Is smokeless tobacco use an appropriate public health strategy for reducing societal harm from cigarette smoking?

Perceived Truthfulness of Reduced Lung Cancer Risk Advertising Claims Influences Consumers' Intention to try and to Purchase Snus

The objective of the current study was to evaluate the impact of a reduced risk claim about lung cancer, presented in various formats, on smokers' and non-smokers' interest in trying Camel Snus and intention to purchase Camel Snus. We varied claim formats by varying advertising messages for Camel Snus in 4 ways (1) text only; (2) bar chart; (3) text/testimonial; and (4) bar chart/testimonial. 3001 participants were recruited from a web-based consumer specialty panel via an email invitation. In 2015, a second study was conducted, using similar methods, where 3001 additional participants were recruited. Overall, controlling for other factors, the presence of an MRTP claim was not significantly related to interest in trying snus [X2 (4) = 8.567, P = .073], or purchase intentions [X2 (4) = 1.148, P = .887]. Relative to a control ad where no explicit health risk claim was made, the Graphic + testimonial [OR = 1.29] or Text only [OR = 1.41] claims did significantly increase interest in trying Camel Snus. However, the adverting format did not impact interest in purchasing Camel Snus. While current smokeless tobacco users (95%) and smokers (59%) expressed interest in trying Camel Snus, non-tobacco users (7%) showed low interest in trying or purchasing Camel Snus (P < .001). Interest in trying Camel Snus was stronger in younger smokers compared to older smokers. Among current smokers, worry about lung cancer (the key focus of the reduced risk claim) was not associated with interest in trying Camel Snus or with purchase intention [OR = .91, 95% CI: .72, 1.14] or intention to purchase snus [OR = 1.07, 95% CI: .86, 1.32]. Future research should evaluate how claim and messaging formats influence perceived truthfulness and whether this effect differs among sub-groups of consumers, such as adolescents, those with tobacco-related disease, and former smokers. It will also be helpful to understand whether perceptions of ad truthfulness result in changes in product use patterns over time. In sum, giving people truthful, credible information about relative product risks, such as through authorized MRTP claims, is important, but such information is likely insufficient to get smokers to switch.

Where college students look for vaping information and what information they believe

Objective: This convergent mixed methods study examined how information sources influence college students' beliefs and knowledge about vaping. Participants: College students either completed a survey (n = 522; January-April, 2016) or were interviewed (n = 33; 2015-2016). Methods: College students completed an online survey asking 'where' students had heard about e-cigarette and 'what' they had heard. Responses were quantified and a chi-square analysis was conducted. Additional college student e-cigarette users were interviewed about the credibility of information sources. Thematic analysis was conducted with the coded interviews. Results: There was a significant relationship between information sources for e-cigarettes (social sources, media, advertising, education/research) and the messages they recalled. Friends who vaped and e-cigarette users were the most credible information sources. Confirmation bias and scientific impotence bias characterized assessment of e-cigarette information. Conclusions: Health education specialists working on college campuses should provide accurate information via communication channels most unitized by college students.

Association between snus use over time and smoking cessation in Norwegian smokers

BACKGROUND AND AIMS

The effect of snus (Swedish moist snuff) use over time on smoking cessation has not been clearly established. This study aimed to assess whether there is an association between snus use over the life-span and smoking cessation in Norway.

DESIGN AND SETTING

Yearly national cross-sectional surveys (2007-17) among Norwegian adults.

PARTICIPANTS

A total of 5353 ever-daily smokers aged 16-79 years, 61.0% of whom (n = 3268) had quit daily smoking, and 16.9% (n = 903) were ever snus users.

MEASUREMENTS

Retrospective data on smoking and snus use initiation and smoking cessation. Cox proportional hazard models were applied to estimate the association between time from initiation of snus use and quitting smoking.

FINDINGS

There was a significant association between snus use and quitting smoking during the 5 first years after starting using snus (hazard ratio = 1.92, confidence interval = 1.62-2.26), but not thereafter.

CONCLUSION

In Norway, snus use appears to be associated with a higher likelihood of quitting smoking within the first 5 years of initiation of this use.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

The Impact of Smokeless Tobacco Risk Information on Smokers' Risk Perceptions and Use Intentions: A News Media Experiment

Little research exists on the impact of risk information comparing smokeless tobacco (SLT) use, particularly snus, to cigarette smoking. This study explored this topic using a communication channel where smokers may be exposed to such information-the news media. We randomly assigned 1008 current smokers to read one of three constructed news stories or to a control group (no article). The "favorable" story framed snus as a "safer" smoking alternative while the "cautious" story described snus risks. The "mixed" version described potential risks and harm-reduction benefits. Participants completed a post-article survey with snus risk and harm perception and use intention measures. Article condition was significantly associated with perceived harm of daily snus use relative to smoking (1 = a lot less harmful - 5 = a lot more harmful; p < .0001), and mean ratings of snus harm in the favorable (2.46) and mixed conditions (2.66) were significantly lower than those of the cautious (2.96) and control conditions (2.98). Mean interest in trying snus in the next 6 months was low, but significantly higher for those in the favorable (1.55) and mixed conditions (1.32) versus those in the cautious (1.17) and control conditions (1.16)(1 = not at all - 5 = extremely interested, p < .0001). There were no significant differences by group in terms of the story's perceived interestingness, importance, or relevance. Exposure to reduced-risk news messages about SLT and snus relative to cigarettes may impact smokers' SLT harm perceptions and use intentions. Tobacco control professionals and FDA officials should consider the potential impact of the news media when communicating about tobacco risks.

A National Comparison of Dual Users of Smokeless Tobacco and Cigarettes and Exclusive Cigarette Smokers, 2015-2016

Introduction

While smoking rates have declined, use of smokeless tobacco (ST) has remained constant. ST is heavily marketed to cigarette smokers, and many ST users smoke cigarettes. This study provides updated comparisons of the characteristics, smoking behaviors, and perceptions of US adult dual ST and cigarette users and exclusive cigarette smokers in 2015-2016.

Methods

Data were from nationally representative, cross-sectional surveys from 2015 and 2016. Adult smokers reported past 30-day use of ST, current cigarette smoking, risk perceptions, smoking, and quitting behaviors. We estimated Rao-Scott χ2 and adjusted odds ratios (AORs) to compare dual users and exclusive smokers.

Results

Dual users were more likely to be younger, reside in nonmetropolitan statistical areas (MSA) and outside the Northeast United States. Adjusting for covariates, dual users did not differ significantly from exclusive smokers on most smoker characteristics, including number of past year quit attempts. Dual users were more likely to report past 30-day use of novel tobacco products (AORs 2.90 [little cigars and cigarillos] to 11.02 [hookah]). Dual users who reported at least 1 past year cigarette quit attempt were more likely than exclusive smokers to report using ST, traditional cigars, hookah, or heat-not-burn as a past year quit method (AOR: 9.54 [95% CI: 3.22 to 28.23]).

Conclusions

Smokers who use ST are more likely than exclusive smokers to attempt to quit smoking cigarettes using other tobacco products. These findings may be attributed to increasing use prevalence of novel products. We recommend further monitoring to assess polytobacco use and differences among these populations.

Implications

Many current ST users smoke cigarettes and ST promotions often target cigarette smokers. As the FDA considers ST regulations and implements a nicotine centered regulatory framework, it is imperative to evaluate how these policies and promotion of ST as potentially reduced risk products impact dual and polytobacco use. Our study found that many dual users engage in novel tobacco use in general and as a cessation method. Consideration of ST and polytobacco use among smokers may be helpful in the development of forthcoming FDA regulations, messaging, and interventions.

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.

Comparative risk assessment and cessation information seeking among smokeless tobacco users

INTRODUCTION

This research examined (1) smokeless tobacco users' comparative optimism in assessing the health and addiction risks of their own product in comparison with cigarettes, and (2) the effects of comparative optimism on cessation information-seeking.

METHODS

A nationally-representative sample from the 2015 Health Information National Trends Survey (HINTS)-FDA was employed.

RESULTS

The analyses revealed the presence of comparative optimism in assessing both health and addiction risks among smokeless tobacco users. Comparative optimism was negatively correlated with most cessation information-seeking variables. Health bias (the health risk rating gap between the subject's own tobacco product and cigarettes) was associated with decreased intent to use cessation support. However, the health bias and addiction bias (the addiction risk rating gap between the subject's own tobacco product and cigarettes) were not consistent predictors of all cessation information-seeking variables, when covariates of socio-demographics and tobacco use status were included. In addition, positive correlations between health bias and past/recent cessation-information searches were observed.

CONCLUSIONS

Optimisic biases may negatively influence cessation behaviors not only directly but also indirectly by influencing an important moderator, cessation information-seeking. Future interventions should prioritize dispelling the comparative optimism in perceiving risks of smokeless tobacco use, as well as provide more reliable cessation information specific to smokeless tobacco users.

Assessing the effect of public health information by incentivised risk estimation: An example on Swedish snus

BACKGROUND

The provision of accurate information on health damaging behaviours and products is a widely accepted and widespread governmental task. It is easily mismanaged. This study demonstrates a simple method which can help to evaluate whether such information corrects recipient risk beliefs.

METHODS

Participants assess risks numerically, before and after being exposed to a relevant risk communication. Accuracy is incentivised by awarding financial prizes to answers closest to a pursued risk belief. To illustrate this method, 228 students from the University of Oslo, Norway, were asked to estimate the mortality risk of Swedish snus and cigarettes twice, before and after being exposed to one of three risk communications with information on the health dangers of snus.

RESULTS

The data allow us to measure how participants updated their risk beliefs after being exposed to different risk communications. Risk information from the government strongly distorted risk perceptions for snus. A newspaper article discussing the relative risks of cigarettes and snus reduced belief errors regarding snus risks, but increased belief errors regarding smoking. The perceived quality of the risk communication was not associated with decreased belief errors.

CONCLUSION

Public health information can potentially make the public less informed on risks about harmful products or behaviours. This risk can be reduced by targeting identified, measurable belief errors and empirically assessing how alternative communications affect these. The proposed method of incentivised risk estimation might be helpful in future assessments of risk communications.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Patterns of Smoking and Snus Use in Sweden: Implications for Public Health

There has been concern that the availability of alternative less harmful forms of nicotine might inhibit smoking cessation and/or encourage those who would not otherwise have smoked to do so. The plausibility of such effects can be best assessed by looking at population trends in use of smoking in relation to alternatives. This paper looks at the relationships between snus use and smoking in Sweden. Analyses are based on a data set for the period January 2003 to February 2011 from a long-term study covering nationally representative samples of the Swedish population aged 18–79, with a total study population of 60,675 individuals. Questionnaires made it possible to identify detailed tobacco use categories and use trajectories. The results showed that uptake of snus use is much more common in males than females. Those who began daily tobacco use using snus were much less likely to subsequently take up smoking than those who had not, both among males (17.6% vs. 45.9%), and females (8.2% vs. 40.2%). Further, among those who started using snus after starting as smokers, 76.3% of men and 71.6% of women had stopped smoking completely, including 31.5% of the men and 28.6% of the women who had quit all forms of tobacco. Indeed, those who were primary snus users were also more likely to have quit altogether than those who only ever smoked. Snus was also reported as the most common smoking cessation aid among men and yielded higher success rates than nicotine replacement therapy and other alternatives. As conclusions, snus has both contributed to decreasing initiation of smoking and, when used subsequent to smoking, appears to facilitate smoking cessation. All these effects suggest that the availability and use of snus has been a major factor behind Sweden’s record-low prevalence of smoking and the lowest level of tobacco-related mortality among men in Europe.

Smokeless tobacco use and fractional exhaled nitric oxide in men in a national survey

BACKGROUND

Tobacco use is an important risk for asthma and increases asthma severity. Fractional exhaled nitric oxide (FeNO) is used as a noninvasive biomarker of eosinophilic airway inflammation. Substantial numbers of men use smokeless tobacco. The effect of use of smokeless tobacco on FeNO is not known.

OBJECTIVE

To estimate the association between use of smokeless tobacco and FeNO among US men.

METHODS

The National Health and Nutrition Examination Survey 2007-2012 was analyzed to assess association of use of smokeless tobacco and FeNO levels in parts per billion in US men. Participants were categorized by smoking status and use of snuff or chewing tobacco in the previous 5 days. FeNO was measured using a device that relies on an electrochemical sensor.

RESULTS

In 3,791 male nonsmokers without asthma, weighted mean natural logarithm FeNO by exposure to smokeless tobacco was 2.81 (geometric mean FeNO, 16.59 ppb; 95% CI, 2.77-2.85) in unexposed and 2.66 (geometric mean, 14.30 ppb; 95% CI, 2.55-2.77) in the exposed. In weighted linear regression analyses, use of smokeless tobacco was associated with significantly lower natural logarithm FeNO after controlling for age and race (black vs nonblack) (coefficient, -0.124; SE, 0.056; P = .03; 95% CI, -0.237 to -0.011). Results were unchanged after additionally controlling for recent nitric oxide-rich vegetable consumption and upper respiratory tract infection (coefficient, -0.118; SE, 0.055; P = .04; 95% CI, -0.228 to -0.007).

CONCLUSIONS

Use of smokeless tobacco was associated with lower mean natural logarithm FeNO levels in nonsmokers with no history of asthma. Interpretation of FeNO should consider all forms of tobacco use.

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.

Use of snus, its association with smoking and alcohol consumption, and related attitudes among adolescents: the Finnish National School Health Promotion Study

Background

The relationship between the use of snus and lifestyle-related habits – especially in adolescence, when these behaviours begin and become established – is not widely studied. Our aim was to analyse associations between snus use and habits of and attitudes towards smoking and alcohol consumption among Finnish adolescents.

Methods

The study is a part of the National School Health Promotion Study in Finland. The study population consisted of a representative sample of Finnish adolescents (n = 183 226). A questionnaire enquired about pupils’ use of snus, habits of and attitudes towards smoking and alcohol consumption, as well as their (age, gender, school type) and their parents’ (education and smoking) background factors. Chi-square tests and logistic regression models served in the statistical analyses.

Results

Of the adolescents, 18 % had used snus (2 % daily, 16 % experimented) while 82 % never had. Snus use was more common among boys than girls (p < 0.05). Concerning smoking, 19 % were daily and 15 % occasional smokers. Regarding alcohol, 11 % consumed it weekly and 57 % monthly or less frequently. More than two thirds of the adolescents held positive attitudes towards smoking (71 %), and alcohol (67 %). Male gender (OR = 9.9; 95 % CI 9.4–10.4), current (OR = 32.8; 95 % CI 26.1–41.1) or former (OR = 10.1; 95 % CI 8.0–12.9) smoking, weekly consumption of alcohol (OR = 27.4; 95 % CI 21.0–35.8), positive attitude towards smoking (OR = 1.4; 95 % CI 1.3–1.6), and higher parental education (OR = 1.4; 95 % CI 1.3–1.4) associated significantly with adolescents’ current snus use, whereas parental smoking did not.

Conclusion

Current snus use among adolescents may signal an accumulation of other lifestyle-related risky behaviours such as current or past smoking and alcohol consumption as well as a positive attitude towards smoking. In addition to these possible co-existing health-related risk factors, health promotion activities should take into account gender and school differences in order to target preventive messages to youth more effectively.

Systematic Review to Inform Dual Tobacco Use Prevention

With more tobacco products now available and heavily marketed, dual tobacco use is increasing among youth. We systematically reviewed literature on dual tobacco use interventions, with an emphasis on mass health communication strategies. The review identified 46 articles meeting initial criteria and ultimately included 8 articles. Included studies reported a mix of health communication and social marketing techniques. Although there is a body of research on dual tobacco use, there is limited literature describing interventions aimed at controlling it. Design and evaluation of such interventions showing reductions in dual use of cigarettes, smokeless, and alternative products would advance the field.

The role of smokeless tobacco use in smoking persistence among male college students

BACKGROUND

Significant changes in the tobacco industry have led to heightened concern about co-use of cigarettes and smokeless tobacco (SLT) products.

OBJECTIVES

The aim of this study was to assess whether male cigarette smokers who also used SLT products, in the first semester of their first year of college, were more or less likely than male cigarette smokers who did not use SLT products to still be smoking by the first semester of their senior year.

METHODS

Using a longitudinal, observational study, we followed a cohort of undergraduate students from 11 four-year universities in North Carolina and Virginia through their college career. Mixed-effects logistic regression analysis was conducted to estimate the likelihood of being a current smoker fall of senior year for male students who used both cigarettes and SLT at baseline, compared to those who only smoked cigarettes, after adjustment for potential confounders (n = 274).

RESULTS

At baseline, 67.2% of participants were smoking cigarettes only (no SLT use) and 32.8% were dual users (cigarettes and SLT). A total of 62% were still smoking at senior year. Dual users were 30% more likely to be current smokers senior year compared to cigarette only users, although this difference was not statistically significant. Having at least one friend who smoked cigarettes and heavier cigarette smoking at baseline were significantly related to senior year smoking.

CONCLUSIONS

Our findings do not support the argument that SLT use may help male college smokers discontinue their smoking habit. In fact, it may contribute to smoking persistence.

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.

The association between smokeless tobacco use and pancreatic adenocarcinoma: a systematic review

BACKGROUND

Smokeless tobacco is a possible risk factor for developing pancreatic adenocarcinoma. This systematic review addressed the question: Is there an association between smokeless tobacco use and pancreatic adenocarcinoma diagnosis?

METHODS

Five electronic databases, grey literature, and citations of relevant articles were searched to identify studies. Six researchers double-reviewed records for inclusion in the review. The information extracted from these studies was selected using criteria outlined in the Newcastle-Ottawa Quality Assessment Scale for observational studies. A qualitative synthesis of included studies was performed.

RESULTS

The search of electronic databases resulted in a total of 1747 citations. Eleven studies met the inclusion criteria for this review, including three cohort studies, seven case control studies and one study that pooled data from multiple case-control studies. Studies were heterogeneous in their assessment of exposure intensity and ascertainment of outcomes. Quality of the studies varied. Existing investigations of the association of interest appear to exhibit several types of biases including selection bias, information bias and bias in the analysis.

CONCLUSION

The association between smokeless tobacco use and pancreatic adenocarcinoma is inconclusive. More definitive conclusions regarding this relationship await the results of more methodologically rigorous epidemiologic studies.

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.

The impact of product information and trials on demand for smokeless tobacco and cigarettes: evidence from experimental auctions

INTRODUCTION

Epidemiological and toxicological evidence suggests lower risk of smokeless tobacco (ST) products compared to cigarettes. Less is known, however, about consumer perceptions and use of novel forms of ST, including snus and dissolvable tobacco.

METHODS

In this study, we conducted in-person experimental auctions in Buffalo, NY, Columbia, SC, and Selinsgrove, PA with 571 smokers to test the impact of information and product trials on smokers' preferences. Auctions were conducted between November 2010-November 2011.

RESULTS

We found no evidence of an impact of product trials on demand in our auctions. Anti-ST information increased demand for cigarettes when presented alone, but when presented with pro-ST information it decreased demand for cigarettes. It did not decrease demand for ST products. Anti-smoking information increased demand for ST products, but did not affect cigarette demand.

CONCLUSIONS

These findings suggest that credible and effective communications about tobacco harm reduction should reinforce the negative effects of smoking.

Estimating demand for alternatives to cigarettes with online purchase tasks

OBJECTIVES

To explore how advertising affects demand for cigarettes and potential substitutes, including snus, dissolvable tobacco, and medicinal nicotine.

METHODS

A Web-based experiment randomized 1062 smokers to see advertisements for alternative nicotine products or soft drinks, then complete a series of purchase tasks, which were used to estimate demand elasticity, peak consumption, and cross-price elasticity (CPE) for tobacco products.

RESULTS

Lower demand elasticity and greater peak consumption were seen for cigarettes compared to all alternative products (p < .05). CPE did not differ across the alternative products (p ≤ .03). Seeing relevant advertisements was not significantly related to demand.

CONCLUSIONS

These findings suggest significantly lower demand for alternative nicotine sources among smokers than previously revealed.

Risk and protective factors of adolescent exclusive snus users compared to non-users of tobacco, exclusive smokers and dual users of snus and cigarettes

The use of snus is increasing in Norway. In this study we examined differences between adolescents who were exclusive snus users, and adolescent non-users, smokers and dual users of snus and cigarettes on a number of psychosocial factors, categorized as risk variables and protective variables associated with involvement in health compromising behavior. We applied separate logistic regression models, where exclusive snus users (n=740) were compared with non-users (n=904), smokers (n=219), and dual users (n=367). Compared to non-users, the group of exclusive snus users was associated with variables traditionally predicting health risk behavior, such as smoking friends (OR=1.74, SD 1.27-2.38) and truancy (OR=2.12, SD 1.65-2.78). Compared to smokers, exclusive snus users were related to variables traditionally associated with protection against involvement in health risk behavior, e.g. higher academic orientation (OR=1.66, SD 1.12-2.45). Associations with protective factors were also observed when exclusive snus users were compared with dual users. While the group of exclusive snus users was associated with a pattern of psychosocial risk compared to non-users, they showed a more conventional pattern when compared to smokers and dual users. The group of exclusive snus users may be described on a continuum varying from psychosocial risk factors to protective factors of risk involvement depending on the group of comparison.

The development and psychometric evaluation of the Smokeless Tobacco Expectancies Scale (STES)

Expectancies regarding the effects of various psychoactive substances are important predictors of the initiation and maintenance of substance use. Although measures of outcome expectancies exist for several addictive substances, there is currently no measure to assess smokeless tobacco (ST) expectancies in an adult population. This article presents 2 studies leading to the development and psychometric evaluation of the Smokeless Tobacco Expectancies Scale (STES). Initially, 155 individuals listed all outcomes they expected to occur if they were to use ST products. From these responses, an initial pool of potential STES items was identified. The STES was then administered to 2 samples totaling 813 individuals (265 ST users, 270 cigarette smokers, and 278 nontobacco users). The first study included 315 participants who completed a 68-item measure. An exploratory factor analysis identified 10 items that may account for individuals' ST expectancies. Items loaded on 2 factors: Negative Health Consequences and Positive Reinforcement. A confirmatory factor analysis on an independent sample (n = 498) supported the proposed factor structure. Furthermore, in both samples, the STES accurately discriminated ST users from smokers and nonusers. Findings are discussed in terms of the potential uses of the STES for advancing the understanding of ST use.

Harm reduction and the medicalisation of tobacco use

In tobacco control the focus has, for some time, been on abstinence from all types of tobacco use as the only solution to the problem of smoking, and harm reduction approaches are controversial. The most recent English tobacco strategy has incorporated harm reduction approaches in the form of new 'routes' to quitting smoking that encourage those who cannot quit to use safer sources of nicotine. This move away from a focus on abstinence can be seen as the result of gradual shifts over the past 50 years in the way that that the problem of smoking is understood and the solutions that are offered. These shifts have involved increasingly seeing tobacco use as a medical problem. This article uses conceptual tools from science and technology studies to examine developments over the last decade in England, primarily the increasing importance of harm reduction approaches. Drawing on 20 semi-structured qualitative interviews with key stakeholders and documentary analysis, I suggest that the shape harm reduction has taken in English tobacco control policy has been another shift towards the medicalisation of tobacco use, but that this process has occurred in ways that provide a contrast to commonly outlined 'drivers' of medicalisation.

Patterns of dual use of snus and cigarettes in a mature snus market

INTRODUCTION

We examine the prevalence of dual use of snus and cigarettes among Norwegian men by categorizing dual use into four categories according to the frequency of use of each product, considering the order of uptake of both products, and examining reasons for additional snus use. We compare dual users and exclusive cigarette smokers with respect to their smoking intensity, plans for quitting smoking, and future smoking identity.

METHODS

We used a data pool of six cross-sectional, national representative surveys conducted annually in the period 2005-2010 containing a total of 3,524 males aged 16-74.

RESULTS

6.8% of men had some kind of current concomitant use of snus and cigarettes--but only 1% reported a daily consumption of both products. The most typical pattern of dual use was a combination where daily use of one product was paired with occasional use of the other. Dual users consumed significantly fewer cigarettes per week (56.6; n = 226; SD, 53.82) than smokers who had either quit snus (79.6; n = 108; SD, 61.47) or single smokers with no history of snus use (80.2; n = 621; SD, 55.86). Only 24% with a history of dual use reported snus to be their first tobacco product, but the proportion who had initiated tobacco use with snus increased significantly with younger age. Among dual users with daily intake of snus, a majority of 53.6% reported that the purpose of their snus use was to quit smoking. A higher proportion of dual users (74.4%; 95% CI, 68.8-80.0; n = 235) than exclusive smokers (61.3%; 95% CI, 57.6-65.0; n = 658) reported that they most definitely or probably would be totally smoke-free 5 years into the future.

CONCLUSIONS

In the mature snus market of Norway, the magnitude of dual use of cigarettes and snus is relatively small. Dual users consume fewer cigarettes, and a higher proportion portray themselves as smoke-free in the future than do exclusive cigarette smokers.

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.

Who is using snus? - Time trends, socioeconomic and geographic characteristics of snus users in the ageing Swedish population

BACKGROUND

The prevalence of smoking in Sweden has decreased in recent decades, and is now among the lowest in the world. During the same period, the use of Swedish moist oral snuff, a smokeless tobacco called snus, has increased. Few studies have evaluated time trends of the socioeconomic and geographic characteristics of snus users in Sweden. This paper contributes to filling that gap.

METHODS

This study utilized the Linnaeus Database, which links national registers with comprehensive individual data on socioeconomic status (SES) to health data from a large ongoing health survey, the Västerbotten Intervention Programme (VIP). The VIP targets the entire middle-aged population of Västerbotten county at ages 40, 50 and 60 years with yearly cross-sectional surveys including self-reported data on tobacco habits. Time trends of snus use among 92,563 VIP-participants across different areas of residence and smoking groups were investigated graphically. Logistic regression was performed to estimate the associations between SES and geographical variables and current use versus non-use of snus.

RESULTS

Overall, in parallel to decreasing smoking, the increasing trend of snus use in this middle-aged population continues, particularly in 40-year-olds. In both genders, the highest prevalence of snus use was observed among previous smokers. The prevalence of snus use also increased over time among smokers, and was consistently higher compared to those who had never smoked. Among males - both those who had never smoked and previous smokers - low education (OR 1.21, 95%CI 1.06-1.40 and OR 1.28, 95%CI 1.14-1.43), living alone (OR 1.16, 95%CI 1.07-1.27 and OR 1.13, 95%ci 1.04-1.23), low income and living in rural areas was associated with using snus, while this was not seen among male current smokers. Among women, living alone was associated with using snus irrespective of smoking habits. Among female smokers, the OR for snus use increased with higher education.

CONCLUSIONS

A disadvantaged social profile and also higher prevalence in rural areas is observed among male snus users who had never smoked or were previous smokers. Among male smokers there was no association between SES and use of snus. The prevalence of snus use among women is increasing, but is still considerably lower than that of men. The association between snus and SES characteristics is less pronounced among women, although snus is clearly linked to living alone. These patterns should be taken into consideration in tobacco control policies.

Smokeless tobacco: a gender analysis and nursing focus

In recent times, rates of consumption of smokeless tobacco have increased significantly amongst specific subgroups of men, particularly young college men. Recent increases in smokeless tobacco consumption have been characterized by a shift from chewing tobacco to moist snuff. In addition to laying out the health risks of moist snuff, this article describes the social and gendered meanings of smokeless tobacco that reinforce its use. Men-centered approaches to raising awareness about the connections between moist snuff and oral cancer and the availability of oral cancer screening are highlighted as 2 key nursing practice considerations.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

Expectancies and intentions to use snus among Norwegian first-year students

Introduction:

The prevalence of use of snus (low-nitrosamine smokeless tobacco, Swedish type) has reached epidemic proportions in parts of Northern Europe, and the trend is escalating. Knowledge of variables influencing use of snus is scarce, and this study set out to explore expectancies related to the use of snus as possible determinants of intentions to use snus in the next 6 months.

Methods:

The data stem from a questionnaire survey among university students in 2004 and included 141 snus users (mean age = 20.9 years, SD = 2.1). Thirteen items derived from a study by Juliano & Brandon (2004) were adapted to the use of snus, and a confirmatory factor analysis was conducted. The predictive power of expectancies on snus intentions and behavioral experience on intentions were examined using structural equation modeling.

Results:

Five meaningful and interpretable expectancy factors were confirmed by the factor analysis: “negative affect,” “weight control,” “health risks,” “quitting smoking facilitation,” and “craving reduction.” “Health risks” turned out to be the only expectancy factor that significantly predicted intentions to use snus. In addition, “current snus behavior” had a significant direct effect on intentions. Altogether, the model explained 27% of the variance in intentions.

Conclusions:

The findings suggest that expectancies of snus use can be applied to understand intentions to use snus. However, the range of expectancy items should preferably be broadened in future studies, and more attention should be paid to the inclusion of groups that differs in nicotine experience.

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.

Tobacco use harm reduction, elimination, and escalation in a large military cohort

OBJECTIVES

We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use).

METHODS

Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months.

RESULTS

Among 114 baseline smokers initiating smokeless tobacco use after basic military training, most demonstrated harm escalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is beneficial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking.

CONCLUSIONS

When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated benefits of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.

Smoking cessation among Norwegian adolescents and young adults: preferred cessation methods

Despite generally declining smoking rates, particularly among young people, a large number of people remain smokers and many young people still pick up smoking. Helping smokers quit therefore remains a high priority for the public health sector. In the present study we examined adolescents and young adults' preferences regarding cessation methods and if these differed between genders and depended on smoking frequency. The data came from a nationally representative survey in Norway among 16-20 year olds. Only regular (weekly and daily) smokers were included in the statistical analyses (n = 509, 51% females). The findings suggest that the majority of both male (83.6%) and female (78.4%) smokers would prefer to quit smoking without help. More males than females reported that they would consider using snus as a cessation aid, while females more often reported willingness to attend cessation classes or use brochures and diaries as cessation aids. Both males and females had similar preferences albeit low, regarding the use of health services, nicotine gum or patches and internet and sms-services to quit smoking. Daily smokers would more often than weekly smokers prefer to attend cessation classes, seek help from health services, use nicotine gum or patches or use brochures and diaries. In contrast, weekly smokers preferred to use snus as a cessation aid more often than daily smokers. Identifying and making appropriate cessation methods attractive may lead to successful quitting and consequently public health gains.

Interventions to reduce harm from continued tobacco use

BACKGROUND

It may be reasonable to try to reduce the harm from continued smoking amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products. The interventions evaluated in controlled trials have predominantly attempted to reduce the number of cigarettes smoked.

OBJECTIVES

To assess the effect of interventions intended to reduce the harm from smoking on the following: biomarkers of damage caused by tobacco, biomarkers of tobacco exposure, number of cigarettes smoked, quitting, and long-term health status.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register using free text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. The initial search was in March 2006, updated in March 2007.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions in tobacco users to reduce amount smoked, or to reduce harm from smoking by means other than cessation. Outcomes were change in cigarette consumption, markers of cigarette exposure and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We pooled trials with similar interventions and outcomes using a fixed-effect model. Other studies were summarised narratively.

MAIN RESULTS

The 13 included trials all evaluated interventions to help smokers cut down the amount smoked. Self-reported reduction in cigarettes per day (CPD) was validated by reduction in carbon monoxide (CO) levels. Most trials tested nicotine replacement therapy (NRT) to assist reduction. No eligible studies evaluated the use of potentially reduced-exposure products. In a pooled analysis of eight trials, NRT significantly increased the odds of reducing CPD by 50% or more for people using nicotine gum or inhaler or a choice of product compared to placebo (n=3273, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.55 to 2.62). Where average changes from baseline were compared for different measures, CO and cotinine consistently showed smaller reductions than CPD. Whilst the effect for NRT was significant, small numbers of people in either treatment or control group successfully sustained a reduction of 50% or more. Use of NRT also significantly increased the odds of quitting (OR 1.90, 95% CI 1.46 to 2.47). One trial of bupropion failed to detect an effect on reduction or cessation. Four trials of different types of advice and instructions on reducing CPD did not provide clear evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence about long-term benefit to give firm support the use of interventions intended to help smokers reduce but not quit tobacco use. Some people who do not wish to quit can be helped to cut down the number of cigarettes smoked and reduce their carbon monoxide levels by using nicotine gum or nicotine inhaler. Because the long-term health benefit of a reduction in smoking rate is unclear this application of NRT is more appropriately used as a precursor to quitting.