Are smokers switching to smokeless tobacco in the U.S?
These promising results from Sweden recently prompted Zhu and colleagues to investigate whether there is any evidence to suggest that a similar pattern could be happening in the U.S. They examined data from a large representative sample of US adults (n=15,056) who were surveyed in 2002 and again in 2003.
Among male tobacco users in 2002, 83% were exclusive smokers and 17% used smokeless tobacco (14.1% exclusive smokeless tobacco users and 2.9% dual users). Among female tobacco users, 98% were exclusive smokers, 1.7% exclusive smokeless tobacco users and 0.3% dual users
The study found that around 12% of both male and female smokers quit smoking from 2002 to 2003. However, less than 1% of male smokers switched from cigarettes to smokeless and no women did. While one could quibble with certain aspects of this study (e.g. none of the participants were specifically asked if they had tried switching temporarily to smokeless as a smoking cessation aid, and there were only around 300 male smokeless users in the study), I think the main conclusion is pretty clear and reliable: from 2002 to 2003 only a negligible (tiny) number of US smokers quit smoking by switching to smokeless tobacco. As the authors state, this is a pattern quite different from Sweden, where a significant proportion of men have quit smoking by switching to smokeless.
It is at this point that I think I differ in my interpretation from the authors of the study. First of all I completely disagree with their opening premise that the key question here is whether the public health community should promote smokeless tobacco as a safer alternative to smoking. While it is blatantly obvious from numerous studies that the form of smokeless tobacco used in Sweden (snus) is a much safer alternative to smoking, I dont believe it should ever be the role of the public health community to promote it for that purpose. The public health community did not promote it for that purpose in Sweden either. The question really is whether the public health community should provide consumers with accurate information about the relative harmfulness of cigarettes and different types of smokeless tobacco? (as the Swedish government did when they reviewed the scientific evidence on snus and decided that the warning that it causes oral cancer should be removed as it was not supported by the scientific evidence).
Here in the United States the public health community, led by the US Surgeon General, have repeatedly provided inaccurate information on the relative risks of these products: ?Smokeless tobacco is not a safer substitute for cigarette smoking.?
And although new forms of smokeless tobacco have been launched in the United States that contain very low levels of toxins and are similar in that respect to the products available in Sweden, little attempt has been made by the public health community to correct the misinformation. As a result, around 90% (or more) of the US public believe that smokeless tobacco is at least or more harmful than smoked tobacco. This is despite the fact that it doesnt cause any lung cancer or respiratory disease, and has a lower oral cancer and cardiovascular risk than smoking.
So one has to ask, if we have enabled the public to (inaccurately) believe that smokeless tobacco is at least as harmful as cigarettes, why would we expect anyone to switch from smoking to smokeless? Quite frankly, I wouldn?t.
Then the question is whether we are really doing the U.S. public a favor by misinforming them? (putting aside the argument that as a general rule we should tell the truth!).
My own view is that it is never the right choice to misinform the public on issues of health risks. It is also never the right choice to encourage the public to use products that contain carcinogens when they could relatively easily avoid them (e.g. they could obtain nicotine without carcinogens from NRT). But if we are asked about the relative risks of different products we have a responsibility to give the most accurate information we have, and then let the informed consumer make their choice.
So the conclusion from the paper by Zhu and colleagues is that very few people are switching from cigarettes to smokeless in 2003 USA. That shouldn?t come as any surprise, and will continue while we keep the US public misinformed about the relative health risks of these products.
Perhaps the enactment of pending legislation that will allow the FDA to regulate tobacco products might create an opportunity for more accurate risk assessment and public education on this important issue?
Link to the full paper by Zhu and colleagues:
Link to a review paper on Swedish snus:
Link to a comprehensive review on Tobacco Harm Reduction by the Royal College of Physicians (ch 8 on smokeless):
(Full pdf downloadable for free):
US Surgeon General?s testimony to Congress on smokeless tobacco, 2003.