Smokeless Tobacco No Cure for Quitting Smoking

In its 2012 legislative session the Kansas House of Representatives passed a resolution (Kansas HR 6026) “requesting the Kansas Department of Health and Environment to conduct a study regarding tobacco harm reduction.”

The resolution specifically directed the KDHE to recommend whether the state should incorporate the promotion of harm reduction by encouraging smokers to switch to smokeless (chewing) tobacco in its tobacco control plans.

It is noteworthy that a number of other organizations are interested in promoting this same approach to tobacco harm reduction.

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These organizations include public health professional organizations such as the American Association of Public Health Physicians and the Royal College of Physicians as well as other well-known promoters of public health: R.J. Reynolds, Altria Group (parent company of Philip Morris USA and US Smokeless Tobacco Company) and British American Tobacco.

Not better, just different

Tobacco harm reduction approaches that promote switching to lower risk tobacco products and legislative action like Kansas HR 6026 undercut legitimate tobacco control and tobacco dependence treatment efforts.

There is little doubt that using smokeless tobacco is associated with lower relative risks of the major smoking attributable diseases such as lung cancer, cardiovascular disease and chronic lung disease.

However the risk of other cancers such as oral/pharyngeal and pancreatic cancers increases substantially with regular smokeless tobacco use.

There is also modest evidence that smokeless tobacco can be substituted for cigarettes in regular smokers and bring about reduction in cigarette use for the short term.

There is no evidence showing that most cigarette smokers could be enticed to use smokeless tobacco exclusively, or that they would use it long term and realize the harm reduction benefits of switching.

In addition, statistical modeling {Mejia AB, Ling PM, Glantz SA. Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA. Tobacco Control 2010;19:297-305} suggests that widespread and vigorous public health advocacy encouraging all smokers to switch to smokeless tobacco may even  result in net population harm with many smokers becoming dual users (i.e., smoking cigarettes and using smokeless tobacco simultaneously).

Dual use of tobacco may be associated with more risk than cigarette smoking alone. When advising patients about any treatment option there is always a discussion of risks, benefits and alternatives.

Why would a health care professional advise the use of smokeless tobacco (a known carcinogen) that has no evidence to support its effectiveness for sustained smoking reduction or smoking abstinence, when an alternative (e.g., nicotine replacement therapy) is proven safe and effective?

At the level of the individual provider-patient relationship, advising smokeless tobacco as a “treatment” for cigarette smoking distracts from legitimate and proven therapies for tobacco dependence treatment.

Who benefits? Big Tobacco

If smokers are widely encouraged to switch to smokeless tobacco, there is a certainty that only one sector of society will benefit: the tobacco industry.

It will continue to market and sell more smokeless tobacco product while leveraging the endorsement of public health advocates that smokeless tobacco is “safe” tobacco.

The decades of work to de-normalize tobacco use and to de-normalize the tobacco industry will have been undermined.

The tobacco industry will use the opportunity to promote new uptake of smokeless products by non-users and promote dual use among smokers. In this confused environment most smokers will not switch to smokeless tobacco products, and those who do use smokeless tobacco as a harm-reduction strategy will likely become dual users.

The self-interest of an industry that has knowingly caused the death of millions upon millions of people is not served by promoting population health through tobacco harm reduction.

The tobacco industry is only and always in the pursuit of promoting its core product, cigarettes.

A recent editorial described the tobacco industry as the “vector” (an agent that carries and spreads a pathogen—primarily cigarettes) of the tobacco epidemic {Mackay JM, Bettcher DW, Minhas R, Schotte K. Successes and new emerging challenges in tobacco control: addressing the vector. Tobacco Control 2012;21:77-79} and described their activities:

“The tobacco industry has traditionally employed a spectrum of deceitful practices to derail tobacco control and undermine public health.”

“Traditional tobacco industry actions include the leveraging of monetary and political influence, vehement opposition to, and circumvention of, the development and implementation of effective tobacco control legislation, the undermining of scientific evidence and the introduction of disingenuous Corporate Social Responsibility (CSR) programmes.”

The tobacco industry vector has “mutated” again, this time as a public health advocate through the promotion of switching smokers to smokeless tobacco.

When health care providers, professional organizations and governments ally with the tobacco industry in tobacco control efforts this undermines the legitimacy of tobacco control efforts by normalizing the tobacco industry.

As health professionals we should advise our patients to use tobacco dependence treatments that are proven safe and effective; we should advocate for sound tobacco control policies; and we should stand against any tobacco control effort that includes the illegitimate tobacco industry as an “ally.”

The harms of tobacco will only be eliminated when the vector is no longer viable.