Swedish Snus: A Reply to Professor Tomar

Professor Scott Tomar (University of Florida) has made a couple of comments to my January 10th posting about the IARC report on smokeless tobacco. As these require a slightly lengthier response than a brief comment, I’m doing it here.

Dr Tomar presented some data showing the quit ratio for specific age groups of ever smokers (including ever occasional smokers). The age groups stop at age 64. My view is that snus availability has helped addicted (i.e. daily) smokers to quit. I doubt it would make much difference to occasional smokers, many of whom can quit if they want to without the need to use snus or NRT. That’s why most of those analyzing this issue have focused on daily smokers. In the Swedish government’s most recent report on tobacco use (2007) on p34 there is a diagram (#10) that presents data on the quit ratio by age and gender, based on ever daily smokers. The quit ratio is similar for men and women up to age 54 (around 30% in 2004-5). Thereafter there are large differences e.g. 50% of 65-74 year-old male ever daily smokers have quit, compared with 29% of female ever daily smokers.

So why the similar quit ratios below that age? In some respects women are not a perfect “control” or comparison group as they experience certain sex-specific life events in their younger years that men don’t (e.g. pregnancy) that are frequent triggers for quitting. Another factor is that across the age range female smokers tend to have a lower cigarette consumption. In the late 70s and early 80s Swedish men had a consistently higher smoking prevalence than women, and over the past 15 years Sweden is the only country in Europe to have male smoking prevalence consistently lower than women. Sweden is also the only EU country where snus can be legally sold and 24-30% of male ex smokers have quit smoking by switching to snus. I interpret this as evidence that snus has helped many Swedish smokers to quit smoking. This really shouldn’t be very surprising as NRT helps people to quit smoking, and snus contains the same active ingredient as NRT, but delivers it in higher quantities (nicotine) and is used for a longer time. This isn’t rocket science.

I’d also like to address the last point in Dr Tomar’s comment in which he stated that he is trying to reconcile my public statements that:
(a) Clinicians should NOT recommend that their patients who smoke try using smokeless tobacco to quit , and
(b) castigate the public health community for not promoting these products (snus) for harm reduction.

The statement (a) above is an accurate representation of my position. However, statement (b) is entirely inaccurate. Many members of the public health community see the potential for snus to have a positive impact on public health by competing with a far more dangerous product: cigarettes. In deed, this was proposed for further exploration in the recent Royal College of Physicians report (and the RCP has a good reputation on getting it right on the science of tobacco and health). I have never suggested that the public health community should “promote” smokeless tobacco. That is not our job. What I have criticized is the banning of a much less harmful product while giving the most dangerous product (cigarettes) a monopoly in the tobacco market in those countries (e.g. Australia or the EU apart from Sweden). Similarly, I have criticized members of the public health community who have misinformed the public by suppressing valid comparisons between the health risks of smoked and smokeless tobacco, or by giving inaccurate statements about the relative harmfulness of cigarettes and smokeless products like snus. I believe that the most basic requirement of public health workers is to provide the public with the most accurate information on the relative risks of competing behaviors or products. When we misinform the public we invite criticism and deserve it.

As an example, former U.S. Surgeon General Carmona (who was an excellent Surgeon General and leader in public health) gave testimony to congress in 2003 including the following statements:

“I cannot conclude that the use of any tobacco product is a safer alternative to smoking”

“There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes”

“smokeless tobacco is not a safer substitute for cigarette smoking.”

Each of these statements misinformed the public (and Congress) about the relative risks from smokeless tobacco and smoking cigarettes. It is entirely accurate to say that smokeless tobacco is not safe, that it can cause various diseases and that it is better to quit smoking completely without using smokeless tobacco. It is simply false to say that smokeless tobacco is not safer (or less harmful) than smoking. Two of the major causes of death from smoking are lung cancer and chronic respiratory disease and neither are caused by smokeless tobacco. Again, this is not rocket science.

So I am surprised that Dr Tomar is claiming that I have castigated the public health community for not promoting smokeless tobacco. This is a misunderstanding on his part. Just to be clear about this, here are some quotes from an article that Professor Lynn Kozlowski and I published in the Lancet in 2007, in response to another paper in the same issue that:

“ challenges the wisdom of bans on snus where cigarettes are widely used and also encourages public health professionals to disclose accurate health information on the relative risks of snus as compared with cigarettes. We are not suggesting that clinicians should advise their smoking patients to switch to snus, where safe and effective medications are available to treat cigarette dependence. Nor do we agree with Gartner et al’s suggestion that health departments should promote snus. On the contrary, we recommend that clinicians advise their smoking patients on more flexible ways to quit smoking using existing approved medicines, rather than snus.”

The rationale for this was described as follows:

“Public health is largely determined outside of clinical settings. Price, advertising, legal restrictions and availability of alternatives all have a large influence on health behavior. Public policy should aim to strongly discourage highly dangerous behaviors, and provide appropriate information and warnings regarding lower risk behaviors.”

Our main point was that:

“It is a perverse public health policy that makes an addictive drug widely available in its most harmful form, yet bans or fails to properly inform consumers of availability of that drug in a much less harmful form (for both the consumer and those around them)15.”

The basis for my position on Swedish snus is also described in three published papers that can be downloaded directly from the following link (Foulds et al, 2003; Ramstrom and Foulds, 2006 and Chapter 8 of the 2007 Royal College of Physicians Report):
www.tobaccoprogram.org/staffarticles.htm

It may be surprising or confusing for members of the public to see two so-called “experts” review similar data but come to such different conclusions. In fact this is more common than you might think. It doesn’t mean that we are both wrong or that we don’t respect each other’s opinions (Professor Tomar is one of the leading experts on oral public health in the country). It just means that we take a different perspective on the data – partly based our personal experiences and backgrounds. Professor Tomar’s background is as a dentist and public health specialist in the United States. He will have seen smokeless tobacco users who developed oral cancer, which is a truly horrific disease. In the United States he has also observed the leading smokeless tobacco manufacturer aggressively market its addictive product to young people. My background is as a clinical psychologist working in smokers clinics in Europe and observing many addicted smokers fail to quit and subsequently die of smoking caused diseases. I have also observed male smoking rates drop remarkably in the one EU country where snus is legal. Both of us hold our opinions based on our experiences as well as on the data we have seen. I suspect that we think its worth arguing about because the outcome of the (wider) debate may influence the direction the tobacco industry takes (or is forced to take) and may affect the lives and deaths of millions of people.

Labels: jonathan foulds, nicotine addiction cigarette smoking tobacco, nicotine regulation reduction smoking smokeless, Philip Morris tobacco snus nicotine smokeless, scott tomar

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Do you wake at night to smoke?

Two papers published this month highlight the fact that a surprising number of smokers wake at night to smoke, and suggest that this is a sign of nicotine addiction.

A paper published in the International Journal of Clinical Practice by Michelle Bover and colleagues at UMDNJ-School of Public Health, found that of over 2,300 cigarette smokers seeking treatment at our Tobacco Dependence Clinic, 51% said that they sometimes wake at night to smoke. Those who sometimes do this were significantly less likely to succeed in quitting smoking (at 6 month follow-up), and relapsed earlier, even after controlling for a bunch of other variables that are predictive of treatment outcome. Interestingly, in this study, night smoking was a better predictor of relapse than the usual measures of dependence: number of cigarettes smoked per day, and time to first cigarette of the day.

Another study by Deborah Scharf and colleagues at University of Pittsburgh (published in "Nicotine & Tobacco Research") measured night smoking using an electronic palm-pilot diary during 2 weeks prior to a quit attempt. They found that a single question about night smoking at baseline correlated well with the electronic diary measures of night smoking and that night smoking was associated with greater nicotine dependence, caffeine consumption, and lapse to smoking within the first 28 days. In this study 41% of participants smoked at night.

So both of these quite different studies yielded remarkably similar results. They suggest that clinicians should start to ask their patients about night smoking as a way to assess nicotine dependence. The two questions we feel are most helpful are:

1. Do you sometimes awaken at night to have a cigarette or use tobacco? (yes/no)
2. If yes, how many nights per week do you typically awaken to smoke?

If you are a smoker who wakens at night to smoke, at least once per week, this may be a sign that you are highly addicted to tobacco. When you are trying to quit smoking it may be worth considering this factor in your quit attempt. You may want to tackle other factors (e.g. caffeine intake) that may disrupt your sleep, you may want to avoid smoking cessation medications known to disrupt sleep (e.g. Zyban) and you may want to consider whether the 24-hour nicotine patch may be helpful for your night cravings. There is insufficient data at the moment to give clear guidance on the implications of night smoking, but these two papers suggest that people who wake at night to smoke will find it harder to quit, and so may need more intensive treatment (counseling support and pharmacotherapy).

If you are a smoker who wakes at night to smoke, I'd be interested in hearing more about it. Does it seem as though you wake up wanting a cigarette, or do you just wake up and smoke for something to do? Do you also get up and eat some food for something to do?

You can find full pdf and HTML versions of the Bover et al paper at:
http://www.tobaccoprogram.org/staffarticles.htm

You can obtain copies of a tobacco assessment questionnaire that includes the two questions mentioned above, at:
http://www.tobaccoprogram.org/questionnaires.htm

Labels: jonathan foulds, night smoking, smoking cessation

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How does your state or country tackle tobacco?

There is very good evidence that adopting a strategy of comprehensive tobacco control can be effective at reducing the number of people smoking. “Comprehensive tobacco control” means a combination of strategies including mass media campaigns, smoke-free air legislation, increased tax on tobacco products, youth education and peer-led projects, provision of tobacco dependence treatment, interventions at the level of the healthcare system, community outreach and education, and evaluation procedures.

In the USA, states such as California and Massachusetts that pioneered this type of approach were successful in reducing tobacco use. It is also clear that these interventions tend not to just appear out of thin air, but need to be adequately funded. When the funding is cut, we find that the decrease in tobacco consumption slows down or stops.

As we now know which policies are effective in reducing tobacco use, a scale has been developed in order to score or rank countries according to the adequacy of their tobacco control interventions. If you are interested in seeing how 30 European countries scored on this scale you can find out all the details via this link:
http://tobaccocontrol.bmj.com/cgi/content/full/15/3/247

In the United States a slightly different but similar approach has been taken by the American Lung Association, who every year publish a scorecard for every state in the nation along 4 key variables: 1. Tobacco control funding 2. Smokefree air legislation 3. Cigarette taxation and 4. Youth access.

Unfortunately, only 9 states obtained an A rating for tobacco control funding – meaning that their annual spending on tobacco control approached the minimum recommended by the Centers for Disease Control. Overall, the most frequent grade was an F, with the federal government also receiving an overall F grade for tobacco control.

The fact that over 2005-6 the two largest tobacco companies contributed $96 million to political party campaigns may have something to do with this.
To see how your state is doing and read the whole report, click on the link: http://www.stateoftobaccocontrol.org/

The single most important thing you can do to ensure that your children and grandhildren will be less likely to smoke and more likely to live a long healthy life, (apart from not smoking yourself), is to vigorously support the funding and implementation of comprehensive tobacco control policies.

Labels: ALA, jonathan foulds, tobacco control scorecard

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New IARC monograph on smokeless tobacco

The latest report from the International Agency for Research on Cancer (IARC) was released at the end of 2007. (downloadable – though very large - at: http://monographs.iarc.fr/ ). This report is based on the opinions of an expert working group that met in Lyon, France in October, 2004. It is not clear why it took over 3 years for the report to become available, but one consequence of that delay is that some of its content (relating to Swedish snus) is already out of date and has been contradicted by subsequent evidence. However, the neutrality and balance of the report itself appears to have been undermined from the start, as indicated by some of the self-contradictory statements contained in it.

For example, on p35 in the intoductory remarks to the report it states:

“Some health scientists have suggested that smokeless tobacco should be used for smoking cessation, and claim that its use would reduce the smokers exposure to carcinogens and risk for cancer. They also attribute declines in smoking in Sweden to increased consumption of moist snuff in that country. However, as discussed in volume 1 of the monograph on smokeless tobacco, these claims are not supported by the available evidence.”

However, the section of the report that reviews the evidence (available in 2004) on snuff use in Sweden ends with the following sentence (p174):

“These findings suggest that snuff use may be associated with smoking cessation among Swedish men but not women.”

Later on in the monograph (p153) it gives another view of the relationship between snuff use and smoking in Sweden:

“ The exact role that snuff has played in reducing the prevalence of smoking in Sweden is unclear, but it has probably been overstated (Tomar et al. 2003).”
(Tomar was one of the IARC report authors).

But now that the report has been released in 2008, we have much more evidence on the relationship between snus use and non-smoking in Sweden, showing that it was unfortunately understated by the IARC expert group. Since 2003/4 (1) there have been subsequent publications that have confirmed that in Sweden, men who start using snus are less likely to become daily smokers, that men who smoke and then start using snus are more likely to stop smoking, and that a higher proportion of men than women in Sweden have quit smoking, with the difference largely attributable to snus use (2,3). It had previously been suggested that the men who quit smoking in Sweden are not the same ones who start using snus (and that snus use is therefore not involved in men quitting smoking) (4). However, studies have now verified that in fact a sizeable proportion (26-30%) of Swedish men who quit smoking use snus as a smoking cessation aid (2,5,6). The latest report found that 30.4% of Swedish men who quit smoking from 2000-2004 did so by switching to snus (compared to 14.8% who quit by using NRT) (6). In northern Sweden, where smokeless use is most prevalent, daily smoking prevalence among male 25-34 year-olds is down to 3%, while daily snus use is 34% (7).

It is now crystal clear (and was fairly clear in 2003) that their transfer of nicotine dependence onto snus has accelerated the rate of decline of smoking among Swedish men in substantial numbers. That transfer from an extremely harmful form of tobacco use (cigarette smoking) to a much less harmful form (snus) has contributed to a reduction in the rate of smoking-caused diseases in Swedish men. Of 100 geographic units (primarily countries) in Europe, Swedish men now have the single lowest rate of lung cancer, and less than a half of the rate of lung cancer in the rest of Europe (IARC).

1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003; 12:349-59.
Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm

2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006 Jun;15(3):210-4.
Pdf available at: http://www.tobaccoprogram.org/staffarticles.htm

3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob Control.2005; 14:422-424.

4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59

5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.

6. Lindström M. Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden. Tob Control. 2007 Dec;16(6):410-6.

7. Stegmayr, B., M. Eliasson, and B. Rodu, The decline of smoking in northern Sweden. Scand J Public Health, 2005. 33(4): 321-4

For further information on smokeless tobacco check out:
Marlboro Snus: what is it? 6/10/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/marlboro-snus-what-is-it.html

Why did Philip Morris’s new smokeless tobacco product (“Taboka”) deliver almost no nicotine? 6/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/why-did-philip-morriss-new-smokeless.html

Carcinogens from smoking and smokeless tobacco use (1). 8/27/07 http://www.healthline.com/blogs/smoking_cessation/2007/08/carcinogens-from-smoking-and-smokeless.html

Smoking, smokeless tobacco and cancer (2). 8/28/07 http://www.healthline.com/blogs/smoking_cessation/2007/08/smoking-smokeless-tobacco-and-cancer-2.html

Labels: jonathan foulds, nicotine addiction, nicotine regulation, smokeless, smoking tobacco

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Not a puff

We’re now about a week into the new year. For many people who recently tried to quit, the tricky part will now be staying stopped. In my last post I emphasized the importance of single-mindedness in successfully stopping smoking. Part of that involves clarity of mind that you will not have a single puff of tobacco (or any other) smoke. For many people the thing that trips them up, is the seemingly logical idea that “just one cigarette won’t do much harm”. In one sense that is correct – a single cigarette on its own is unlikely to kill you. But there is plenty of research and plenty of experience from people trying to quit, showing that having a few slips seems to be highly predictive of a full relapse shortly afterwards. It doesn’t have to happen that way. So if you have already had a few slips, don’t feel that you’ve already blown it. Rather it means you have got to be extra focused for the next few weeks to not have another puff. And if you havn’t had a single lapse since your quit day, you are off to a great start and its really important to keep that going. With every additional smoke-free day you achieve, your chances of remaining smoke-free in the long run increase significantly.

So what can you do to make it easier to stay smoke-free? We’ve discussed a lot of the methods on previous blog posts (see one at end of December that lists all of 2007 posts), and I’d be interested to hear directly from readers’ experiences. But in my experience, making sure you have gotten rid of all your tobacco, staying away from places where people are smoking, making use of available social support (whether friends, family or formal treatment services), and taking effective tobacco treatment medicines (e.g. NRT, Chantix or Zyban) are the main factors.

If you are starting to doubt your ability or resolve to stay quit, remember that that’s how the addiction works sometimes. It pops little questioning thoughts into your head (one won’t do any harm, perhaps I can just cut down instead of quitting, maybe this isn’t the best time for me to quit, maybe the stress will be worse for me than smoking, maybe the weight gain will be worse for my health than smoking…etc..etc). Almost always its best to see these for what they are: the addiction trying to get you to smoke again. If you can keep your focus on not putting another cigarette in your mouth, and never inhaling another puff of smoke, you will succeed.

Labels: jonathan foulds, relapse, smoking cessation

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Time to quit….now

Today is one of the most popular days of the year on which to quit smoking. If you havn’t thrown away your last cigarette yet, there is still time to do it. While my personal opinion is that its best to do some preparation for quitting (finding out what medications may help, getting your prescription if necessary, telling friends and family you are quitting, anticipating difficult situations etc), there is no doubt that many people can successfully quit by simply deciding that the one they are smoking is their last, stubbing it out, and making a personal commitment to not smoke again.

For many people who successfully quit, one of the keys to success is having a single-minded focus on remaining smoke free. I think that’s one of the characteristics of successful treatment programs, and even self-help materials (e.g. the Allen Carr books I wrote about a couple of weeks ago) – they very strongly encourage the smoker to make quitting their number one priority, and keep reinforcing that message. So to succeed I think that’s what you have to do. An attitude of “I’ll give it a go and see how it goes” is unlikely to cut it. Whereas an attitude that, “Nothing can make me smoke and I’m choosing not to, no-matter what”, is more likely to succeed. And that means being prepared to do what it takes, and using all the help you can get.

I’d be interested to hear from people who tried to quit recently…what has been the most difficult part and what has helped.

Labels: jonathan foulds, smoking cessation

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