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Harm reduction policies for tobacco
Abstract
Tobacco harm reduction is a controversial policy due to the experience with filtered and 'light' cigarettes and concerns that the tobacco industry will use reduced harm products to undermine tobacco control strategies. The most promising harm reduction products are high dose pharmaceutical nicotine preparations and low nitrosamine smokeless tobacco, such as Swedish snus. However, despite widespread availability, existing pharmaceutical nicotine preparations have not been taken up by smokers as an alternative to smoking. In Sweden, increased snus use was associated with decreased cigarette smoking and mortality from tobacco-related disease. We suggest a graduated series of policies to explore of the public health costs and benefits of encouraging smokers to switch to these less harmful nicotine products.
... Due to the increased pressure by public health authorities to reduce smoking, the tobacco industry has promoted numerous products that seem to be less harmful, such as "light" cigarettes. 1 More recently, electronic cigarettes (e-cigarettes) were patented as a cigarette substitute to help smokers quit 2 and quickly became popular. 2,3 This has created a heated debate on the pros and cons of e-cigarette use. ...
... One of the crucial questions is whether SLT is a gateway to smoking or a help away from smoking, 18 particularly among young people. 1 However, the gateway effect may apply only to a small minority, since most SLT users either never began smoking or began prior to using SLT. 19 It is important to distinguish between studies on young people and general population surveys of all ages. ...
Introduction:
There are few recent longitudinal studies on smokeless tobacco products (SLT) and smoking outside the United States or European Nordic countries. The present longitudinal study tests whether Swedish type snus and nasal snuff use decreases smoking incidence and prevalence in a central European country.
Methods:
The sample consisted of 5,198 Swiss men (around 20 years of age). Retention rate was 91.5% over 15 months. Regression models, adjusting for a variety of psychosocial, smoking-related, and other risk factors, assessed whether no, low (<weekly) and high (weekly+) use baseline groups showed changes or maintenance in snus and snuff use related to smoking initiation, cessation, and reduction.
Results:
Among baseline non-smokers, snus initiators (OR=1.90, p=.003) and low baseline maintainers (OR=4.51, p<.001) were more likely to start smoking (reference: persistent non-users of snus). Among baseline smokers, initiators (OR=2.79, p<.001) and low baseline maintainers (OR=2.71, p=.005) more often continued smoking, whereas snus quitters less frequently continued smoking (OR=0.57, p=.009). High baseline maintainers were non-significantly less likely to continue smoking (OR=0.71, p=.315). Among continuing smokers, only snus quitters significantly reduced the number of cigarettes smoked per day (b=-1.61, p=.002) compared to persistent non-users of snus. Results were similar for snuff.
Conclusions:
SLT use did not have any significant beneficial effects on young men in Switzerland, but significantly increased the likelihood of smoking initiation and continuation, independent of whether the substance is legally sold (snuff) or not (snus). This does not exclude that there may be beneficial effects at older ages.
Implications:
Our research provides evidence that SLT use has no benefits for cigarette smoking initiation, cessation or reduction among young men in a central European country, where SLT is not highly promoted or receives tax incentives. This is true for both legally sold nasal snuff and Swedish type snus that cannot be legally sold. Results indicate that without incentives for using it, among young people shifts from smoking to SLT use are questionable, and confirms the need for country-specific studies before the global public health community engages in promoting smokeless tobacco.
... Discomfort can be experienced from " dabbing " too much too quickly (Prichard, 2015c, June 19). Evidence remains limited regarding potential health benefits of consuming lower quantities of more potent forms of cannabis (Hall & Fischer, 2010). Conversely, a recent study has suggested links between daily use of higher potency cannabis with low CBD ratios and schizophrenia (Di A c c e p t e d M a n u s c r i p t 22 ...
... Recently popularised by the e-cigarette movement, another perceived advantage of 'vaping' is the potential for harm reduction as the method creates substantially fewer carcinogens and toxicants in inhaled THC content (Hall & Fischer, 2010). A c c e p t e d M a n u s c r i p t 23 the Colorado scheme (such as outlined by Daley, Lampach, and Sguerra (2013)) may reduce some, but not all, harmful outcomes associated with vapourised marijuana consumption (see below for a more detailed discussion regarding testing protocols in Colorado). ...
Background:
For almost a century, the cultivation, sale and use of recreational cannabis has been prohibited by law in most countries. Recently, however, under ballot initiatives four states in the US have legalised commercial, non-medical (recreational) cannabis markets. Several other states will initiate similar ballot measures attached to the 2016 election that will also appoint a new President. As the first state to implement the legislation in 2014, Colorado is an important example to begin investigating early consequences of specific policy choices while other jurisdictions consider their own legislation although the empirical evidence base is only beginning to accrue.
Method:
This paper brings together material sourced from peer reviewed academic papers, grey literature publications, reports in mass media and niche media outlets, and government publications to outline the regulatory model and process in Colorado and to describe some of the issues that have emerged in the first 20 months of its operation.
Results:
These issues include tension between public health and profit, industry and investment, new methods of consumption, the black market and product testing.
Conclusion:
The paper concludes that, while it is too early to determine the impact of the scheme, and noting that it includes some features designed to mitigate adverse impacts, it faces major challenges. Not least of these are the lack of an effective overarching federal regulatory structure, as a consequence of the federal prohibition on cannabis, combined with a rapidly growing cannabis industry which, like other industries, will seek to exploit loopholes to maximise profit.
... On the other hand, other authors note that the current tobacco control policies, including the prevention of smoking in workplaces and public areas and the increases in prices and taxes, have had limited effectiveness, leading to a small reduction in smoking rates of 1 % per year, at best, in countries where smoking is common (Britton et al., 2008). Based on these figures, some authors argue for more drastic policies to reduce rates of smoking (Britton et al., 2008;Gartner and Hall, 2010). ...
... We start with a brief summary of the nicotine reduction proposal (Benowitz and Henningfield, 1994), followed by a comparison of addiction and reinforcement thresholds as behavioral targets for nicotine reduction approaches; finally, we conclude with suggestions for future research. Our review will not address issues related to the rationale and potential adverse consequences of nicotine reduction policies, which are extensively discussed in other recent reviews (Gartner and Hall, 2010;Hatsukami et al. 2007;2010;Parascandola, 2011). ...
Cigarette smoking represents an enormous public health problem worldwide that leads to over 5 million deaths per year. The gradual reduction of the nicotine content of cigarettes below the threshold that is required to develop addiction is one strategy that might substantially reduce the number of addicted smokers and prevent adolescents from becoming addicted to nicotine (Benowitz and Henningfield, 1994). While the potential public health benefits of this approach are enormous, the guiding concepts and relevant empirical evidence needed to support the implementation of a nicotine reduction policy require a critical examination.
The purpose of this paper is to briefly review the current concepts and research regarding nicotine reduction while also discussing the utility of the addictive threshold for nicotine in this approach. The accurate determination of the nicotine addiction threshold presents some conceptual challenges as there is a lack of consensus on how to best measure nicotine addiction. This difficulty can impede the progress for developing a science-based tobacco control policy. As an alternative, the nicotine reinforcement threshold is a relatively clear concept, and well-accepted methods and criteria are available to measure nicotine reinforcement.
However, there are many gaps in our current knowledge concerning the nicotine reinforcement threshold in humans. The threshold for nicotine reinforcement remains to be determined in controlled settings using different populations of current or potential tobacco users. In addition, the value of the nicotine reinforcement threshold in predicting tobacco use in real-world settings needs to be examined. The results of such studies will determine the potential utility of the estimated threshold for nicotine reinforcement in developing science-based tobacco control policies.
... 5,6 Internationally, public health researchers debate whether Swedish snuff, with lower levels of nitrosamines but higher levels of nicotine than tobacco smoke, should be recommended as a harm reduction drug for smoking cessation. [7][8][9][10] The rate of female snuff users has more than tripled during the last decade in Sweden, and the use of smokeless tobacco has increased globally, especially among women of childbearing age. 11,12 There are few studies of the effects of snuff use during pregnancy, but a recently published study revealed an association between maternal snuff use during pregnancy and an increased risk of stillbirth. ...
... It also differs from US moist snuff, which contains less nicotine but higher levels of nitrosamines. 8 The effects of Swedish snuff can be compared with those of NRT in many ways. Both snuff and NRT mainly contain nicotine, with the nicotine level remaining continuously high during use. ...
Maternal smoking is associated with disturbed cardiorespiratory control in the infant. Despite lacking knowledge of whether the harmful effects of smoking are caused by combustion products in tobacco smoke or by nicotine, it has been argued that nicotine-replacement therapy during pregnancy is safer than smoking.
The goal of this study was to investigate if the disturbances in cardiorespiratory control associated with maternal smoking are also seen in infants prenatally exposed to snuff. We hypothesized that prenatal nicotine exposure (via moist snuff) causes disturbances in autonomic control and thereby increases the risk of apnea in the newborn.
In a nationwide Swedish cohort study, we studied associations between maternal tobacco use during pregnancy and neonatal apnea. Of 609 551 live-born singleton infants, 7599 were born to snuff-using mothers, 41 391 and 16 928 were born to light (1-9 cigarettes per day) and heavy (≥ 10 cigarettes per day) smokers, respectively. Logistic regression was used to calculate odds ratios, using 95% confidence intervals.
Compared with infants of nontobacco users, infants with prenatal exposure to snuff were at an increased risk of apnea even after adjustment for differences in gestational age (odds ratio: 1.96 [95% confidence interval: [1.30-2.96]) Smoking was associated with increased risk of apnea before, but not after, adjusting for gestational age.
Snuff use during pregnancy is associated with a higher risk of neonatal apnea than smoking. Maternal use of snuff or nicotine-replacement therapy cannot be regarded as an alternative to smoking during pregnancy.
... The use of snus by smokers has been associated with decreased cigarette smoking and increased abstinence of smoking [63][64][65][66][67][68][69]. Other studies do not support some of these findings [68,70,71]. ...
Introduction
The objective was to systematically review studies on health outcomes from smokeless tobacco (SLT) products.
Methods
We analysed published literature on the health outcomes from SLT use between 01/01/2015 to 01/02/2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol using PubMed, Embase, Scopus, and Google Scholar.
Results
Of 53 studies included, six were global, 32 from Asia, Middle East and Africa (AMEA), nine from USA and six from Europe. ‘Poor’-rated studies predominated (23;43%), in particular, for global (4;66%) and AMEA (16;50%). Health outcomes differed between SLT-products and regions; those in AMEA were associated with higher mortality (overall, cancer, Coronary heart disease (CHD), respiratory but not cardiovascular disease (CVD)), and morbidity (CVD, oral and head and neck cancers), with odds ratios up to 38.7. European studies showed no excess mortality (overall, CVD, from cancers) or morbidity (ischemic heart disease (IHD), stroke, oral, head and neck, pancreatic or colon cancers) from several meta-analyses; single studies reported elevated risk of rectal cancer and respiratory disorders. Pooled study data showed protection against developing Parkinson’s disease. US studies showed mixed results for mortality (raised overall, CHD, cancer and smoking-related cancer mortality; no excess risk of respiratory or CVD mortality). Morbidity outcomes were also mixed, with some evidence of increased IHD, stroke and cancer risk (oral, head and neck). No studies reported on switching from cigarettes to SLT-products.
Conclusion
Our review demonstrates stark differences between different SLT-products in different regions, ranging from zero harm from European snus to greatly increased health risks in AMEA. The literature on the safety profile for SLT-products for harm reduction is incomplete and potentially misinforming policy and regulation.
... In this way, the ROA-related challenges for cannabis use are not dissimilar from the challenges that have unfolded in the realms of other psychoactive substances at different stages, e.g. towards efforts for 'smoke-less' forms of tobacco use or for 'non-injection' use of narcotics commonly injected to reduce acute or chronic adverse health outcomes related to these ROAs (Dolan et al., 2004;Gartner & Hall, 2010). ...
Background:
Cannabis use is common, and associated with adverse health outcomes. 'Routes of administration' (ROAs) for cannabis use have increasingly diversified, in part influenced by developments towards legalization. This paper sought to review data on prevalence and health outcomes associated with different ROAs.
Methods:
This scoping review followed a structured approach. Electronic searches for English-language peer-reviewed publications were conducted in primary databases (i.e., MEDLINE, EMBASE, PsycINFO, Google Scholar) based on pertinent keywords. Studies were included if they contained information on prevalence and/or health outcomes related to cannabis use ROAs. Relevant data were screened, extracted and narratively summarized under distinct ROA categories.
Results:
Overall, there is a paucity of rigorous and high-quality data on health outcomes from cannabis ROAs, especially in direct and quantifiable comparison. Most data exist on smoking combusted cannabis, which is associated with various adverse respiratory system outcomes (e.g., bronchitis, lung function). Vaporizing natural cannabis and ingesting edibles appear to reduce respiratory system problems, but may come with other risks (e.g., delayed impairment, use 'normalization'). Vaporizing cannabis concentrates can result in distinct acute risks (e.g., excessive impairment, injuries). Other ROAs are uncommon and under-researched.
Conclusions:
ROAs appear to distinctly influence health outcomes from cannabis use, yet systematic data for comparative assessments are largely lacking; these evidence gaps require filling. Especially in emerging legalization regimes, ROAs should be subject to evidence-based regulation towards improved public health outcomes. Concretely, vaporizers and edibles may offer potential for reduced health risks, especially concerning respiratory problems. Adequate cannabis product regulation (e.g., purity, labeling, THC-restrictions) is required to complement ROA-based effects.
... This low-nitrosamine, smokeless tobacco product has been reported to be 90% less harmful than smoking cigarettes 42 and has been discussed as a potential strategy to reduce tobacco harm. 43,44 However, although most adult smokers were aware of it, as of 2012 only 20% tried it, and very few migrated to regular use because of dissatisfaction with mouth feel and preference for other forms of tobacco. 45 In addition, newer tobacco products, such as electronic cigarettes, which made smoking cessation and reduced harm claims 46 20 which may have impacted consumer interest in snus. ...
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.
... Cannabis can be consumed in a variety of ways. Smoking is thought to be the most toxic mode of delivery (Hall & Fischer, 2010), and remains the predominant method of consumption for recreational users (Pacula, Jacobson, & Maksabedian, 2015). In a study testing toxicity from three common pesticides, Sullivan, Elzinga, and Raber (2013) demonstrated that chemical residues will transfer into mainstream smoke, and therefore the end-user, at levels ranging from 1-10% for filtered water pipes up to 60-70% for unfiltered glass pipes. ...
Background:
In 2014, Colorado implemented the world's first seed-to-sale recreational cannabis market under a commercial model. This paper aims to provide a thick descriptive account that gives insight into the issues and complexities of Colorado's pioneering and evolving attempt to regulate the use of pesticides on commercial cannabis plantations.
Methods:
The paper examines multiple data sets including: (i) Colorado State Government documents; (ii) recreational cannabis regulations; (iii) mass and niche media publications (n=175); (iv) face-to-face interviews with key stakeholders, including seniors, regulators and industry executives (n=8); and (v) field notes from relevant conferences and cultivation facility tours in Denver in October, 2016.
Results:
Two key issues are identified. First, a public safety threat has arisen relating to application of pesticides on cannabis with intensified toxicity in concentrated products of particular concern. Second, as a pioneering jurisdiction, Colorado faces a considerable knowledge gap. To expand collective learning on this issue, for which no regulatory template and little research exists, state regulators tapped industry and other stakeholder expertise while attempting to ensure public safety goals were achieved and regulatory capture by industry was limited.
Conclusion:
Four years since the recreational cannabis market in Colorado was legalised, the State continues to grapple with the pesticide issue as testing regulations and cultivation standards are yet to be finalised. While more work is needed, Colorado has made significant progress in developing regulations relating to this complex matter. As governments of countries such as Canada and US states, including California, contemplate changes to recreational cannabis laws, Colorado's experience can assist regulators in other jurisdictions considering policy change.
... Factors such as these likely contributed to the reinvigoration of the snus market in Sweden in the 1970s and 1980s. 6 This approach to promoting alternative products should be limited to ways that minimise uptake by young people. ...
The paper by Hatsukami et al 1 in this issue of the journal shows that nicotine gum is at least as effective as snus as a cessation treatment. This result may surprise many, especially those exploring additional benefits of low-toxin tobacco products over pure nicotine as cessation aids. We think it raises two important issues: First, that a product containing only medicinal nicotine could do at least as well as a product with all the attributes of tobacco strongly suggests that the other ingredients in tobacco, such as minor alkaloids, that many have hypothesised as being important may not play much if any role in treating nicotine dependence.
The second issue arises from the finding that there was more continued (longer term) use of snus even though it was not rated as potent in quelling cravings. This finding mirrors the situation in Scandinavia where snus use is widespread, but nicotine gum is primarily used for …
... Among MRTPs on the market, electronic nicotine delivery systems (ENDS), popularly known as electronic cigarettes (e-cigarettes) have become increasingly popular in the US since their introduction in 2007 21,22 . E-cigarettes outwardly resemble conventional cigarettes and typically consist of a battery (either disposable or rechargeable), a reservoir containing a liquid mixture typically composed of propylene glycol, glycerol, nicotine, flavorants, and other additives, and a heating element linked to an air flow activated sensor such that upon puffing the atomizer generates a warm aerosol mist or e-vapor 23,24 . ...
Electronic cigarettes (e-cigarettes) generate an aerosol vapor (e-vapor) thought to represent a less risky alternative to main stream smoke (MSS) of conventional tobacco cigarettes. RNA-seq analysis was used to examine the transcriptomes of differentiated human bronchial epithelial (HBE) cells exposed to air, MSS from 1R5F tobacco reference cigarettes, and e-vapor with and without added nicotine in an in vitro air-liquid interface model for cellular exposure. Our results indicate that while e-vapor does not elicit many of the cell toxicity responses observed in MSS-exposed HBE cells, e-vapor exposure is not benign, but elicits discrete transcriptomic signatures with and without added nicotine. Among the cellular pathways with the most significantly enriched gene expression following e-vapor exposure are the phospholipid and fatty acid triacylglycerol metabolism pathways. Our data suggest that alterations in cellular glycerophopholipid biosynthesis are an important consequences of e-vapor exposure. Moreover, the presence of nicotine in e-vapor elicits a cellular response distinct from e-vapor alone including alterations of cytochrome P450 function, retinoid metabolism, and nicotine catabolism. These studies establish a baseline for future analysis of e-vapor and e-vapor additives that will better inform the FDA and other governmental bodies in discussions of the risks and future regulation of these products.
... One of the areas where researchers have produced disaggregated data is in relation to the use of substances, such as cannabis. Cannabis is the most widely used illegal drug in the world (Hall & Degenhardt, 2014). Compared to men, women generally report lower rates of lifetime cannabis use (47.9% vs. 35.5%, ...
This study reports the prevalence of cannabis use among bisexual women in Ontario, Canada, and identifies correlations among levels of cannabis use (no use, some use, active use) and measures of mental health and social support. Analysis focused on 262 bisexual women from a bisexual mental health study using respondent-driven sampling. Among networked bisexual women in Ontario, Canada, the weighted prevalence of past-year cannabis use was 33.6%, with 13.8% of bisexual women using cannabis twice or more per week. Cannabis use was positively associated with social support, gay community involvement, outness to family, and depression. There was no significant association between cannabis use and anxiety, posttraumatic stress disorder, antibisexual experiences, or suicidal ideation. Bisexual women's rate of past-year cannabis use is more than 5 times that for Canadian women in general, and is consistent with rates for bisexual women found in U.S. studies.
... Moreover, some cigarettes products that have claimed to be harm reduction products do not necessarily reduce harm. For example, "light" cigarettes were marketed as having lower tar and nicotine yields; however, as was learned after they had been used many years, smokers compensated for lower nicotine by puffing longer and harder and smoking more frequently, which negated their harm reduction benefit (Gartner and Hall, 2010;Zeller et al., 2009). Another harm reduction strategy has been to lower the level of carcinogens and known toxicants in cigarette smoke either by using filters, diluting the smoke with ventilation holes in the cigarette paper, or modifying the curing procedures used to prepare tobacco (Hatsukami et al., 2004;Shields, 2002). ...
Human embryonic stem cells (hESCs) provide unique tools for toxicological studies as they model prenatal stages of development, the period of the life cycle that is generally the most sensitive to environmental toxicants. Live cell imaging of stem cells can be used to solve toxicological problems and provides a powerful method for examining numerous dynamic end points affected by toxicant treatment. Collection of video data has recently been simplified and improved by the introduction of new instrumentation suitable for both small-scale and high-content imaging of living cells. However, video data are complex and difficult to evaluate quantitatively. Manually mining data from videos is laborious and prone to inaccuracies. This challenge can be overcome by applying video bioinformatics (VBI) software tools to video analysis problems. VBI software improves the speed of analysis and accuracy. Methods for collecting video data with stem cells as well as software and protocol development are discussed. Application of VBI tools to the analysis of hESC colony growth, motility of mouse neural stem cells, and differentiation of osteoblasts from hESCs is presented. Potential future improvements in VBI tools as they apply to stem cell toxicology are also discussed.
... Most regulators, therefore, apply no time limit for NRT use to support reduction, confident that this alone facilitates quitting and may have direct health benefits, not least to those living with the smoker. Similarly, many countries also support 'temporary abstinence' (Gartner, Hall, & McNeill, 2010). An overview of approaches over time in the UK is presented in Fig. 1. ...
Over the last 50years, the concept of tobacco harm reduction has been well established. It is now understood that nicotine itself is not very harmful and nicotine replacement therapy products have been widely used as an aid to quit, reduce to quit or temporarily abstain from smoking for many years. The popularity of the unlicensed electronic cigarette has increased despite an unknown risk profile and snus use in Sweden provides strong evidence in support of a harm reduction strategy. The regulatory environment around harm reduction has changed in the UK and is continuing to evolve across the globe. The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. The significant positive impact on public health that could be gained from encouraging people to switch from cigarettes to licensed medicinal nicotine products cannot be ignored.
... Indeed, this highlights the need to encourage access to and support the uptake of credible information on cannabis. Admittedly language use remains a challenge in public health [28] ; conveying precise and accurate " risk " information to youth and adult populations regarding cannabis is no easy task when much remains unclear [29]. Our study findings point to the importance of using clear and precise terminology. ...
Contradictory evidence on cannabis adds to the climate of confusion regarding the health harms related to use. This is particularly true for young people as they encounter and make sense of opposing information on cannabis. Knowledge translation (KT) is in part focused on ensuring that knowledge users have access to and understand best evidence; yet, little attention has focused on the processes youth use to weigh scientific evidence. There is growing interest in how KT efforts can involve knowledge users in shaping the delivery of youth-focused public health messages. To date, the youth voice has been largely absent from the creation of public health messages on cannabis.
This ethnographic study describes a knowledge translation project that focused on engaging young people in a review of evidence on cannabis that concluded with the creation of public health messages generated by youth participants. We facilitated two groups with a total of 18 youth participants. Data included transcribed segments of weekly sessions, researcher field notes, participant research logs, and transcribed follow-up interviews. Qualitative, thematic analysis was conducted.
Group dynamics were influential in terms of how participants made sense of the evidence. The processes by which participants came to understand the current evidence on cannabis are described, followed by the manner in which they engaged with the literature for the purpose of creating an individual public health message to share with the group. At project end, youth created collaborative public health messages based on their understanding of the evidence illustrating their capacity to "weed out" the information. The content of these messages reflect a youth-informed harm reduction approach to cannabis use.
This study demonstrates the feasibility of involving young people in knowledge translation initiatives that target peers. Youth participants demonstrated that they were capable of reading scientific literature and had the capacity to engage in the creation of evidence-informed public health messages on cannabis that resonate with young people. Rather than simply being the target of KT messages, they embraced the opportunity to engage in dialogue focused on cannabis.
... Some scientists have pointed to the Swedish experience to demonstrate there is a reduced risk of becoming a smoker among male primary snus users compared to non-primary snus users (Ramstrom and Foulds, 2006). In addition, use of snus by smokers has been associated with decreased cigarette smoking and increased chances of becoming abstinent (Bates et al., 2003;Fagerstrom and Schildt, 2003;Gartner and Hall, 2010;Gartner et al., 2007;Ramstrom and Foulds, 2006;Stegmayr et al., 2005;Stenbeck et al., 2009). Other studies do not support some of these findings (Tomar, 2002;Tomar, 2007), particularly in specific populations (Stenbeck et al., 2009). ...
Recently, oral tobacco products have been marketed specifically towards cigarette smokers. These products come in different nicotine doses and formulations (snus vs. lozenge). To date, little research has been conducted to determine how smokers respond to these products. The goal of this study was to examine if smokers prefer certain oral tobacco products based on their specific characteristics.
Smokers interested in quitting underwent a sampling phase and a treatment phase. The sampling phase consisted of testing five different products varying in nicotine dose (high vs. moderate vs. low) and formulation (snus vs. lozenge): General Snus, Camel Snus, Marlboro Snus, Stonewall and Ariva. Each product was sampled in the natural environment on separate days. At the end of the sampling period, subjects chose which product they would use during the 2-week cigarette abstinence phase.
General Snus (high nicotine) was not preferred by any smoker. No significant differences in preferences were observed across the other tobacco products. During the smoking cessation phase, Camel Snus was generally associated with greater craving relief and satisfaction, reduced use of cigarettes, and greater abstinence during follow-up compared to other products.
There were no differences in preferences for four of the five oral tobacco products but higher nicotine oral tobacco products were associated with better cessation outcomes among smokers who chose these products.
... Similar to Shiffman's survey findings,[27] we also found that among smokers willing to try an oral nicotine product more were interested in using a pharmaceutical nicotine product (Commit) compared to three alternative smokeless tobacco products. This finding of willingness to use a nicotine replacement product for temporary substitution is consistent with prior literature showing substantial use of NRT products for reasons other than quitting (e.g., smoking reduction, temporary abstinence) by smokers [39,40] The observed preference for the nicotine lozenge counters an implicit assumption [41,42] that smokers would more likely prefer smokeless tobacco to nicotine products. At the same time, the greater the range of products offered, the greater the proportion of smokers who may find a product they see as a viable substitute for cigarettes. ...
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.
This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.
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.
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).
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.
This review outlines the important oral implications of tobacco use. The lining of the mouth (oral mucosa), if exposed to tobacco and its products in a susceptible individual, can develop benign, potentially malignant, and malignant tumours. Treatment and prognosis depend on tumour type, how early it is detected, its size and site in the oral cavity and whether it has spread. Advanced oral squamous cell carcinoma (OSCC) has a 20% 5‐year survival rate. Tobacco use also increases the risk of periodontitis, peri‐implantitis, caries, alveolar osteitis and halitosis. While less life threatening than OSCC, these tobacco related conditions create a substantial financial and health burden for individuals and society. Dental practitioners routinely examine the oral cavity for signs of mucosal and tooth changes, are experienced in recognising variations from normal and have established management and referral pathways. They are also ideally positioned to provide brief interventions to assist their patients to quit smoking.
This chapter provides a brief introduction into tobacco harm reduction and discusses the key parameters of the equation that influences harm reduction policies. It also provides an approach to balance the risk of introducing “noncombustible alternative” to cigarettes into the market in the absence of complete knowledge about effectiveness in harm reduction. This chapter concludes with examples of existing regulatory frameworks.
Introduction-
Motivating tobacco consumers to change their behavior, and harm reduction strategies, are the predominant traditional approaches to tobacco cessation. Recent trends worldwide have shown the emergence of Electronic Nicotine Delivery Systems (ENDS), such as electronic cigarettes (e-cigarettes), as a purported harm reduction strategy to traditional cigarettes. Considering the global rise in the popularity of ENDS, our study aims to survey the online retail market for ENDS in India.
Methods-
The current study was conducted in September- October, 2015 and 4 keywords were used to search Google India to identify online retail websites marketing ENDS. Each website was searched using the same keywords and all specific website pages displaying ENDS models were considered. Thus, Data was obtained for various measures of ENDS present on the model descriptions.
Results-
A total of 6 retail shopping websites were searched which revealed 65 different models of ENDS (34 brands). 45 models (69%) were flavored and 21 models (33%) mentioned about nicotine strengths. 17 models (26%) provided health warnings in their product descriptions. “No Tar No Tobacco” was most common claim accounting to 34 models (51%).
Conclusions-
This paper provide insight into the current status of evident online sales of ENDS in India. There is urgent need to implement regulations on online sales of these products and protect the future from such approaches of tobacco control which still have divided opinions.
IMPLICATIONS-
The study permits the use of web search engine to explore market availability of ENDS at various online retail websites. Recommendations from the study can be used to guide policy makers in developing strategies tailored to regulate availability and online sales of ENDS in India.
Background:
YouTube is the most popular video sharing website, and is increasingly used to broadcast health information including smoking cessation advice. This study examines the quality and quantity of YouTube quit smoking videos targeted at people living with mental illness (MI).
Methods:
We systematically searched YouTube using selected relevant search terms. The first 50 videos obtained for each search term were screened for relevance and further videos screened through snowball sampling. Forty unique, English language videos focussing on people with MI were included in the assessment and evaluated for general video characteristics, themes, format, targeted smoking cessation and harm reduction information.
Results:
Most videos either discussed the problem of high smoking rates among people with MI (n=12) or smoking cessation programmes and policies at an institutional level (n=13). Only nine videos were aimed at providing quit smoking advice to this population. One video recommended higher doses of nicotine replacement therapy (NRT) for people with MI while six videos referred to possible changes in medication dosage on quitting smoking. Four videos suggested cutting down smoking for harm reduction.
Conclusions:
Very few YouTube videos specifically focus on the problem of high smoking rates among people with MI and even fewer provide targeted smoking cessation and harm reduction advice for this priority population. There is a need to develop comprehensive, evidence based, quit smoking video resources for smokers with a MI.
This chapter focuses on neuroscientific approaches to reducing smoking prevalence. Given the heritability of many aspects of smoking behavior, the early identification of individuals who are genetically most at risk of becoming smokers could facilitate prevention of uptake. Genetic information could also be used to match smokers to the treatment that is most likely to assist them to become abstinent. Nicotine vaccines induce the immune system to produce antibodies that bind to nicotine molecules in the bloodstream to form a molecule that is too large to cross the blood-brain barrier and produce its rewarding effects. Various cortical regions of the brain have been implicated in the maintenance of drug addiction, leading some authors to suggest deep brain stimulation (DBS) as a treatment of addiction including for smoking cessation. If addiction produces neurobiological changes that make quitting difficult or even unachievable, then there is a strong case for attempting to reduce the harm caused by tobacco addiction by encouraging smokers who are unable or unwilling to quit to switch to less harmful ways of using nicotine.
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.
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.
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.
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.
This study investigated the removal of heavy metal ions from cigarette mainstream smoke using chitosan. Chitosan of various deacetylation degrees and molecular weights were manually added to cigarette filters in different dosages. The mainstream smoke particulate matter was collected by a Cambridge filter pad, digested by a microwave digestor, and then analyzed for contents of heavy metal ions, including As(III/V), Pb(II), Cd(II), Cr(III/VI) and Ni(II), by graphite furnace atomic absorption spectrometry (GFAAS). The results showed that chitosan had a removal effect on Pb(II), Cd(II), Cr(III/VI) and Ni(II). Of these, the percent removal of Ni(II) was elevated with an increasing dosage of chitosan. Chitosan of a high deace tylation degree exhibited good binding performance toward Cd(II), Cr(III/VI) and Ni(II), though with poor efficiency for Pb(II). Except As(III/V), all the tested metal ions showed similar tendencies in the growing contents with an increasing chitosan molecular weight. Nonetheless, the percent removal of Cr(III/VI) peaked with a chitosan molecular weight of 200 kDa, followed by a dramatic decrease with an increasing chitosan molecular weight. Generally, chitosan had different removal effects on four out of five tested metal ions, and the percent removal of Cd(II), Pb(II), Cr(III/VI) and Ni(II) was approximately 55%, 45%, 50%, and 16%, respectively. In a word, chitosan used in cigarette filter can remove toxic heavy metal ions in the mainstream smoke, improve cigarette safety, and reduce the harm to smokers.
Purpose:
To determine test market awareness and promotional effects of Camel dissolvable tobacco.
Design:
Cross-sectional survey.
Setting:
Indiana test market.
Subjects:
Stratified sample of Indiana adults (N = 472).
Measures:
Data were poststratified and weighted to account for the sampling and demographics.
Analysis:
Descriptive statistics and multivariate analysis.
Results:
The study results indicate that 31.2% of participants were aware of Camel Dissolvables, 4.5% had tried them, and 8.3% were likely to try them. Tobacco use was a significant predictor of all outcomes; dual (cigarettes and smokeless tobacco) users were more likely to be familiar with, try, and be interested in trying Camel Dissolvables than single tobacco users and nonusers (p < .05). Male gender was a significant predictor only for likelihood of trial (p < .05). Education was a significant predictor only of actual trial (p < .05). Familiarity was predicted by in-store, magazine, and mail promotions. Trial was predicted by having seen magazine ads. Web site exposure predicted likelihood of trial. Of those who reported trying Camel Dissolvables (N = 37), 49% no longer used them, 43% used them some days, and 8% used them daily. Continued use was reported by 87% of dual users and 26% of single tobacco users (p < .01).
Conclusion:
Smokers and male dual tobacco users appear most affected by Camel Dissolvables promotions.
Substances, such as alcohol, opiates and cannabis, have been used by humans for millennia. Today, a much wider range of substances are used for a range of purposes, including the enhancement of performance during university studies, sexual experiences, sports, exercise, at celebrations, socializing and the experience of art and music. Substance use is also associated with a range of harmful effects to the individual and society as a whole. Prohibitions, regulation, prevention and treatment have all been used to protect against this harm. In this commentary, it is argued that public health interventions should target relevant harms and not to evaluate which aspects of human endeavors and experiences should be enhanced and which should not. It is argued that interventions should directly target the harmful effects, using the best available evidence. Two examples are given of substances that may be altered to prevent serious harm--one for alcohol and one for cannabis. In the case of alcohol, the addition of dissolved oxygen could reduce both the risk of accidents and the risk of liver damage associated with alcohol consumption. In the case of cannabis, there is strong indication that the reduction of content Delta-tetrahydrocannabinol and the increase of cannabidiol could reduce the risk of psychoses and the addiction associated with its use. The aim of this article is to show that responsible regulation should not necessarily be restricted to preventing the use and/or (in the case of alcohol) a reduction in the amounts and frequency of its use, but should also aim to include a range of other strategies that could reduce the burden of illness associated with illicit substance use.
Both the recent Institute of Medicine (IOM) report1 and the article by Henningfield and Fagerstrom2 in this issue of Tobacco Control consider the value of adding harm reduction products to the main public health strategies for dealing with tobacco use—prevention, cessation, and protection of non-smokers from tobacco smoke pollution.3 4 Harm reducing products are those that lower total tobacco caused morbidity and mortality, even though these products might involve continued exposure to one or more tobacco related toxicants. The IOM committee developed a testing strategy to assess which products (tobacco or pharmaceutical) are truly harm reducing, along with surveillance and regulatory principles for the protection of public health. Henningfield and Fagerstrom2 discussed the possible benefits from an uncontrolled harm reduction “intervention” in Sweden involving Snus (Swedish moist snuff) and to some extent nicotine replacement pharmaceuticals or medicinal nicotine (MN).
It will take years, if ever, before any battery of IOM-type tests will be in place. Given the probability of legal and political battles, the final form of testing and regulation may be far from adequate, leading to further decades of the promotion of ostensibly reduced risk products falsely reassuring tobacco users. Cigarette smoking remains the single leading preventable cause of death in most developed countries5 and a major cause of current and future deaths in developing countries.6 For health, non-smokers should never start smoking, and current smokers should become former smokers as soon as possible. Harm reduction, if done well, offers additional promise. Once it was hoped that lower tar cigarettes would have harm reducing properties and be good for the public's health,7but, on current evidence, they have been a public health disaster.8-11
One harm reduction strategy is to alter cigarettes to try to reduce or eliminate toxic ingredients. Such altered …
To understand the development, intent, and consequences of US tobacco industry advertising for low machine yield cigarettes.
Analysis of trade sources and internal US tobacco company documents now available on various web sites created by corporations, litigation, or public health bodies.
When introducing low yield products, cigarette manufacturers were concerned about maintaining products with acceptable taste/flavour and feared consumers might become weaned from smoking. Several tactics were employed by cigarette manufacturers, leading consumers to perceive filtered and low machine yield brands as safer relative to other brands. Tactics include using cosmetic (that is, ineffective) filters, loosening filters over time, using medicinal menthol, using high tech imagery, using virtuous brand names and descriptors, adding a virtuous variant to a brand's product line, and generating misleading data on tar and nicotine yields.
Advertisements of filtered and low tar cigarettes were intended to reassure smokers concerned about the health risks of smoking, and to present the respective products as an alternative to quitting. Promotional efforts were successful in getting smokers to adopt filtered and low yield cigarette brands. Corporate documents demonstrate that cigarette manufacturers recognised the inherent deceptiveness of cigarette brands described as "Light"or "Ultra-Light" because of low machine measured yields.
Tobacco harm reduction (THR) has garnered recent attention due to the introduction of novel nicotine delivery products ostensibly intended to reduce risk for inveterate cigarette smokers. This study evaluates the grassroots tobacco control community's knowledge, opinions, and beliefs about THR.
A web/mail survey conducted in October and November 2002, with a telephone survey of a sample of non-respondents.
The 2833 US based registrants for the 2001 National Conference on Tobacco or Health.
Respondents' awareness of THR, perception of its importance, support for regulation, and perception of which THR products should be recommended to inveterate cigarette smokers.
70% of respondents were aware of THR but respondents had low recognition of specific products at the forefront of the debate, such as Swedish snuff. Half believe THR will reduce smoking cessation and cause nicotine experimentation by children; 63% anticipate unintended adverse side effects. More expect THR to have a negative than a positive impact on health. Large majorities support government regulation of THR and conventional tobacco products, but fewer than 30% expect legislation regulating either. Most would recommend nicotine patches (76%) and gum (70%) to inveterate smokers, but no other product was supported by a majority. Scientists are more supportive of THR than activists, while respondents focusing on national/international issues are more supportive than those concentrating on local/state issues.
Many members of the US tobacco control community are unaware of the THR "movement", while others possess only rudimentary familiarity with it. If and as THR achieves an increasingly prominent role on the tobacco-or-health scene, this community will have to become educated about THR, and be prepared to advocate for regulatory policies that will maximise the potential for positive outcomes. The potential for negative outcomes remains significant.
To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden.
Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden.
Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.
Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.
Scientists and public health practitioners are sharply divided today over the risks and benefits of tobacco harm-reduction strategies. At the same time, a range of novel tobacco products is being marketed with claims of reduced exposure or risk. Current scientific efforts to study tobacco products and harm reduction should be informed by past experience. During the 1960s and 1970s, there was substantial support within government and academia, as well as among voluntary health organizations, for efforts to modify tobacco products to reduce harm. This paper analyzes the former National Cancer Institute (NCI) Smoking and Health Program, which, between 1968 and 1980, pursued the development of "less hazardous" cigarettes as its primary goal. During this period, the program spent over dollar 50 million on contract research, of which 74% went toward biological and chemical analysis of modified cigarettes, 9.6% to epidemiological studies of risk factors, and only 1.4% to studies evaluating smoking cessation or prevention programs. NCI officials predicted during the mid-1970s that new "low-tar" cigarette brands would substantially reduce smoking-related mortality, but by 1978 the research agenda began to change in response to a reorganization of NCI research activities, modification of government antismoking efforts, and an emerging understanding of nicotine addiction that challenged key scientific assumptions. In retrospect, the program suffered from significant weaknesses that severely limited the likelihood that it would generate knowledge beneficial to public health, including a research agenda that failed to include surveillance and behavioral research, tobacco industry influence of the research agenda, and a lack of access to information about the characteristics of products on the market. There exists today a need for a public health-oriented research agenda on tobacco products and harm reduction, but current efforts should include input from a diverse range of disciplines, collect data on users' behavior, and limit the involvement of industry scientists.
To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking.
Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001-2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures.
15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum.
Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking.
The contentious debate over the promotion of Swedish snus, a form of moist snuff, as an alternative to cigarettes has often focused on the product's potential as a gateway to smoking. Findings from prospective studies in the United States have suggested that smokeless tobacco (SLT) is a significant predictor of smoking onset, before and after adjustment for baseline covariates. Use of conventional regression methods in these studies may have resulted in biased parameter estimates, arising from imbalanced covariate distributions in the users and nonusers of SLT. An alternative approach, which has been used widely in the econometric literature, matches exposure or treatment levels on the basis of the propensity score distribution.
Using this approach, we matched current SLT users from the National Longitudinal Study of Adolescent Health with nonusers (496 pairs) and followed them from adolescence into young adulthood for determination of smoking status.
Prior to matching, the unadjusted risk of becoming a daily smoker was significantly greater for the SLT users compared with nonusers (n = 10,820; range of relative risk = 1.3-2.0, p < .001). However, after pairing individuals on propensity score, we found no evidence for an increased risk of smoking among the SLT users.
Baseline differences in the risk factors for smoking likely account for the association between the two tobacco products.
In increasing numbers, Americans will seek to satisfy nicotine addictions through the use of novel nicotine-delivery products devoid of several of the poisons that make cigarettes so deadly. In the vanguard are tobacco industry devices that heat tobacco derivatives rather than burn tobacco, and pharmaceutical industry nicotine-replacement products, with nicotine gum and the patch now available over the counter. Ostensibly, these 2 industries have diametrically opposed objectives, the tobacco industry striving to sustain nicotine addictions, the pharmaceutical industry to end them. However, a series of technological, economic, political, regulatory, and social developments augurs a strange-bedfellows competition in which these industries will vie for shares of a new multibillion dollar long-term nicotine-maintenance market. Regulatory options range from encouraging competition to banning all nicotine-delivery devices. A more realistic approach discourages use of the most dangerous products, while making less hazardous products readily available to adults.
This study was designed to test the hypothesis that smokeless tobacco (SLT) serves as a gateway drug for smoking among young adult males. Methods. A cohort (n = 7,865) of U.S. Air Force recruits who claimed to have never smoked cigarettes was followed prospectively for 1 year. The participants were male, 32.9% were ethnic minorities, and their average age was 19.84 years (SD = 2.29). Among recruits entering basic military training, 403 (5.1%) reported current SLT use and 198 (2.5%) reported a past history of SLT use.
At the 1-year follow-up current SLT users were 233% more likely to have initiated smoking than nonusers (odds ratio = 2.33, 95% CI = 1.84-2.94). Similarly, recruits who reported past SLT use were 227% more likely to begin smoking than participants who had never used SLT (odds ratio = 2.27, 95% CI = 1.64-3.15). SLT use remained a potent predictor of smoking initiation in a multivariate logistic model that included demographic factors and other risk factors for initiation.
SLT use appears to be an important predictor of smoking initiation among young adult males. This study suggests that smoking prevention and cessation programs should also include strategies related to SLT use.
Two respected agencies of the U.S. Department of Health and Human Services (DHHS)-the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA)- have maintained websites which have erroneously reported that smokeless tobacco is not safer than cigarettes, 1,2 This claim is not supported by science and acts unethically to mislead readers of these websites. 3-10 Although others have examined ethical issues in health communication, 11-15 we think these scholars did not go far enough. We think that the explicit ethical standards embodied in current federal regulations for deception in research should be applied to judge deceptive or misleading information in health communication interventions. 16 The term deception usually refers to intended acts of deception; regardless of intention, however, erroneous information can cause the recipient to be deceived about the true state of affairs. The misleading health information on smokeless tobacco fails to meet the government criteria against deception in research. First, the misleading information may have adverse effects on some individuals (e.g., those who switch to cigarettes or fail to switch from cigarettes because they think they are not more dangerous than smokeless). Second, individuals have a right to know about the dramatically different dangers of smokeless tobacco and cigarettes. Third, there are alternative communication strategies that could be employed to inform people of the risks of both products. And, finally, such misleading information would be unallowable because it is not linked to debriefing. This article reviews the misleading information on the governmental websites, shows how modern ethical rules against deception can be applied to health information, and argues that providing information about the comparative risks of cigarettes and smokeless tobacco is the least evasive and most ethical course of action.
Those who either never progress from smokeless tobacco (SLT) to smoking or smoked before using SLT logically cannot have smoking caused by SLT use. The prevalence of such use permits strong inferences about the overall importance of the potential causal effects of SLT on cigarette smoking. We found that the majority of SLT ever users (66%) in the 2000 National Household Survey on Drug Abuse (NHSDA) were noncausal users. For these individuals, SLT use cannot have caused them to smoke. We also compared our results in 2000 with a similar sample in 1987, using current SLT users only. Potentially, the causal uses of SLT were in the minority and had not increased significantly over time (24% in 1987 to 29% in 2000, P>.05). Logistic models showed that, when noncausal users were removed, SLT was a minor predictor of current smoking. This is likely due to linked experimentation. We argue that that the majority of SLT use cannot cause smoking, such that SLT effects on smoking initiation are minimal at best. Policy implications of these findings are discussed.
Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus.
We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked.
There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking.
Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.
Systematicreviewofthehealtheffectsofmodifiedsmokeless tobacco products
- M Broadstock
Broadstock,M.(2007).Systematicreviewofthehealtheffectsofmodifiedsmokeless tobacco products. NZHTA Report, 10(1)
Tobacco or health in the European Union. Luxem-bourg: European Commission The Cigarette Century
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Harm reduction in nicotine addiction: helping people who can't quit. A report by the Tobacco Advisory Group of the Royal College of Physicians
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