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Response to Ross G ELetter Regarding "Pharmacotherapy for Nicotine Dependence"
Re: What about smokeless tobacco?
What about smokeless tobacco?
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S. Jane Henley, MSPH, Epidemiologist American Cancer Society, Michael J. Thun, Thomas J. Glynn
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jane.henley{at}cancer.org S. Jane Henley, MSPH, et al.
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We strongly disagree with the proposal by Dr. Ross that chewing tobacco and snuff be offered to cigarette smokers to facilitate smoking cessation.(1) While it is true that spit tobacco products are less lethal than cigarettes, there is no evidence that these are more effective than conventional pharmacotherapies in helping smokers to quit, such as nicotine replacement and antidepressants, and they are certainly more toxic and carcinogenic. The example of Swedish snuff (snus) provides no evidence that these products are effective in reducing smoking rates or facilitating cessation. The “Swedish experience” is based on an ecologic analysis that relates per capita consumption of snus to the prevalence of cigarette smoking in the entire population. Surveys indicate that the increase in use of snus occurred largely among adolescent boys and younger men in Sweden, whereas smoking cessation occurred in older men and women.(2) Sales data indicate that per capita consumption of cigarettes and snus increased in parallel during the 1970s; surveys of Swedish men and women Sweden show that most men and nearly all women quit smoking without using snus.(3) It is remarkable that the manufacturers of snuff and chewing tobacco sold in America would seek health claims for their products, when the concentration of total nitrosamines in their products is 4-38 times higher(4) than the concentration in Swedish snus.(5) The most effective way to reduce cigarette smoking, in Sweden and elsewhere, is through broad and sustained tobacco control efforts that include restrictions on marketing, increased cigarette prices, clean indoor air laws, and increased access to safe and established treatments.(6) It is not sufficient to compare the hazards of spit tobacco with those of cigarette smoking; the appropriate comparison is between these products and established treatments for tobacco dependence. Henningfield et al appropriately excluded spit tobacco from their comprehensive review of pharmacotherapies. (7) We consider it irresponsible for individuals and organizations to advocate the use of spit tobacco for smoking cessation without evidence that it is more effective and at least as safe as conventional therapies. Sincerely, Michael J. Thun, MD, MS S. Jane Henley, MSPH Thomas J. Glynn, PhD References 1. Ross G. What About Smokeless Tobacco? Letter to the Journal. CA: Cancer J Clin 2005 http://caonline.amcancersoc.org/cgi/eletters/55/5/281. 2. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control's efforts? Tob Control. 2003;12(4):368–71. 3. Lindstrom M, Isacsson SO; Malmo Shoulder-Neck Study Group. Smoking cessation among daily smokers, aged 45-69 years: a longitudinal study in Malmo, Sweden. Addiction. 2002;97(2):205–15. 4. Brunnemann KD, Qi J, Hoffmann D. Chemical profile of two types of oral snuff tobacco. Food Chem Toxicol 2002;40:1699–703. 5. Osterdahl BG, Jansson C, Paccou A. Decreased levels of tobacco- specific N-nitrosamines in moist snuff on the Swedish market. J Agric Food Chem 2004;52:5085–8. 6. Henningfield JE, Fagerstrom KO. Swedish Match Company, Swedish snus and public health: a harm reduction experiment in progress? Tob Control. 2001;10(3):253–7. 7. Henningfield JE, Fant RV, Buchhalter AR, Stitzer ML. Pharmacotherapy for nicotine dependence. CA: Cancer J Clin 2005;55:281–299. |
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Jack E. Henningfield, Vice President for Research and Health Policy Pinney Associates, Reginald V. Fant, August R. Buchhalter
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jhenning{at}pinneyassociates.com Jack E. Henningfield, et al.
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Smokeless Tobacco is Not Treatment – Reply to Ross We do not recognize or recommend smokeless tobacco as treatment for tobacco dependence. Although it contains nicotine, it meets none of the criteria for “pharmacotherapy” described in our article. Smokeless tobacco products, Swedish and American, are designed to promote and sustain addiction, not break it. They contain numerous toxins and are recognized as carcinogenic by the International Agency for Research on Cancer (1). The risks of smokeless tobacco use include oral cancers and diseases of gingival and periodontal tissues (2). One study found that 38% of daily snuff users in the US have oral tobacco lesions, a mucosal condition that may be premalignant (3). Smokeless tobacco use may increase the risk of cardiovascular diseases and cancers of the larynx, esophagus, and other sites (2). From a public health perspective, the United States has already witnessed side effects of promoting smokeless tobacco products as “safer substitutes” for cigarettes— many youth interpreted the message as “safe”, a perception that contributed to the increased use of smokeless tobacco use from the 1970s to the present (4). Although smokeless tobacco marketed in Sweden (“snus”) appears less toxic than that in the US, this does not qualify it as a treatment for tobacco dependence. Furthermore, because there is no regulatory oversight of ingredients in the US, nor any labeling requirement for ingredients and toxins, clinicians recommending smokeless tobacco as “treatment” could very well lead their patients to expose themselves to decades of the highest carcinogen and nicotine containing products in the US and increased risk of head and neck cancers, oral diseases, and other diseases as compared to tobacco cessation (5,6). Setting aside the issues of product toxicity, the designation of pharmacological treatment implies the criteria including the following for the medicine: (1) drug dose labeling, (2) guidance for dose selection, (3) scientifically validated treatment protocol guidance (note that this differs across nicotine replacement medications), (4) a behavioral support program adapted to the dosing system. Related to dosing and further highlighting the Russian roulette nature of recommending smokeless tobacco as treatment is that smokeless tobacco products vary widely in nicotine content and dosing characteristics with no labeling to guide consumers or clinicians. For example, nicotine gum or lozenge contain 2 or 4mg nicotine and deliver about 50-80% over 30 minutes. In contrast, smokeless tobacco products in the US vary from less than 1 mg to approximately 10 mg per gram of tobacco with people typically using approximately 2 grams but also showing wide variation in amount and speed of absorption, thereby producing widely variable plasma nicotine levels, cardiovascular effects, subjective effects and other side-effects (6). 1. International Agency for Research on Cancer. Tobacco Products, Smokeless. IARC Monographs 1987; Supplement 7:357. 2. Winn DM. Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco. Adv Dent Res 1997;11:313–321. 3. Tomar SL, Winn DM, Swango GA, Giovino GA, Kleinman DV. Oral mucosal smokeless tobacco lesions among adolescents in the United States. J Dent Res 1997;76:1277–1286. 4. US Department of Health and Human Services. Prevention tobacco use among young people. A Report of the Surgeon General. Washington, DC: US Government Printing Office; 1994. 5. Hoffmann D, Djordjevic MV, Fan J, Zang E, Glynn T, Connolly GN. Five leading U.S. commercial brands of moist snuff in 1994: assessment of carcinogenic N-nitrosamines. J Natl Cancer Inst 1995;87(24):1862-9. 6. Fant RV, Henningfield JE, Nelson RA, Pickworth WB. Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tob Control 1999;8:387-92. |
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Gilbert Ross, MD, Executive and Medical Director American Council on Science and Health, Mara Burney
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rossg{at}acsh.org Gilbert Ross, MD, et al.
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To the Editor: Henningfield et al.'s almost-comprehensive article "Pharmacotherapy for Nicotine Dependence" [1] stated that in order for smokers to succeed in quitting permanently, they must be "offered a 'menu' of treatment options." Unfortunately, the authors' menu is missing one vital component. Their failure to mention the Swedish experience with smokeless tobacco- - which saw a significant decrease in smoking rates over the past 20 years largely attributable to the increase in smokeless use [2]-- is yet another example of the all too prevalent willful blindness on this subject. Smokeless tobacco may well be a realistic harm reduction tool for smokers who are unable or unwilling to give up tobacco. It is understandable, to a degree, that anti-tobacco educators and researchers bear a substantial abhorrence towards all things tobacco- related. It is also true that while smokeless tobacco is not without risks, those risks are drastically lower than those of smoking. But in an article dealing with smoking cessation modalities, which mentions smokeless only insofar as to unfavorably compare it with cigar smoking [1], the absence of any discussion of smokeless as a cessation aid smacks of unscientific bias. Avoiding the topic does a disservice to the 45 million addicted adult smokers in this country, depriving them of information about one modality that has the potential to increase quit rates and save lives. [1] Hennifield J. “Pharmacotherapy for nicotine dependence.” Cancer Journal for Clinicians, 2005;55:281-299. [2] Rodu B., Stegmayr B., Nasic S., Asplund K. Impact of smokeless tobacco use on smoking in northern Sweden.” J Int Med 2002;252:398-404. |
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