June 2003
Can Smokeless Tobacco Reduce the Health Consequences of Smoking?

Nearly four decades after the 1964 surgeon general’s report on smoking and health, almost 25 percent of adults in America still smoke. The current surgeon general recently stated that smokeless tobacco is as harmful as cigarettes. A June 25 AEI seminar explored the latest research regarding the effects of smokeless tobacco and the politics of harm reduction.

The current controversy surrounding smoking asks whether smokeless tobacco is less harmful to health than tobacco smoke. There is evidence that it is. Currently there is no data linking smokeless tobacco to the diseases attributed to smoking, including cancer, cardiovascular, and respiratory diseases. Cigarette smoke contains over 4000 compounds, 43 of which are toxic and/or carcinogenic. In smokeless tobacco products the major carcinogens are tobacco specific nitrosamines (TSNAs), which are associated with oral cancer.

There are many types of smokeless tobacco. Most contain dark tobacco varieties and come in a multitude of forms from powdered to stripped and packed. Most importantly, these products differ in their constituents of health concern. Among brands of smokeless tobacco, TSNA levels differ by more than one thousand-fold in poor nations and by several hundred-fold in advanced economies.

Swedish use of smokeless tobacco has provided data supporting the benefits of smokeless tobacco. Snus, a traditional form of oral smokeless tobacco, is now used by about 20 percent of men and 2 to 3 percent of women. During the past twenty-five years, the use of snus among men has increased while the rate of cigarette smoking has decreased. The smoking rate for men in Sweden is now the lowest in the developed world. Also, men with a history of snus use have a higher rate of quitting cigarette use.

For the last twenty years, Swedish snus has been prevented from containing high levels of TSNAs. Case studies have shown no significant increases in mouth cancer among snus users. These same studies found an elevated risk of mouth cancer among smokers and heavy drinkers. An Institute of Environmental Medicine study found that long-term use of snuff does not alter risk factors for cardiovascular disease. Furthermore, studies do not indicate that use of snus increases the risk of cancer. However, there is still insufficient evidence to completely exclude the risk of cancer. It is important to note that while snus use in Sweden is higher than in Canada, Denmark, France, or the United States, the death rate for smoking-related diseases and oral cancer is lower in Sweden than in any of these countries. The Swedish case is an example of the possibility of using smokeless tobacco to reduce the adverse health consequences of smoking.

Smokeless tobacco is an important tool for tobacco harm reduction. The American anti-smoking campaign is a failure for adult inveterate smokers, as we continue to have 440,000 deaths attributable to smoking each year. There are up to 24 million inveterate smokers in the United States who will not respond to behavioral therapy or the temporary use of nicotine. Quitting smoking through nicotine use is expensive, unsatisfying, and often temporary.

An alternative strategy is harm reduction through the use of smokeless tobacco for permanent nicotine maintenance. There is evidence that this strategy works, that modern products are socially acceptable, that they are 98 percent safer than smoking, and that nicotine levels in smokeless tobacco are comparable to those in cigarettes.

Nicotine is much like caffeine; it is an addictive drug used safely. Neither causes cancer, emphysema, or heart disease. Smokeless tobacco is safer than cigarettes, as there is no risk for emphysema, lung cancer, and heart disease, and the risk of mouth cancer is less than half of that from smoking. Modern products are becoming even safer and are socially acceptable; they are invisible in use because they require no chewing or spitting.

The most compelling case is the Swedish experience, where smokeless tobacco has worked for Swedish men for fifty years. Sweden has Europe’s highest per capita consumption of smokeless tobacco and the lowest oral cancer mortality, cigarette consumption, lung cancer mortality, and percentage of smoking-related deaths among developed countries. The Royal College of Physicians Report states that the consumption of smokeless tobacco is 10 to 1000 times less hazardous than smoking. Furthermore, if manufacturers were to market products as harm reducing, they might garner support from the public health community. Smokers have a right to information about safer tobacco alternatives such as smokeless tobacco. Withholding this information has no public health justification and may be unethical.

Sally Satel
AEI

The harm reduction movement has been effective in minimizing the health consequences of drug and alcohol abuse and dependence. However, a number of health advocacy organizations, as well as the U.S. surgeon general, are strongly opposed to harm reduction for smokers, a practice that would entail substituting smokeless tobacco for cigarettes.

In the realm of illicit drugs, harm reduction strategies have received support from the public health community. The goal is to render drug-related behaviors less harmful. Common examples include needle exchange programs for intravenous drug users, methadone maintenance for heroin addicts, and drug courts (which downplay the criminalization of illicit drug involvement by sending offenders to treatment instead of jail).  Harm reduction philosophy withholds moral judgment. It is less concerned with heroin abuse, for example, than with a utilitarian calculus: weighing costs and benefits of a new (reduced harm) strategy versus the status quo. By these criteria, there is a persuasive case for smokeless tobacco as a harm reduction technique.

So why is there such aversion to tobacco programs and smokeless tobacco while harm reduction for hard drugs is embraced? One is explanation is simple lack of knowledge. The testimony by the surgeon general, Richard Carmona, at the House Energy and Commerce Subcommittee hearing on June 3, 2003, appears to be such an example. Dr. Carmona stated that smokeless tobacco was a “myth” and not a safer substitute for cigarette smoking and also that smokeless tobacco represents a “significant health risk.” These are simply uninformed statements.

Another aversion to smokeless tobacco may be rooted in the idea that any addictive substance should be avoided at all costs. A little known truth about tobacco, however, is that it is the smoking behavior and associated rituals that are far more seductive than the drug nicotine. The latter, by itself, is much less stimulating to the brain’s reward pathways than are heroin or cocaine. Animals unenthusiastically administer nicotine, but they will perform, often energetically, for other abusable drugs. Many have trouble quitting cigarettes because the Pavlovian conditioned cues that stimulate the desire for smoking (or any activity we find pleasurable) are virtually always present. People smoke practically everywhere, and thus the visual triggers and smells associated with smoking are abundant and stimulate craving. Behavioral treatments for heroin and cocaine addiction revolve around avoidance of the “people, places, and things;” this is very hard to do when an activity, like smoking cigarettes, is legal and ubiquitous.  Moreover, there is generally a vast time lag between the consequences of heavy smoking (health problems years down the road if one is relatively young) and the act of smoking. In the case of highly intoxicating drugs like alcohol, heroin and cocaine, the impact is often swift, resulting in, for example, car accidents, job loss, or family disruption. These myriad factors make smoking “addictive” and difficult (though by no means impossible) to quit.

Perhaps the greatest animus toward smokeless tobacco stems from a principled hostility to business. Such a Naderite aversion to industry and profit making makes contempt for tobacco so powerful that it overrides concern for the smokers’ improved health through harm reduction. The National Center for Tobacco Free Kids, headed by Matt Myers, epitomizes this posture. According to Elizabeth Whelan, president of the American Council on Science and Health, this amounts to a “quit or die” approach. Myers himself is quick to accuse Brad Rodu and others who present favorable data on tobacco harm reduction of “getting funding from the smokeless tobacco makers.”

The robust health benefits of smokeless tobacco should point to an obvious public health decision: Make the product available to adults. By ignoring or distorting otherwise straightforward epidemiological data, opponents have turned this into a bitter controversy.   Next time you hear a broadside against smokeless tobacco, think subtext. Often, its detractors have motives that eclipse the best interests of smokers. Behind the rhetoric about advancing public health may lurk an entirely different agenda.

AEI intern Priyanka Gupta prepared this summary.