Public health implications of smokeless tobacco use as a harm reduction strategy

Consumption of chewing tobacco alters the serum metal contents in pregnant women at Tandojam and adjoining areas

Chewing tobacco may play a contributing role in complications during pregnancy as it contains various kinds of toxic metals such as lead (Pb), cadmium (Cd), cobalt (Co), manganese (Mn), chromium (Cr), and can cause alteration in serum metal concentration. Hence, the present study aimed to explore the effects of chewing tobacco consumption on serum metal contents in pregnant women. A total number of 200 chewing tobacco consumer pregnant women and 200 age-matched non-consumer pregnant women were selected for the study from the outpatient department of gynaecology at Rural Health Centre Tandojam, Pakistan. After obtaining the sociodemographic characteristics of all participants, 10 ml of venous blood was also drawn for serum metal analysis by atomic absorption spectroscopy. Different chewing tobacco samples consumed by consumer pregnant women were collected from local shops of Tandojam, Pakistan. Drinking water samples from the residential areas of consumer and non-consumer pregnant women were prepared and analysed for the same metal contents. In present study, serum Pb, Cd, K and Co were found significantly increased in CPW as compared to NCPW. Serum Pb was found significantly increased in gutkha consumers in comparison to mainpuri consumers. Serum Pb, Cd, and Co were present with significantly increased concentration in serum of CPW who were taking canal and well water for drinking purpose when compared with NCPW. Significant negative strong correlation of serum Pb with K and Cr of drinking water and Na of chewing tobacco samples were observed. Strong positive correlation of serum Cd and Cr with Co of drinking water had been observed. Whereas, serum maternal Co was strongly negatively correlated with Mn of chewing tobacco samples, and serum Cu of CPW had a strong positive correlation with K and Cr of drinking water and Na of chewing tobacco samples. In conclusion, consumption of chewing tobacco alters the serum metal contents in pregnant women at Tandojam and adjoining areas, Pakistan.

Smokeless and combustible tobacco use among 148,944 South Asian adults: a cross-sectional study of South Asia Biobank

INTRODUCTION

Tobacco use, in both smoking and smokeless forms, is highly prevalent among South Asian adults. The aims of the study were twofold: (1) describe patterns of SLT and combustible tobacco product use in four South Asian countries stratified by country and sex, and (2) assess the relationships between SLT and smoking intensity, smoking quit attempts, and smoking cessation among South Asian men.

METHODS

Data were obtained from South Asia Biobank Study, collected between 2018 and 2022 from 148,944 men and women aged 18 years and above, living in Bangladesh, India, Pakistan, or Sri Lanka. Mixed effects multivariable logistic and linear regression were used to quantify the associations of SLT use with quit attempt, cessation, and intensity.

RESULTS

Among the four South Asian countries, Bangladesh has the highest rates of current smoking (39.9% for male, 0.4% for female) and current SLT use (24.7% for male and 23.4% for female). Among male adults, ever SLT use was associated with a higher odds of smoking cessation in Bangladesh (OR, 2.88; 95% CI, 2.65, 3.13), India (OR, 2.02; 95% CI, 1.63, 2.50), and Sri Lanka (OR, 1.36; 95% CI, 1.14, 1.62). Ever SLT use and current SLT use was associated with lower smoking intensity in all countries.

CONCLUSIONS

In this large population-based study of South Asian adults, rates of smoking and SLT use vary widely by country and gender. Men who use SLT products are more likely to abstain from smoking compared with those who do not.

Determinants of initiation, continuation and cessation of smokeless tobacco use among pregnant and lactating women: a qualitative study from low-income communities in urban India

Smokeless tobacco (SLT) consumption increases the risk of cardiovascular diseases and cancer and leads to adverse reproductive health outcomes among women and newborns. This study examines the factors associated with initiation, continuation and cessation of SLT use among women in the reproductive age so as to formulate and include prevention and cessation interventions from its inception. The study was conducted in urban low-income communities in India. Using snowball and purposive sampling techniques, in-depth interviews were conducted with 20 pregnant and 22 lactating women who currently used SLT products. Data were analysed using thematic analysis with the help of QSR NVivo software. Findings revealed that factors such as people influencing usage change with different life stages including pre-marital and post-marital periods. Perceived health benefits, altered taste preferences during pregnancy and social influences were also studied. Women were found to be more aware of the harmful effects of tobacco during pregnancy than during breastfeeding. Social stigma around women consuming tobacco acted as a major driving factor for cessation. Most of the participants were willing to quit but were not aware of any technique or programme for cessation. The findings of the study highlight the need to develop behavioural change intervention tools, which are culturally and locally appropriate and have a gender-sensitive approach. Different socio-cultural factors associated with initiation/cessation at different life stages should also be taken into consideration while developing these tools.

How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking?

INTRODUCTION

Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common.

METHODS

Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking.

RESULTS

Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT.

CONCLUSIONS

In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation.

IMPLICATIONS

In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.

Use of Traditional Smokeless, Snus, and Dissolvable Tobacco Among U.S. Youth

INTRODUCTION

Snus, dissolvable, and traditional smokeless tobacco product use is often amalgamated in youth epidemiologic research despite differences across these products. Prevalence, trends, and correlates of U.S. youth use across different classes of oral tobacco products are unknown.

METHODS

Using 2011-2020 National Youth Tobacco Survey (N=193,933) data, the authors tested for cross-year linear and quadratic trends in the weighted prevalence of ever and current use of traditional smokeless tobacco, snus, and dissolvable tobacco. Multivariable logistic regressions estimated the demographic and tobacco use factors associated with the use of different oral tobacco products in 2020. Analyses were conducted in 2022.

RESULTS

During 2011-2020, there were declines in the prevalence of ever use of traditional smokeless tobacco (11.0% to 5.6%; linear trend, p<0.0001) and snus (5.2% to 2.4%; p<0.0001) but no change in ever dissolvable tobacco use (0.8%-1.2%). In 2020, an estimated 1,546,000 U.S. youth ever used traditional smokeless tobacco (7.7% high school, 3.0% middle school), 662,000 ever used snus (high school: 3.5%, middle school: 1.0%), and 326,000 ever used dissolvables (high school: 1.5%, middle school: 0.8%). In 2020, females and non-Hispanic Blacks and Hispanics had lower smokeless or snus ever use odds than males and non-Hispanic Whites, respectively, whereas sexual minorities (than heterosexuals) or those speaking a language other than English at home were more likely to report ever use of dissolvable tobacco. Flavored tobacco use was common, particularly for dissolvable current users (72.8% used any flavor).

CONCLUSIONS

Differences in the epidemiology of oral tobacco use across product types among U.S. youth suggest that oral tobacco products should be disaggregated in future research and policy strategies.

Common assumptions in tobacco control that may not hold true for South-East Asia

Tobacco is a threat to public health in South-East Asia and its control should be a priority. However, many common assumptions about tobacco control may not hold true for the region and can misdirect policy. The substantial health risks associated with smokeless tobacco have been largely misunderstood and neglected. The syndemic association between tuberculosis and tobacco has also been overlooked. Similarly, less attention has been paid to address second-hand smoke exposure of pregnant women to indoor smoking (caused predominantly by men). On the other hand, our poor understanding of the diverse tobacco supply chain has been blocking progress in tobacco control. Finally, the rising popularity of electronic cigarettes has thrown new challenges; many governments, concerned for its youth, have banned such products. We argue for a nuanced approach to tobacco control in South-East Asia. We also encourage a wider debate in public health, where other established assumptions may be hampering progress.

Smokeless tobacco industry's brand stretching through FM radio: A study from Delhi National Capital Region, India

Smokeless tobacco (SLT) consumption is associated with multiple adverse health effects and mortality, with the highest burden in India. The WHO FCTC has banned tobacco advertisement, promotion and sponsorship via Article 13. Indian laws also prohibit any kind of direct or indirect advertisements in all forms of audio, visual, and print media; brand promotion; and sponsorship of tobacco products. However, the tobacco industry continues to find aggressive marketing ways to advertise their products. This study aims to assess the extent of surrogate advertisement of smokeless tobacco products through frequency modulation (FM) radio stations in the city of Delhi (National Capital Territory of India). In this study, the advertisements broadcasted over FM radio across different channels (private and government owned) in total 162 h were analyzed. The time duration was spread evenly over morning peak hours, off hours, and evening peak hours. It was found that multiple brands including Vimal, Kamla Pasand, and Rajshree have used surrogate advertising to market their brands that are commonly associated with smokeless tobacco products. However, no such advertisement was found to be aired on government-owned FM channels. The total surrogate advertisements broadcasted were over 286 times, where no significant difference was found in distribution among peak and non-peak hours. The study indicated that the tobacco industry is making its way to sell the products through indirect advertisements. The need of the hour is to not only enforce tobacco advertising ban laws in all forms of advertising media but also to strictly regulate smokeless tobacco products.

The effect of emerging tobacco related products and their toxic constituents on thrombosis

Although conventional cigarette smoking is declining, emerging tobacco related products (ETRPs) are currently gaining ground, especially among the youth. These products include electronic cigarettes, waterpipes/hookah, cigars/cigarillo, smokeless tobacco, and heat-not-burn cigarettes. The observed increase in the use of ETRPs is multifactorial and complex but appears to be mainly driven by efforts from the major tobacco companies to reinvent themselves, and present more appealing and allegedly safe(r) tobacco products. However, it is becoming apparent that these products produce substantial amounts of toxic chemicals, many of which have been shown to exert negative health effects, including in the context of the cardiovascular system. Thus, there has been research efforts, albeit limited in general, to characterize the health impact of these products on occlusive/thrombotic cardiovascular diseases (CVD). In this review, we will discuss the potential impact of ETRPs on thrombosis-based CVD. Specifically, we will review how these products and the major chemicals they produce and/or emit can trigger key players in the process of thrombosis, namely inflammation, oxidative stress, platelets, coagulation, and the vascular endothelium, and the relationship between these effects.

Modern lifestyle risks associated with alcohol consumption and cigarette smoking in Ukraine

Background

Substance uses confer huge risks for public health in modern society. This study aimed to evaluate current factors related to alcohol drinking and tobacco smoking in the republic of Ukraine.

Methods

We distributed a questionnaire to healthy volunteers in four Ukrainian regions and collected 929 responses regarding demographic information, reasons for starting substance use, substance use family history, environmental factors, use pattern (internet, drinking or smoking), consequences of drinking, and insomnia. Linear regression and logistic regression analyses were performed to identify factors related to alcohol drinking and cigarette smoking.

Results

Aging appeared to attenuate either drinking or smoking. To reduce school- or job-related stress, staying awake, peer pressure, friend-related issues, or to increase sexual desire and single parenting all would trigger drinking; male gender, family divorce, unhealthy diet and lack of awareness about harmful consequences were the main factors leading to smoking. Logistic regression suggested that education background, sleep problems, celebration events and lengthy internet work all could contribute to drinking.

Conclusions

Various real-world factors related to substance uses were identified for the public of Ukraine. A validated instrument would help to identify risk factors in patients with substance use disorders.

Aqueous extract of tobacco induces mitochondrial potential dependent cell death and epithelial-mesenchymal transition in gingival epithelial cells

Smokeless tobacco habits are detrimental to oral health. A correlation between tobacco use and local epithelial tissue damage exists. Yet, the underlying cellular mechanism is not precisely characterized. This study assessed the dose-dependent action of Smokeless tobacco extract on gingival epithelial cells. Gingival tissue was taken from 5 healthy donors. Gingival epithelial cells were isolated by an enzymatic method and cultured up to passage 2. The cultured cells were treated with smokeless tobacco extract at 10%, 25%, 50%, and 75% volume concentration. After 48 h of incubation, MTT assay, Annexin V/PI assay, and DiIC1(5) assay were used to evaluate viability, apoptosis, and mitochondrial potential of the cells. RT-qPCR was used to determine the expression of BAX, BCL2, ECAD, NCAD, and TWIST. The Smokeless tobacco extract reduced cell viability by disrupting the mitochondrial potential and inducing apoptosis. Further, the Smokeless tobacco extract induced a dose-dependent epithelial-mesenchymal-transition in gingival epithelial cells. Apoptotic cellular death caused by tobacco extract on the gingival epithelial system was dependant on the mitochondrial potential of the cell. The results demonstrate that smokeless tobacco causes detrimental metabolic alterations of the periodontium.

Featured application

This study elucidates the mechanism by which Smokeless tobacco products cause cellular damage to the gingival epithelium. The use of Smokeless tobacco products can lead to major cellular and surface changes in the gingiva and its appearance. The consequences of these changes are not limited to oral cancer but also increases a person's risk for dental and periodontal disease.

White paper on smokeless tobacco & women's health in India

Smokeless tobacco (SLT) use is widespread across many nations and populations, and India shares more than three-quarters of the global burden of SLT consumption. Tobacco use in India has been largely viewed as a male-dominant behaviour. However, evidence from medical, social and behavioural sciences show significant SLT use among women and young girls. This paper highlights key dimensions of SLT use among women in India including prevalence and determinants, the health effects arising from SLT use and cessation behaviours. The paper concludes by providing recommendations with the aim of setting research priorities and policy agenda to achieve a tobacco-free society. The focus on women and girls is essential to achieve the national targets for tobacco control under the National Health Policy, 2017, and Sustainable Development Goals 3 of ensuring healthy lives and promote well-being for all.

Betel Quid Addiction: A Review of Its Addiction Mechanisms and Pharmacological Management as an Emerging Modality for Habit Cessation

Areca-nut (AN) and added smokeless-tobacco (SLT) are considered agents that may cause addiction to betel-quid (BQ). However, the primary addictive substance in AN is not clearly understood. Objective: The present review evaluates possible addictive chemicals in AN with their mechanisms of action for progression to BQ dependence, as it is essential to overcome barriers in BQ cessation. It also identifies innovative treatment modalities in BQ cessation including the scope for research on pharmacotherapy using Monoamine-oxidase Inhibitors, Selective Serotonin Re-uptake Inhibitors and Norepinephrine Dopamine Reuptake Inhibitors. Methods: This is a narrative review on addictive properties of BQ and trials undertaken to promote cessation of SLT or AN use. Results: Twenty interventional studies, three by behavioral therapy and seventeen using pharmacotherapy were reviewed. There was heterogeneity in reported follow up times, most studies reporting data at 12 weeks with abstinence rates of 45-55% for SLT cessation and at 8 weeks with abstinence rates around 35% for AN cessation. Conclusion: Even though literature reveals a few cessation programs through behavioral support for BQ addiction, its success has been limited in certain instances mainly due to addictive properties of AN, resulting in withdrawal and relapse. Hence, in line with pharmacotherapy in tobacco smoking cessation, potential pharmacological agents to assist in cessation of SLT and AN require more attention. Several clinical trials for SLT cessation have been carried out with varying levels of success using Nicotine Replacement Therapy and Varenicline while trials on antidepressants for SLT and AN cessation are also emerging.

The greater use of flavoured snus among ever-smokers versus never-smokers in Norway

Background

Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status.

Methods

Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked “Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model.

Results

Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44–.46), highest among daily (.51, 95% CI .47–.54) and former daily smokers (.50, 95% CI .48–.52), and lowest among never (.41, 95% CI .39–.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38–.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65–.69) compared to males (p = .35, 95% CI .34–.36), highest among the youngest age group, 15–24 years (p = .58, 95% CI .56–.60) and decreased with increasing age.

Conclusion

Regulation that would ban or limit flavoured snus use may affect smokers—an at risk population—more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.

Practitioners' Views on Nicotine Replacement Therapy in Pregnancy during Lapse and for Harm Reduction: A Qualitative Study

Many countries, including the UK, recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy. However, adherence to NRT is generally low, smoking lapse or relapse is common and using NRT to reduce the harm from the number of cigarettes smoked is only advocated in non-pregnant smokers. Two focus groups were conducted with 13 professionals involved in antenatal stop smoking services (SSS). The data were analysed thematically. Two themes were extracted that describe health professionals' attitudes towards using NRT either during lapses or to reduce smoking in women who cannot quit (harm reduction). These are presented around a social-ecological framework describing three hierarchical levels of influence within smoking cessation support: (1) Organizational: providing NRT during lapses could be expensive for SSS though harm reduction could result in services helping a wider range of clients. (2) Interpersonal: participants felt using NRT for harm reduction was not compatible with cessation-orientated messages practitioners conveyed to clients. (3) Individual: practitioners' advice regarding using NRT during smoking lapses varied; many were generally uncomfortable about concurrent smoking and NRT use and had strong reservations about recommending NRT when smoking during all but the briefest lapses. Further evidence is required to guide policy and practice.

A review of the effects of tobacco smoking on cancer treatment: smoking cessation intervention should be integrated into the cancer care continuum

Background:

The adverse health effects associated with smoking tobacco have been well investigated, and its detrimental effects on cancer treatment outcomes, efficacy and quality of life (QOL) for cancer patients have also been well documented. Tobacco smoke contains many thousands of chemicals, including a plethora of carcinogens, and the exposure of human cells to these carcinogens, and their metabolic activation, is the main mechanism by which smoking-related cancer is initiated.

Materials and Methods:

This paper reports on a narrative review of recent studies in the field of effects of tobacco smoking on cancer treatment, including the effects of carcinogens in smoke on carcinogenesis, cell mutations and the immune system. The health effects of smokeless tobacco, effects of tobacco smoking on cancer treatment, and its impact on surgery, radiation therapy and chemotherapy are reported. The potential risks of second primary cancers or recurrence from tobacco use, the effects of second-hand smoking and cancer treatment, the impact of smoking on the QOL after cancer treatment and the need to integrate smoking cessation programs into the cancer care continuum are also reported.

Conclusions:

Tobacco use has a direct impact on cellular function by inhibiting apoptosis, stimulating proliferation and decreasing the efficacy of cancer treatment; therefore, quitting its use has the potential to improve treatment response rates and survival, as well as reduces the risk of developing second cancers and potentially improves the QOL after treatment. Smoking cessation is one of the most important interventions to prevent cancer and is also essential after the diagnosis of cancer to improve clinical outcomes. Due to the numerous benefits of smoking cessation, it should become a critical component of the cancer care continuum in all oncology programs – from prevention of cancer through diagnosis, treatment, survivorship and palliative care. Evidence-based smoking cessation intervention should be sustainably integrated into any comprehensive cancer program, and the information should be targeted to the specific benefits of cessation in cancer patients.

Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society-An Observational Study over a 16 Year Period

Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003⁻2018), 13,381 respondents (aged 16⁻79 years) answered questions about risk perceptions in Statistics Norway's nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: "We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful". Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14⁻79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement

RATIONALE

The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency.

METHODS

Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public.

RESULTS

Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction.

DISCUSSION

This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

Trends in point-of-sale tobacco marketing around college campuses: Opportunities for enhanced tobacco control efforts

OBJECTIVE

Colleges have implemented policies to limit tobacco use on-campus; however, the off-campus environment is often overlooked in tobacco control efforts. We assessed availability, marketing, and promotion of cigarettes, snus, and traditional smokeless tobacco (SLT) in a sample of communities surrounding 11 college campuses in North Carolina and Virginia.

PARTICIPANTS

Between January-March of 2011, 2012 and 2013, 481 tobacco-selling retailers, including convenience stores, pharmacies and supermarkets, located near campuses were assessed.

METHODS

Trained observers completed annual point-of-sale assessments.

RESULTS

The percentage of stores selling (81.4% to 58.6%; p < .0001) and advertising snus (80.1% to 53.11%; p < .0001) significantly decreased over time. Convenience stores increased promotions of cigarettes (65.4% to 72.8%; p = 0.04) and SLT (3.1% to 23.3%; p = 0.02).

CONCLUSIONS

Off-campus environments have abundant tobacco availability and marketing. Colleges should collaborate with state and local tobacco control advocates to address tobacco promotion near campuses to potentially decrease product appeal and access among young adults.

Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015

INTRODUCTION

Changes to the U.S. smokeless tobacco landscape in recent years include a change to health warnings on packages, the implementation of bans in some stadiums, and the launch of a federal youth prevention campaign. It is unclear whether such changes have impacted consumer beliefs about smokeless tobacco. This study examines relative harm perceptions of smokeless tobacco compared to cigarettes among adults and assesses changes in smokeless tobacco harm perceptions over time.

METHODS

We analyzed data from three cycles (2012, 2014, 2015) of the Health Information National Trends Survey (HINTS). Using 2015 data, we assessed bivariate associations between smokeless tobacco harm perceptions and tobacco use, beliefs, information seeking, and demographics. Using 2012, 2014, and 2015 data, we assessed whether smokeless tobacco harm perceptions changed over time within demographic groups using chi-square tests. We then used a weighted multinomial logistic regression to assess the association between smokeless tobacco perceptions and survey year, adjusting for covariates.

RESULTS

When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of respondents across cycles said "no." The percent of respondents who selected this response option decreased over time. Findings showed significant differences in relative harm perceptions of smokeless tobacco versus cigarettes for specific demographic subgroups. Among subgroups, these shifts did not occur with a discernible pattern.

CONCLUSIONS

Understanding factors associated with perceptions of smokeless tobacco can inform tobacco control efforts. Additional monitoring of these trends may provide researchers with a deeper understanding of how and why smokeless tobacco harm perceptions change.

Shammah (Smokeless Tobacco) and Public Health

Shammah is a preparation of smokeless tobacco (ST) that is frequently used in the Arabian Peninsula, especially in Saudi Arabia. A mixture of powdered tobacco, lime, ash, black pepper, oils and flavorings, shammah in is placed in the buccal cavity or lower labial vestibule of the mouth. The user (or dipper) spits out insoluble debris. ST is linked to a number of harmful effects such as dental disease, oral cancer, oesophagus cancer, and pancreas cancer. It also causes adverse reproductive effects including stillbirth, premature birth and low birth weight. The importation of ST products is prohibited in Saudi Arabia. Legislative action to combat the use of ST (moist snuff and chewing tobacco) in Saudi Arabia appeared in 1990. The actual percentage use may be higher than reported since shammah is illegal in Saudi Arabia and there may be some unwillingness to admit to its use. Data on ST use in the Arabian Peninsula are sparse. Most studies conducted there focused on the prevalence of shammah use among adolescents rather than among adults. This review paper aimed to understand the pattern of use of shammah and its adverse health effects. It also aimed to provide suitable epidemiological data for public health policy makers.

Do never smokers make up an increasing share of snus users as cigarette smoking declines? Changes in smoking status among male snus users in Norway 2003-15

AIMS

To examine how the relative size of six groups of male ever snus users (current and former users of snus who were current, former or never cigarette smokers) varied over time in Norway, and how these groups differ with regard to important measures of tobacco behaviour.

DESIGN

Repeated cross-sectional nationally representative surveys of tobacco use. The association between survey year and the six categories of ever snus use was examined using cross-tabulation and multinomial logistic regression. Differences in tobacco behaviour across snus use categories were examined using logistic and ordinary least squares (OLS) regression.

SETTING

Norway, 2003-15.

PARTICIPANTS

A total of 2067 males aged 15-79 years.

MEASUREMENTS

The categories of ever snus use represented all six combinations of cigarette smoking (current, former or never) among current and former users of snus. The variables measuring tobacco behaviour were: order of product uptake (snus or cigarettes first), mean cigarette consumption, reduction from daily to occasional smoking, intention to quit cigarettes, future smoking identity and use of snus in latest quit attempt.

FINDINGS

During the period 2003-15, the relative share of current snus users who had never smoked, and current snus users who were former smokers, increased. The share of dual users, and smokers who were former snus users, decreased. Among men who reported life-time experience with both products, a large majority had initiated their tobacco use with cigarettes. The average number of cigarettes smoked weekly was lower among dual users compared with current smokers who were former snus users or had never used snus.

CONCLUSIONS

During the period 2003-15 in Norway, which has a mature snus market, even though smoking has declined and the relative size of the category of never-smokers among male users of snus has increased, the majority of snus users are still former or current smokers.

High levels of tobacco-specific N-nitrosamines and nicotine in Chaini Khaini, a product marketed as snus

INTRODUCTION

Recently, a tobacco product, Chaini Khaini, identified as snus appeared in India. The product marketing emphasises its discreet nature and explicitly claims safety by referring to the existing evidence on Swedish snus. We analysed tobacco-specific nitrosamines and nicotine in 12 samples of Chaini Khaini purchased in 2013 at open markets in India.

METHODS

Samples were purchased twice: in March 2013 from Mumbai and in November 2013 from Mumbai and Ahmedabad. Chemical constituents were measured by our routine validated methods.

RESULTS

Levels of carcinogenic nitrosamines NNN, NNK and NNAL averaged 22.9 (±4.9), 2.6 (±1.0) and 3.1 (±1.5) µg/g tobacco (wet weight), respectively. The levels of NAB, which is normally present in trace levels in tobacco products, ranged from 3.9 to 12.9 µg/g tobacco. Total nicotine levels in all samples averaged 10.0 mg/g tobacco and unprotonated nicotine accounted for an average 95.4% of the total nicotine content.

CONCLUSIONS

Chaini Khaini, which is labelled as snus and is marketed as a safe alternative to other tobacco products contains very high levels of carcinogenic nitrosamines and biologically available nicotine. Interventions are urgently needed to educate current and potential consumers of this product.

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.

Validation of a Measure of Normative Beliefs About Smokeless Tobacco Use

INTRODUCTION

Validated methods to evaluate consumer responses to modified risk tobacco products (MRTPs) are needed. Guided by existing literature that demonstrates a relationship between normative beliefs and future intentions to use tobacco the current research sought to (1) develop a measure of normative beliefs about smokeless tobacco (ST) and establish the underlying factor structure, (2) evaluate the structure with confirmatory factor analysis utilizing an independent sample of youth, and (3) establish the measure's concurrent validity.

METHODS

Respondents (smokers and nonsmokers aged 15-65; N = 2991) completed a web-based survey that included demographic characteristics, tobacco use history and dependence, and a measure of attitudes about ST adapted from the Normative Beliefs about Smoking scale. A second sample of youth (aged 14-17; N = 305) completed a similar questionnaire.

RESULTS

Exploratory factor analysis produced the anticipated three-factor solution and accounted for nearly three-quarters of the variance in the data reflecting (1) perceived prevalence of ST use, (2) popularity of ST among successful/elite, and (3) approval of ST use by parents/peers. Confirmatory factor analysis with data from the youth sample demonstrated good model fit. Logistic regression demonstrated that the scales effectively discriminate between ST users and nonusers and are associated with interest in trying snus.

CONCLUSIONS

Assessment of MRTPs for regulatory purposes, which allows messages of reduced risk, should include measurement of social norms. Furthermore, surveillance efforts that track use of new MRTPs should include measures of social norms to determine how norms change with prevalence of use.

Risk perceptions of smokeless tobacco among adolescent and adult users and nonusers

The recent growth in smokeless tobacco (ST) consumption has raised questions about consumer risk perceptions of ST products, especially in high-risk vulnerable populations. This qualitative study examined risk perceptions of ST among adolescent and adult users and nonusers in Ohio Appalachia. Focus groups and interviews were held with adolescents (n = 53; M age = 17 years) and adults (n = 63; M age = 34 years) from four Ohio Appalachian counties. Participants were asked about their perceptions of ST-related health risks, ST safety, and the relative safety of ST compared with cigarettes. Transcriptions were coded independently by two individuals. Overall, participants were knowledgeable about health problems from ST use (e.g., oral cancers, periodontal disease). Nearly all participants stated that ST use is not safe; however, there was disagreement about its relative safety. Some perceived all tobacco products as equally harmful; others believed that ST is safer than cigarettes for either the user or those around the user. Disagreements about ST relative safety may reflect mixed public health messages concerning the safety of ST. Comprehensive consumer messages about the relative safety of ST compared with cigarettes are needed. Messages should address the effect of ST on the health of the user as well as those exposed to the user.

Involvement of the Heme Oxygenase System in the Development of Preeclampsia and as a Possible Therapeutic Target

The enzyme heme oxygenase (HO) is an important regulatory molecule present in most nucleated mammalian cells which functions to break down the pro-oxidant molecule heme into three products, carbon monoxide (CO), biliverdin and free iron. The HO system has been associated with many physiologic functions, including vascular tone, regulation of inflammation and apoptosis, angiogenesis and antioxidant capabilities. Deficiencies in HO are associated with several pregnancy disorders, including preeclampsia. With no present cure, this disorder continues to affect 5–7% of all pregnancies worldwide, leading to maternal and fetal morbidity and mortality. Researchers continue to strive for therapeutic potentials and this review will outline the possible use of the HO/CO system as a target treatment/prevention of preeclampsia in the future.

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.

Monitoring tobacco-specific N-nitrosamines and nicotine in novel smokeless tobacco products: findings from round II of the new product watch

INTRODUCTION

Analysis of novel smokeless tobacco products purchased in Round I of the New Product Watch (NPW)-a national tobacco monitoring network-demonstrated that some tobacco constituents vary not only across various brands but also regionally and over time within the same product. In this study, we analyzed snus and dissolvable tobacco products that were purchased in Round II of the NPW.

METHODS

We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in snus and dissolvable tobacco products that were purchased in various regions of the country during the spring and summer of 2011. The results were compared against the Round I data, across different U.S. regions, and among products.

RESULTS

A total of 216 samples were received from different states representing 6 regions of the country. Compared with the previous analyses, TSNA levels increased significantly in Marlboro and Camel Snus and some dissolvable Camel products. The levels of unprotonated nicotine in Marlboro Snus and Camel Snus in this study were not different from Round I but varied significantly by regions; the differences between the highest and the lowest average regional levels were ~3.2-fold in Marlboro Snus ~1.7-fold in Camel Snus.

CONCLUSIONS

Our results indicate that some novel smokeless tobacco products contain TSNA at the levels found in the conventional moist snuff. Observation of regional variations in unprotonated nicotine content in both Round I and Round II of NPW suggest that manufacturers may tailor the levels of this constituent consistently to different regions.

Snus use and rejection in the USA

OBJECTIVE

To determine whether snus might become a strategy for reducing the harm associated with cigarette smoking in the USA as appears to be the case in Sweden, we examined receptivity to snus use in two cities with the greatest exposure to the major brands.

METHODS

A dual frame, telephone survey and a brief mail survey were conducted in 2011 and 2012 in Indianapolis, Indiana and Dallas/Fort Worth Texas. Over 5000 adults completed surveys. Trial, ever use, current use and reasons for using or quitting snus after trial were measured.

RESULTS

Among male smokers, 29.9% had ever tried snus (CI 22.7 to 38.1) and 4.2% were current users (CI 1.6 to 10.7). Among female smokers, 8.5% ever tried snus (CI 4.4 to 15.7) and current use was unknown. Current use was virtually absent among former smokers and never smokers. A major predictor of any level of snus use was current use of conventional smokeless tobacco. Those who tried and gave up snus cited curiosity (41.3%) and the fact that it was available at low or no cost (30%) as reasons for trial; reasons for not continuing included preferring another form of tobacco (75.1%) and disliking the mouth feel (34.6%). Almost all current snus users indicated that they were trying to cut down on cigarettes, but few (3.9%) were using it to quit smoking entirely.

CONCLUSIONS

The low rate of adoption of snus suggests that neither the hopes nor the fears surrounding this new product are likely to be realised in the USA with the current marketing patterns.

Association of smokeless tobacco use and smoking in adolescents in the United States: an analysis of data from the Youth Risk Behavior Surveillance System survey, 2011

BACKGROUND

Using smokeless tobacco and smoking are behaviors that increase the risk of developing oral cancer, soft-tissue lesions, caries, periodontal disease and other oral conditions. The author conducted a study to examine use of smokeless tobacco and smoking by adolescents.

METHODS

The study was a cross-sectional analysis of participants with complete data regarding smoking, smokeless tobacco use and other variables of interest from the 2011 national Youth Risk Behavior Surveillance System survey (n = 9,655). The author performed descriptive analysis and multivariable logistic regression analyses.

RESULTS

The unadjusted odds ratio for smokeless tobacco use and smoking was 9.68 (95 percent confidence interval [CI], 7.72-12.13; P < .0001), and the adjusted odds ratio was 3.92 (95 percent CI, 2.89-5.31; P < .0001). Adolescents who used smokeless tobacco were more likely to be male, to smoke and to have engaged in binge drinking.

CONCLUSION

Adolescents who were using smokeless tobacco were more likely to be engaging in concomitant smoking and to be participating in other risk-taking behaviors. Practical Implications. Dentists are involved in helping patients with tobacco-use cessation. The association of smoking with using smokeless tobacco needs to be considered in the design of tobacco-use cessation programs for adolescents.

Tobacco and areca nut chewing--reproductive impairments: an overview

A large number of people are using smokeless tobacco and areca nut worldwide. Sufficient data on tobacco smoking have harmful effect on human health and reproduction is available. However, data on the smokeless tobacco and areca nut use on human reproduction is scanty. This overview is an attempt to compose on the consumption of smokeless tobacco and areca nut on human reproduction and some relevant experimental data were also included. The existing studies suggest that tobacco and areca nut chewing alone, together or with other ingredients had reproductive toxic potential. Pregnant women using smokeless tobacco during pregnancy also had adverse effect on pregnancy and its outcome. Thus pregnant women must avoid consumption of any mixture containing areca nut and tobacco in order to protect the pregnancy and outcome. The data suggest that smokeless tobacco use is also harmful as smoking for reproduction and use of areca nut might have further compounded the problem.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Smokeless tobacco use and its relation to panic disorder, major depression, and posttraumatic stress disorder in American Indians

INTRODUCTION

Rates of nicotine use are high in American Indians. Anxiety and depression tend to be associated with cigarette use, but the association of anxiety and depression with smokeless tobacco (ST) is less clear. We asked if panic disorder, major depression, and posttraumatic stress disorder (PTSD) are related to lifetime ST use in 2 American Indian tribes.

METHODS

Logistic regression analyses examined the association between lifetime panic disorder, major depression, and PTSD and the odds of lifetime ST use status after controlling for sociodemographic characteristics, smoking status, and alcohol use disorders in 1,506 Northern Plains and 1,268 Southwest tribal members.

RESULTS

Odds of lifetime ST use was 1.6 times higher in Northern Plains tribal members with a lifetime history of PTSD after controlling for sociodemographic variables and smoking (95% CI: 1.1, 2.3; p = .01). This association remained significant after further adjustment for panic disorder and major depression (odds ratio [OR] = 1.5; 95% CI: 1.0, 2.2; p = .04) but was diminished after accounting for alcohol use (OR = 1.3; 95% CI: 0.9, 1.9; p = .23). In the Southwest, lifetime psychiatric disorders were not associated with lifetime ST use status. Increasing psychiatric comorbidity was significantly linked to increased odds of ST use in both tribes.

CONCLUSIONS

This study is the first to examine psychiatric conditions and lifetime ST use in a large, geographically diverse American Indian community sample. Although approximately 30% of tribal members were lifetime users of ST, the association with lifetime psychiatric disorders was not as strong as those observed with cigarette smoking. Understanding shared mechanisms between all forms of tobacco use with anxiety and depressive disorders remains an important area for investigation.

Assessment of smokeless tobacco use in the history and physical examination by primary healthcare providers

PURPOSE

Following a simple descriptive research design, we examined how and to what extent primary healthcare providers in rural southern regions of the United States ask patients about the use of smokeless tobacco as indicated in the document used for the patient history.

DATA SOURCES

Copies of blank history and physical forms used in offices of primary care providers in Alabama, Georgia, South Carolina, and Tennessee were examined to identify items related specifically to tobacco use.

CONCLUSIONS

Twenty-nine providers returned history and physical forms, which revealed 24% showed no item related to tobacco use. Others included questions related to smoking, but only 7% mentioned any sort of smokeless tobacco use.

IMPLICATIONS FOR PRACTICE

Although a few studies have suggested the use of smokeless tobacco to be less harmful than smoking, all forms of smokeless tobacco are recognized carcinogens and dangerous for health. It is not sufficient to simply ask patients about smoking behaviors. Primary care providers, especially nurse practitioners, have the unique opportunity to assess use of smokeless tobacco and to offer treatment and counsel to help patients to stop the behavior.

Prevalence of trial of snus products among adult smokers

A 2008 survey assessed the proportion of smokers in 8 geographic areas who reported trying snus. In test markets, 10% of smokers had tried snus in the past year. Among young adult men, the trial rate was 29%. Trial was more likely among Whites than among minorities, among respondents with lower education than among those with higher education, and among those without immediate plans to quit smoking than among those intending to quit in the next 30 days. The association between trial and low cessation motivation is an important target for research.

US smokers' reactions to a brief trial of oral nicotine products

BACKGROUND

It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction.

OBJECTIVES

This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.

METHODS

The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use.

RESULTS

After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

CONCLUSIONS

Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Does dual use jeopardize the potential role of smokeless tobacco in harm reduction?

INTRODUCTION

The use of smokeless tobacco as part of a strategy to reduce the harm from cigarette smoking is a topic of debate within the tobacco control and public health communities. One concern voiced regarding endorsement of such a tactic is the possibility of actually increasing harm should current smokers adopt dual cigarette/smokeless tobacco use (dual use), which could lead to unintended consequences by perpetuating cigarette smoking, diminishing tobacco cessation, or increasing tobacco-related harm.

METHODS

Here, we review the available literature on health effects and trajectories of use among dual users from a variety of U.S. and European epidemiological studies.

RESULTS

These data suggest that there are not any unique health risks associated with dual use of smokeless tobacco products and cigarettes, which are not anticipated or observed from cigarette smoking alone. Furthermore, studies show that dual users smoke fewer cigarettes than exclusive smokers, and studies of tobacco use patterns over time (tobacco use trajectory data) indicate that dual users are more likely than exclusive cigarette smokers to cease smoking.

CONCLUSIONS

Overall, the concern about dual use appears to be contradicted by the evidence in the literature that dual use of smokeless tobacco and cigarettes may result in reduction in smoking-related harm as smoking intensity is decreased and smoking cessation increases.

Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA

BACKGROUND

Snus (a form of smokeless tobacco) is less dangerous than cigarettes. Some health professionals argue that snus should be promoted as a component of a harm reduction strategy, while others oppose this approach. Major US tobacco companies (RJ Reynolds and Philip Morris) are marketing snus products as cigarette brand line extensions. The population effects of smokeless tobacco promotion will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns.

OBJECTIVE

To quantitatively evaluate the health impact of smokeless tobacco promotion as part of a harm reduction strategy in the US.

METHODS

A Monte Carlo simulation of a decision tree model of tobacco initiation and use was used to estimate the health effects associated with five different patterns of increased smokeless tobacco use.

RESULTS

With cigarette smoking having a health effect of 100, the base case scenario (based on current US prevalence rates) yields a total health effect of 24.2 (5% to 95% interval 21.7 to 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health-concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with a health effect of 30.4 (5% to 95% interval 25.9 to 35.2). The anticipated health effects for additional scenarios with lower rates of smokeless uptake also overlapped with the base case.

CONCLUSIONS

Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.

Test marketing of new smokeless tobacco products in four U.S. cities

INTRODUCTION

This exploratory study was designed to assess the availability, price, and point-of-purchase marketing strategies for new smokeless tobacco products in 4 test market areas.

METHODS

A random sample of 50 gas stations, convenience and food stores, and tobacco shops was selected in each of 4 test market areas. Pairs of observers visited each store, recorded product information, and engaged vendors in conversation about product demand.

RESULTS

Snus was available in 64% of the stores, but availability and price differed by brand. Point-of-purchase marketing also varied by brand on a variety of dimensions and all brands appeared to be marketed primarily to smokers. Camel Snus was described by store attendants as having the highest demand and was also the most expensive of the observed products. In light of the number of test market cities and intensity of promotion at retail locations, Camel Snus was the most intensively marketed product.

DISCUSSION

The results appear to reflect differences in marketing strategy by American snus manufacturers. These strategies may help to predict future marketing of snus and other tobacco products and may provide a baseline for later assessments of product acceptance.

Surveillance indicators for potential reduced exposure products (PREPs): developing survey items to measure awareness

Background

Over the past decade, tobacco companies have introduced cigarettes and smokeless tobacco products (known as Potential Reduced Exposure Products, PREPs) with purportedly lower levels of some toxins than conventional cigarettes and smokeless products. It is essential that public health agencies monitor awareness, interest, use, and perceptions of these products so that their impact on population health can be detected at the earliest stages.

Methods

This paper reviews and critiques existing strategies for measuring awareness of PREPs from 16 published and unpublished studies. From these measures, we developed new surveillance items and subjected them to two rounds of cognitive testing, a common and accepted method for evaluating questionnaire wording.

Results

Our review suggests that high levels of awareness of PREPs reported in some studies are likely to be inaccurate. Two likely sources of inaccuracy in awareness measures were identified: 1) the tendency of respondents to misclassify "no additive" and "natural" cigarettes as PREPs and 2) the tendency of respondents to mistakenly report awareness as a result of confusion between PREPs brands and similarly named familiar products, for example, Eclipse chewing gum and Accord automobiles.

Conclusion

After evaluating new measures with cognitive interviews, we conclude that as of winter 2006, awareness of reduced exposure products among U.S. smokers was likely to be between 1% and 8%, with the higher estimates for some products occurring in test markets. Recommended measurement strategies for future surveys are presented.

The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US

The issues related to tobacco harm reduction continue to challenge the tobacco control research and policy communities. The potential for combusting tobacco products to reduce exposure and risk remains largely unknown, but this has not stopped manufacturers from offering such products making these claims. The role of oral tobacco products in a harm reduction regimen has also been a source of dialogue and debate. Within the last few years, major cigarette manufacturing companies have begun selling smokeless products for the first time, claiming to target current cigarette smokers. Other cigarette manufacturers are also offering smokeless products in markets around the world. The harm reduction debate has at times been divisive. There has been no unifying set of principles or goals articulated to guide tobacco control efforts. In particular, the research needs are extraordinarily high in order to drive evidence-based policy in this area and avoid the mistakes made with "light" cigarettes. This paper discusses recommendations from a strategic dialogue held with key, mostly US-based tobacco control researchers and policy makers to develop a strategic vision and blueprint for research, policy and communications to reduce the harm from tobacco for the US. Short-term and long-term objectives are described.

Receptivity to Taboka and Camel Snus in a U.S. test market

INTRODUCTION

The two largest U.S. cigarette manufacturers introduced Swedish-style low-nitrosamine smokeless tobacco (snus) to several U.S. test markets in summer 2006. Since then, snus brands and test markets have proliferated.

METHODS

This article assesses consumer response by analyzing data from the 2006 and 2007 Indiana Adult Tobacco Survey (IATS), a statewide telephone survey of 3,544 adults. During those years, the IATS included questions on awareness and trial of Camel Snus and Taboka. Analyses examined rates and predictors of awareness and trial statewide, and within the central Indiana test market.

RESULTS

Nineteen percent of Indiana adults were aware of either Taboka or Camel Snus in 2006 and 2007. Estimates are larger (29%) for central Indiana and larger still (70%) for central Indiana smokers. Trial of snus, however, was very low (1.5% statewide), except among male smokers in central Indiana, 20% of whom are estimated to have tried it. Multivariate analyses showed that trial was more likely among men than women (odds ratio [OR] 13.85), residents of central Indiana than those farther from Indianapolis (OR 2.96), recipients than nonrecipients of tobacco promotions (OR 6.08), and those believing that smokeless tobacco is less harmful than cigarettes compared with those who believe it is equally or more harmful (OR 3.86).

DISCUSSION

Results from this study suggest substantial initial interest in the new products among male smokers in this test market, especially those who receive promotional mailings from tobacco companies, which often include coupons for free or discounted products.

The STAGE cohort: a prospective study of tobacco use among Swedish twins

We investigated patterns of cigarette smoking and Swedish snus (oral smokeless tobacco) use in a population-based sample of 19,073 Swedish twins 20-47 years old who participated in the baseline assessment of a prospective study of tobacco use and cessation in 2005-2006. Age-adjusted prevalence odds ratios (POR) and 95% confidence intervals (CI ) describe the association between tobacco use and sex, after adjustment for non-independence of twin pairs. Kaplan-Meier survival methods produced cumulative incidence curves of age at initiation of tobacco use. Slightly more than half of the baseline population was female (55.2%); the mean age at interview was 33.3 (+/-7.2) years and did not differ by sex. Having ever smoked daily was less common among males than females (11.9% vs. 15.3%; POR = 0.70 [0.64-0.77]), while having ever used snus daily was more common among males than females (31.1% vs. 4.8%; POR 11.7 [95% CI = 10.6-13.1]). The median age at initiation of smoking was 15 years for both sexes; median age at onset of snus use was 15 years for males and 18 years for females. Nicotine dependence scores were higher for males than females, and for current than former smokers. Findings from this study are in contrast to our previously published report on tobacco use among 32,123 Swedish twins 42-64 years old who completed a similar survey, and reported lower rates of snus use at later ages. Patterns of tobacco use may be changing in Sweden; snus use appears to be increasing, while daily smoking appears to be decreasing in popularity among the younger Swedish twins.