion of health science.