Are Americans Switching to Smokeless Tobacco?
The paper, published in the online Harm Reduction Journal, used data from the year 2000 National Health Interview Survey (NHIS) which asked 3622 male smokers and 3653 male former smokers about the methods used and outcome of their most recent attempt to quit smoking. Because the NHIS survey is administered to a fairly representative sample of the US population, Rodu and Phillips then used the results of the survey to estimate the total number of male smokers in the US using each quit rate and quitting smoking in the United States. So far this all sounds fairly sensible. However, the authors then took that fairly simple data and made rather far-reaching claims without critically examining the quality (and quantity) of data.
For example, the main conclusions drawn in the paper and its abstract (summary) were that a reasonably large number of smokers in the US (261,000) have quit smoking by switching to smokeless tobacco on their latest quit attempt. It is also claimed that the quit rate among those trying to quit smoking by switching to smokeless tobacco is higher than among those trying other methods (e.g. nicotine replacement therapy). However, examination of the data tables in the paper revealed that a total of only 33 people in the survey claimed to have quit smoking by switching to smokeless tobacco. Unfortunately this is too small a number to provide reliable estimates of numbers using this as a quit method nationally. The ubsurdity of using such very small samples to estimate national numbers is even clearer when one looks at the figures for those using the nicotine nasal spray (NNS). Only 3 people in the survey claimed to have used the nicotine nasal spray on their last quit smoking attempt, and none remained free of smoking at the time of the survey. Despite this extremely small sample, the authors went ahead and used it to estimate that at a national level,14,000 smokers used the NNS on their latest quit attempt and none (0%) succeeded.
One other issue with this study stems from the fact that the various smoking cessation aids differed in the time periods in which they were available. For example, while smokeless tobacco has been available for over 100 years, the pharmacological aids only became available in the 1980s and 1990s. So 48% of those who quit by using smokeless tobacco quit at least 10 years ago, compared to 11% of those who quit with the patch. In some ways this may make those quits on smokeless more impressive in that they are longer term quits, but it also serves to underline that in some ways these comparative figures are not comparing like with like. Smokers who quit 20-20 years ago may differ from those trying to quit in recent years, and memory for more distant events maybe less accuarate.
But overall, the biggest weakness of this study was the very small sample of participants who used smokeless tobacco in their quit attempt and then the inappropriate use of these very small numbers to estimate national numbers. Perhaps the main thing that can be concluded from this study report is that the vast majority of smoking cessation attempts in the United States do not involve the use of a proven smoking cessation aid, and a small but measurable proportion of smokers succeed in quitting smoking by switching to smokeless tobacco. If the NHIS survey uses similar questions in future it may be interesting to see how the pattern of use of smoking cessation aids changes over time.
I’d encourage smokers to use smoking cessation treatments that have been demonstrated to be safe and to increase your chances of success. These include counseling from a trained healthcare provider, nicotine replacement therapy, bupropion and varenicline.
The paper by Rodu and Philips is available at: