Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA

Abstract

Background Snus (a form of smokeless tobacco) is less dangerous than cigarettes. Some health professionals argue that snus should be promoted as a component of a harm reduction strategy, while others oppose this approach. Major US tobacco companies (RJ Reynolds and Philip Morris) are marketing snus products as cigarette brand line extensions. The population effects of smokeless tobacco promotion will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns. Objective To quantitatively evaluate the health impact of smokeless tobacco promotion as part of a harm reduction strategy in the US. Methods A Monte Carlo simulation of a decision tree model of tobacco initiation and use was used to estimate the health effects associated with five different patterns of increased smokeless tobacco use. Results With cigarette smoking having a health effect of 100, the base case scenario (based on current US prevalence rates) yields a total health effect of 24.2 (5% to 95% interval 21.7 to 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health-concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with a health effect of 30.4 (5% to 95% interval 25.9 to 35.2). The anticipated health effects for additional scenarios with lower rates of smokeless uptake also overlapped with the base case. Conclusions Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.

Cigarettes, Smokeless Tobacco, and Poly-Tobacco Among Workers in Three Dusty Industries

“…19,22,28 As such, promoting SLT as a safe alternative to cigarettes is unlikely to provide substantial population-level health benefits if it leads to ongoing dual product use rather than complete product substitution. 29 To the extent that smokers use SLT as a substitute for smoking rather than mitigating or quitting tobacco use, dual use may constitute more harm rather than harm reduction. As well, SLT use incurs increased health risks, including increased risk of some cancers (oral cavity and pharynx, pancreas, and lung) 15 and periodontal disease.…”

Tobacco harm reduction in the real world: has the availability of snus in Norway increased smoking cessation?

“…Direct observations of dual use from Norway and Sweden, two countries with a full blown snus epidemic, might be a more valid input in such models than different scenarios of dual use disconnected from any empirical basis, as was the case in a model from the relatively snusnaïve US (Mejia et al, 2011).…”

Misleading Conclusions From Altria Researchers About Population Health Effects of Dual Use

“…They also represent the U.S. study by Zhu et al (2009) as supporting the assertion that smokeless tobacco use promotes cessation despite the fact that Zhu et al concluded, "Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation. "We published an analysis (Mejia, Ling, & Glantz, 2010) of the effects of aggressive smokeless promotion in the United States that accounts for likely changes that will result from explicit tobacco industry promotion of dual use of cigarettes and smokeless tobacco (branded as cigarette line extensions). Altria and other companies are promoting dual use as a way to continue tobacco use despite expanding smoke-free environments.…”

“…We published an analysis (Mejia, Ling, & Glantz, 2010) of the effects of aggressive smokeless promotion in the United States that accounts for likely changes that will result from explicit tobacco industry promotion of dual use of cigarettes and smokeless tobacco (branded as cigarette line extensions). Altria and other companies are promoting dual use as a way to continue tobacco use despite expanding smoke-free environments.…”