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NEWS & VIEWS |
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A recent report from Britain's Royal College of Physicians (RCP) says tobacco harm-reduction strategies are urgently needed to help hard-core smokers who can't kick the habit—and smokeless tobacco should be among the options.
But American Cancer Society (ACS) experts counter that encouraging smokeless tobacco use is not only a dangerous tactic in the drive to reduce smoking rates, but scientifically unproven as well.
"This approach puts us at great risk of repeating the fiasco of ‘Light’ and ‘Mild’ cigarettes," says Michael Thun, MD, ACS Vice President of Epidemiology and Surveillance Research. "There is no evidence that smokers will switch to smokeless tobacco products and give up smoking. In fact, the tobacco companies market these products as a ‘bridge’ that provides smokers with nicotine in settings where smoking is prohibited. Any product that encourages smokers to postpone quitting will increase rather than decrease their risk of lung cancer, as was the case with ‘Light’ and ‘Mild’ cigarettes."
Lung cancer is, of course, only one of the well-documented hazards of smoking. The habit is directly responsible for some 87% of lung cancer deaths, around 30% of all cancer deaths, as well as substantial morbidity and mortality from heart disease, stroke, emphysema, and other conditions.
Yet quitting remains a challenge for the millions of smokers worldwide who are addicted to smoking and the nicotine rush it delivers. The RCP report, titled "Harm reduction in nicotine addiction: Helping people who can't quit," contends that this challenge is simply insurmountable for some people and that the current dearth of harm-reduction strategies is "perverse, unjust and acts against the rights and best interests of smokers and the public health."
"This too relies on a false assumption," says Thun. "Most people who continue to smoke have never received sufficient counseling and treatment to help them succeed at quitting. The premise that smokeless tobacco products are more effective than conventional treatments has never been tested in a randomized clinical trial. It is simplistic to assume that smokeless tobacco products will have a net public health benefit simply because they are less lethal than cigarettes. Conventional nicotine-replacement therapies have been tested extensively and shown not to be carcinogenic, to have low toxicity, and to be effective in helping smokers quit. None of these is true for smokeless tobacco products."
The report says smokers should have access to alternative products that can deliver nicotine to satisfy their addiction, with fewer adverse health consequences.
According to the report and an accompanying Viewpoint piece published online October 5, 2007, in The Lancet (doi:10.1016/S0140-6736(07)61482-2), smokeless tobacco fits that bill, even though it is known to increase the risk of oral cancers, pancreatic cancer, heart disease, gum recession, and bone loss around the teeth.
"Whatever the true overall hazard, use of low nitrosamine smokeless products is clearly substantially less harmful than tobacco smoking," write editorialists John Britton, MD, and Richard Edwards, MD. Britton is Chair of the RCP Tobacco Advisory Group and Professor of Epidemiology at the University of Nottingham, England; Edwards is a member of the RCP Tobacco Advisory Group and Senior Lecturer in Epidemiology at the University of Otago, Wellington, New Zealand.
They cite Swedish snus (moist snuff) in particular as a lower-hazard smokeless product that should be considered for harm reduction because it has been linked only to pancreatic cancer, but not lung or oral cancers or cardiovascular disease. There is also some data to suggest that in Sweden, some reduction in smoking is attributable to substitution of snus for cigarettes, they say.
"On the basis of the Swedish data we believe that the potential role of smokeless products at least merits further consideration and investigation to find out whether and to what extent these products can act as substitutes for smoking; whether tobacco products are more effective smoking substitutes than medicinal nicotine; and, if so, whether the product characteristics responsible can be identified and used to develop more acceptable low-risk medicinal products," they write.
The RCP report does cite nicotine-replacement therapy as an obvious smoking alternative. However, the report notes that because these products deliver nicotine more slowly and in lower doses than cigarettes, many smokers who use them tend to relapse. Moreover, nicotine-replacement products tend to be expensive, putting them out of reach for many addicted smokers with low incomes.
Thun agrees that cost of nicotine replacement is a problem. "The solution to this is to fix the health care system, not invite the tobacco companies to sell more tobacco," he says.
Another problem with promoting smokeless tobacco over cigarettes is the danger of youth uptake, Thun adds. "Now that all of the large tobacco companies have introduced their own lines of smokeless products, their marketing strategies will inevitably target susceptible adolescents. They have already introduced flavors such as apple, peach, and mint."
He continues, "There is no evidence that smokers will quit rather than kids taking up the product. In fact, the last time smokeless products were marketed in the US, it was adolescent males who began using it, not smokers trying to quit."
The RCP report calls for the creation of new national and even international nicotine- and tobacco-regulating authorities to enact harm-reduction strategies. Among the proposed reforms are the following:
The report emphasizes that cessation and prevention should remain the primary goals of tobacco control efforts.
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