Drug Policy

Tobacco Harm Reduction Catches On

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Yesterday I mentioned the controversy over legislation that would give the FDA authority to regulate tobacco products, authority the FDA itself (or at least its current head) does not want. One reason for the agency's leeriness is the possibility that FDA regulation could actually increase the harm associated with tobacco use. One way that could happen, as I've noted before, is through censorship of truthful comparative risk claims—in particular, efforts to promote smokeless tobacco as a harm-reducing alternative to cigarettes. Last week there were a couple of positive developments in this area.

Britain's Royal College of Physicians endorsed the concept of tobacco harm reduction, saying snus (Swedish-style oral snuff) and other nicotine-delivering products should be available to smokers who want to cut their risks but are not prepared to give up their drug habit. In a commentary published by The Lancet (which has long supported "less harmful nicotine delivery systems"), two doctors who worked on the RCP report, John Britton and Richard Edwards, note that the health risks associated with snus are roughly 90 percent lower than the health risks associated with cigarettes. They question the E.U.'s ban on smokeless tobacco (which does not apply in Sweden) and the policy of treating nicotine replacement products as quitting aids instead of long-term replacements for cigarettes:

We believe that the absence of effective harm reduction options for smokers is perverse, unjust, and acts against the rights and best interests of smokers and the public health. Addicted smokers have a right to choose from a range of safer nicotine products, as well as accurate and unbiased information to guide that choice.

Britton told The Independent:

Smokers smoke because they are addicted to nicotine, but it isn't nicotine in cigarette smoke that kills….We need to liberalise the medicinal market and introduce a decent cigarette substitute. We may end up with millions of people addicted to nicotine inhalers, but so what? Millions are addicted to caffeine.

Although there is more to the cigarette habit than nicotine (one reason the success rates for "nicotine replacement therapies" are so low), smokers certainly should be free to switch to other, less dangerous sources of nicotine if that's what they want. The distinction that Britton draws between addiction and the harm associated with it is a vitally important one that discussions of drug policy tend to overlook. There is no rational reason we need to pretend that nicotine gum, patches, and inhalers are medicines that treat the disease of nicotine addiction, as opposed to safer ways of getting the same drug. 

Another encouraging sign regarding snus: Last week The New York Times ran a story about snus products in the U.S. that clearly reported the truth: Although not 100 percent risk-free, snus is indisputably less dangerous than cigarettes. The Times quoted Thomas Glynn, director of cancer science and trends at the American Cancer Society, who questioned the evidence that "smokers are able to switch to smokeless tobacco and remain switched." But even Glynn conceded that "if every smoker in the United States were to switch to smokeless tobacco, 'in the next decade we would see fewer cancers and less heart disease.'" That acknowledgment is significant, since American anti-smoking groups (like American public health agencies) generally have been hostile toward harm reduction via smokeless tobacco, muddying or denying the product's clear health advantages. By contrast, Britain's Action on Smoking and Health has supported tobacco harm reduction for years.

Why was last week's story more scientifically accurate that the usual Times take on smokeless tobacco? Probably because it ran in the business section instead of the health section.

[Thanks to Brad Rodu and Bill Piper for the tip about the RCP report.]

NEXT: The Toleration Trap

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  1. This same idea — that nicotine users should be allowed to satisfy their cravings with as little tar as possible — first came to my attention back in the 1970s when it appeared in the book Licit and Illicit Drugs, by Edward M. Brecher and the editors of Consumers Reports.

    It is now available on line here:
    http://www.druglibrary.org/Schaffer/Library/studies/cu/cumenu.htm

  2. I’m not being a puritan here, but smokeless tobacco is __________________.

    Nanny staters will fill in the blank for me.

  3. A friend of mine works in a hospital which just went “smoke free.” I said something about people shifting their habit to smokeless, and was told “smoke free” equals “tobacco free.” The claimed need to protect patients, staff and visitors from the lethal effect of secondhand smoke was just a smokescreen, so to speak, to allow them to impose a total ban on the evil weed.

  4. When I was freshman, one of my roommates used snus.

    I was curious about it, so he was kind enough to explain to me, a non-smoker, that you lay out two lines of the powder, each about an inch long and half an inch thick, and snort one into each nostril. Then, he was kind enough to lend me his snus, and form the lines for me.

    Woooooo!!!!!

  5. That’s snuff, which is different than snus.

    I also had a disgusting friend who would accomplish the so-called tobacco trifecta: pop in a horseshoe lip, light up a camel wide, and snort a bump of snuff at the same time.

    We made that kid wear a slop bucket around his neck halfway through the year.

  6. I thought snus was Swedish for snuff.

    Light brown stuff, about the consistency of flour.

    No?

  7. I think it’s actually the same thing, but with snus you put it in your lip, rather than snorting it. The snuff my friend had was in a little thing that looked like a mint container, and when you clicked a button on it some snuff would come out.

  8. I have all but quit smokes using snus. Really, the transition isn’t all that difficult. The only problem with the snus habit is that it has to be ordered from Sweden. (Whatever the Camel stuff is, it ain’t snus.)

  9. Joe-It’s similar. Snus is intended to be held between the lip and gum, like dip. There’s something about the process of making it that results in a lower health risk than is associated with regular chewing tobacco/dip. I use the stuff that comes in pouches, which have the advantage of not causing the user to spit.

  10. I thought snus was Swedish for snuff.

    Snus is cured differently, so it doesn’t have nearly the carcinogens as snuff.

    American “snuff” (Copenhagen, Skoal, what have you)and Swedish “snus” are taken in the same way these days – orally, between the lip or cheek and gum. I think the Swedes tend to use the upper lip, and Americans the lower lip, but I really can’t be sure about the Swedes on this one.

  11. I’m not an anti-tobacco activist or anything like that(and I have tried snus and found it to be mildly enjoyable), but doesn’t nicotine itself carry some health risks? It seems that that nicotine is here being treated as if it is, by itself, an innocuous if addictive substance. I remember reading an article or two (hardly helpful, I know, sorry) associating nicotine with degeneration of vertebral discs in some people, and chronic sleep disorders in others.

  12. They have found that part of the attraction of smoking is the act itself. It is about more than nicotine. The act of smoking becomes an integral part of people’s daily routine, so quitting immediately and directly diminishes smokers’ quality of life. It is more than just finding a better way for people to get nicotine. If it were just that, patches would work and they really are not that effective.

  13. It seems that that nicotine is here being treated as if it is, by itself, an innocuous if addictive substance. I remember reading an article or two (hardly helpful, I know, sorry) associating nicotine with degeneration of vertebral discs in some people, and chronic sleep disorders in others.

    Well, even if that is true, it is rightly of vastly less importance than the risk than getting lung cancer or heart disease from smoking cigarettes. The point of the post was not to say that the alternatives were entirely “risk-free”, just that they are much less risky than smoking and people ought to be given that information.

  14. I am all for nicotine replacement therapy. My question given that there are inhalers for delivering it out there (Rx) nasal sprays, and more, plus OTC products like Nicogel that you just rub on your hands… why does TOBACCO have to be the delivery vehicle for it? Thanks so much Dr. Rodu for the heads up, and seeing that the smokeless tobacco companies that have paid for your harm reduction chair and your past work are being well taken care of. Good harm reduction, like needle exchange programs, do not introduce NEW harm. Yes, the person is still an addict, but harm reduction takes place in less transfer of other diseases. Methadone also comes to mind. There are links of snus to pancreatic cancer, and other issues still unknown since it is like all tobacco products in the US unregulated, and while research has been done in the parent country, our institutions have not examined it in detail. What ore will be found from the long-term use of snus? We just do not know and I ma not trusting a few studies out of another country to make it an OK product in our world. Think China, their studies and regulations, and assurances have certainly benefited us?

    But for once could we suggest that a delivery vehicle for nicotine could be something other than tobacco? There are many people, me included, that agree that if everyone that used cigarettes switched, death rates would go down in lung cancers etc. BUT, people on both sides of this issue know that smokers smoke, many times for reasons that are beyond their addiction. There are psychological reasons that they do it, from being cool, sexy, or tough looking, to having something in their hands to fidget with as a habit. Even in people who use snus, there are many reports that it is not used exclusively, that they use it when they are in a no smoking environment, and smoke when able. So while it may protect some of us from second hand smoke, it really isn’t gong to stop them from getting cancers and other problems associated with combustion of tobacco. There is also the question, if for the nicotine buzz, it will become an introduction drug for our kids to become another life long addicted customer to big tobacco. We can do better than snus as a solution. And rather than having tobacco paid individuals like Rodu continue to push this, we need several things. An FDA that allows existing NRT’s to have the same amount of nicotine in them as cigarettes. Congressmen and senators have to finally get past the money that comes to them from tobacco and vote for what’s good for us for a change. The patches and the gums don’t work the bulk of the time because the FDA regulates them, and they don’t come close to containing a nicotine content that satisfies the cravings. There is big money behind all this, and as usual whether we are getting hosed at the pump, or given yet another tobacco addictive vehicle to serve those profits, we lose.

  15. I have a fair amount of faith in the Swedish studies. They have done long term studies and found no link between snus and any cancer other than the pancreas. That link is only twice that for a non-tobacco user and less than the risk a smoker faces. Some of these were long term studies including snus users from the mid 70s with follow ups in 2004. Nicotine gum and the patch haven’t even been around that long to perform studies on yet most assume they are safe.

    I switched from American dip to snus after learning that snus is even safer than American dip. The sad thing is I had to find the information on my own as neither my dentist nor my doctor told me about the relative benefits.

  16. All youngers are addicted in nicotine. but they are not realised to their kills. It caused the lungs disease.

  17. At last people are starting to wake up to the fact that it is smoke that kills, NOT nicotine.
    Snus is indeed the Swedish word for snuff, but it is prepared differently to the European snuff, which is inhaled, not placed on the gums.

    The smoking ban came into the UK recently and I set up Snuff Tobacco UK to provide smokers with another alternative to cigarettes. Personally I have given up cigarettes by using nasal snuff and it is a much more pleasurable and sociable habit.

    No one has ever died from nasal snuff, apart from someone in Northern England who put it in his ear for 40 years (very odd!!!).

    Snuffing is the way forward, especially if you want to give up those deadly cigarettes. If you want to read more i have a website dedicated to this at http://www.snufftobacco.co.uk

    Happy snuffin’
    The Snuffman.

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