Pinch Me

For Smokers Only: How Smokeless Tobacco Can Save Your Life, by Brad Rodu, New York: Sulzburger & Graham, 210 pages, $11.99 paper

In 1972, Consumers Union published a book called Licit and Illicit Drugs that devoted several chapters to the history and hazards of tobacco. The authors were troubled that smoking had declined only slightly in the wake of the surgeon general's 1964 report. They concluded that public health officials had underestimated nicotine's grip on smokers. "[E]fforts should be made to popularize ways of delivering frequent doses of nicotine to addicts without filling their lungs with smoke," they wrote. Among other options, they suggested that people concerned about the health effects of smoking might seek to "popularize chewing tobacco and snuff."

That recommendation was conspicuously absent from The Facts About Drug Use, a 1991 Consumers Union book. Indeed, the authors seemed worried by the rising popularity of smokeless tobacco, especially among adolescents. "The evidence is compelling that smokeless tobacco produces nicotine levels in the body comparable to those produced by smoking and carries additional risk of cancer of the mouth," they said, giving no indication that snuff and chewing tobacco might pose less of a health hazard than cigarettes.

This change of heart reflects the current attitude of the anti-smoking establishment. In 1986, Surgeon General C. Everett Koop issued a report that condemned smokeless tobacco as carcinogenic and addictive. He warned against "the tragic mistake of replacing the ashtray with the spittoon." Congress followed up by banning broadcast ads for smokeless tobacco and requiring warning labels. One of those labels sums up the prevailing view, echoed by public-health officials, anti-smoking activists, self-help books, and newspaper columnists: Smokeless tobacco "is not a safe alternative to cigarettes."

But as Brad Rodu observes in For Smokers Only, that advice is hardly helpful to a smoker who is thinking about switching to snuff or chewing tobacco. "In their zeal to convince the American public that tobacco is inherently evil, the anti-tobacco zealots…have created the illusion that all forms of tobacco produce the same health problems," he writes. "Smokeless tobacco use has risks, but [it] is unquestionably much safer, resulting in far fewer and significantly less serious health risks which are more easily managed, than cigarette smoking."

Rodu, chairman of the oral pathology department at the University of Alabama at Birmingham, notes that oral cancer is the only major, well-established health risk associated with the use of smokeless tobacco (and even that disease is twice as common among smokers). A 1981 study published in The New England Journal of Medicine found an oral-cancer rate of 26 per 100,000 among long-term users of smokeless tobacco, compared to 6 per 100,000 among nonusers. Noting that the survival rate for oral cancer is 50 percent, Rodu estimates that "if all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from oral cancer [a year], versus the current 419,000 deaths from smoking-related cancers, heart problems, and lung disease." (Emphasis in original.) By this measure, he concludes, smokeless tobacco is 98 percent safer than smoking. Rodu and his colleagues estimate that life expectancy for a 35-year-old smokeless-tobacco user is 80.9, virtually the same as for nonusers. The average 35-year-old smoker, by contrast, lives to be 73.1.

Rodu's message to smokers is straightforward: You can enjoy tobacco flavor and nicotine at a fraction of the risk, without the pesky smoke. He reassures the wary that today's moist snuff, placed between the cheek and gum, does not produce unsightly bulges or large quantities of saliva. It can be enjoyed discreetly at work or play, even where smoking is banned, and no one need ever know. Unlike nicotine gum or patches–which, Rodu notes, require a prescription, are relatively expensive, and have modest success rate–switching to smokeless tobacco is not aimed at weaning smokers from tobacco. "This book will make denial of smoking's dangers impossible," he writes, "but it does not deny the smoker's pursuit of pleasure. You can have your tobacco and enjoy it too."

Rodu compares smokers to heroin addicts and smokeless tobacco to methadone. "Just as heroin addicts get treatment with methadone maintenance programs we must be bold enough to offer smokeless tobacco (a safer, more acceptable delivery system for nicotine) to millions of cigarette smokers," he writes. "The smokeless tobacco solution, like methadone maintenance, is scientifically sound but will generate a lot of controversy based entirely on inappropriate and condescending attitudes and beliefs." Indeed, the reaction of the anti-smoking establishment to Rodu's message has been reminiscent of the hard-line drug warrior's attitude toward "harm reduction" measures such as methadone maintenance, the distribution of clean needles, and honest drug education.

"To say that one form of tobacco is safer than the other at this point in the debate is just irresponsible," Greg Connolly, a spokesman for the American Cancer Society and the American Dental Association, told the Associated Press after Rodu discussed his ideas in medical journals and on television last year. "Tobacco is tobacco….It's like telling someone to jump from the fifth floor instead of the 10th floor." The oral surgeons' association preferred a different analogy: "Suggesting this switch is like telling someone to use a rifle instead of an Uzi."

Rodu, who speculates that "the anti-tobacco crusade has entered a stage where scientific facts are simply ignored as irrelevant," was clearly shaken by "the strong emotional reaction that the smokeless tobacco solution elicits from tobacco crusaders." He emphasizes that "smokeless tobacco should only provide a viable and comparatively safe damage control measure for the current and last generation of nicotine addicts. Forty years or so from now I hope there are no tobacco users left on the planet."

Thus Rodu, like his critics, wants not only a smoke-free society but a tobacco-free world though he generally opposes using coercive measures to achieve that goal. He acknowledges that smokers get pleasure–and not just withdrawal-symptom relief–from cigarettes. But he does not allow for the possibility that someone could rationally accept the risks of smoking (including the difficulty of quitting) in exchange for the benefits. And he insists that even the relatively small risks posed by snuff are acceptable only in comparison to the hazards of smoking.

For Rodu, it seems, tobacco is fundamentally different from other products that consumers are free to take or leave, because it is addictive. Nicotine affects the body in such a way that smokers who try to quit often experience cravings, weight gain, headaches, anxiety, and other unpleasant effects. Rodu's "smokeless tobacco solution" is aimed precisely at those smokers who are deterred by such costs. But although he sometimes describes these individuals as "unable" to give up smoking, it would be more accurate to say that they were unwilling to do so, given the costs involved. As Rodu notes, about 44 million smokers have managed to give up the habit, typically on their own.

Rodu's tendency to view addiction as a chemical compulsion ultimately undermines his opposition to coercive anti-smoking measures. "I would agree completely that the use of tobacco by adults is a freedom of choice issue," he writes. "I am concerned here with the 46 million American adults who are addicted to tobacco, regardless of how they became imprisoned. Once an individual is addicted, where is his or her freedom of choice?" If smokers are literally unable to stop, if nicotine has robbed them of their will, it is not hard to justify the sort of prohibitionist schemes–such as FDA Commissioner David Kessler's plan to forcibly "detoxify" the nation's smokers by gradually reducing nicotine levels in cigarettes–that Rodu decries.

Still, Rodu is refreshingly skeptical of anti-smoking dogma, even on the issue of addiction. He pokes fun at the notion, promoted with a straight face by anti-smoking activists and trial lawyers, that cigarette makers have been concealing the fact that tobacco contains an addictive drug from an unwary public. "Nicotine addiction is no deep dark secret recently blown out of hiding," he writes. The addictive potential of tobacco has been common knowledge for centuries. Nicotine was first chemically purified in 1828, and experiments in the early 1940s confirmed that it relieved smokers' craving for cigarettes. By the 1950s, nicotine addiction was being discussed in books aimed at the general public, and thousands of research articles on the topic were published during the '60s and '70s, when the tobacco companies were supposedly working so hard to suppress the truth.

Similarly, Rodu demonstrates the vacuity of complaints that tobacco companies "manipulate" nicotine levels in cigarettes. "Cigarettes are blended from several different strains of tobacco," he writes. "Thus, it is conceivable that cigarette manufacturers adjust the nicotine concentration to achieve consistency in taste–[in] which nicotine plays an important role. Even if the amount of nicotine in cigarette tobacco is artificially modified, you cannot deny that a Marlboro smoker deserves the same product uniformity as a McDonald's, Pizza Hut, or Coca-Cola customer." As for reports that Brown & Williamson developed a high-nicotine tobacco plant, Rodu notes that people genuinely concerned about the health of smokers should welcome such innovation. Smokers of high-nicotine, low-tar cigarettes (like smokers of high-potency marijuana) would tend to absorb lower levels of toxins while achieving the effect they desire.

Rodu also questions the received wisdom about the hazards of environmental tobacco smoke, noting that the evidence is open to question and that the Environmental Protection Agency has been criticized for prejudging the issue. But he adds that fears about ETS, well grounded or not, are widespread, feeding hostility against smokers and driving the movement to ban smoking in restaurants and workplaces.

Although Rodu pulls no punches in describing the hazards of smoking, he criticizes the idea that smokers impose huge costs "on society" because of the illnesses to which they are prone. After all, everybody dies of something. The smoker who drops dead at 45 from a heart attack will not live to develop Alzheimer's–or collect Social Security checks. When you look at the long-term savings as well as the short-term costs, Rodu notes, "the excise taxes on cigarettes more than compensate for the external costs that smokers impose on society's nonsmokers." He is not impressed by popular support for raising tobacco taxes. "Polls currently indicate that Americans favor increasing excise taxes on cigarettes by a margin of 3 to 1, which should surprise no one," he writes. "That's the ratio of nonsmokers to smokers."

Rodu's common sense and intellectual honesty are especially striking in light of his strong anti-smoking views. He questions claims ("secondhand smoke kills," "smokers are a burden on society") that he considers shaky or erroneous, even though they would reinforce his argument for switching from cigarettes to smokeless tobacco. That kind of rigor is rare in the anti-smoking movement, which could use a few more heretics.