04/2007 © American Council on Science and Health (16,000)

This publication, written by Molly Lee, is based on a peer-reviewed ACSH report entitled "Tobacco Harm Reduction: An

Alternate Cessation Strategy for Inveterate Smokers" (seehttp://www.acsh.org/healthissues/newsID.1484/healthissue_detail.asp) by Dr. Brad Rodu and William T. Godshall, M.P.H., from theDec. 21, 2006 issue (Vol. 3, issue 1) of Harm Reduction Journal.

That report also formed the basis of the ACSH publicationHelping Smokers Quit: A Role for Smokeless Tobacco? by

Kathleen Meister (see http://www.acsh.org/publications/pubid.1403/pub_detail.asp).

AMERICAN COUNCIL ON SCIENCE AND HEALTH

1995 Broadway, 2nd FloorNew York, NY 10023-5860Tel: 212.362.7044 Fax: 212.362.4919E-mail: acsh@acsh.orgURL: http://www.acsh.org

Scientific Rationale for HarmReduction with ST

Comparison of risks from ST use and smoking

The established health risks associated with ST useare vastly lower than those of smoking. In the pasttwenty-five years, almost eighty peer-reviewed scientif-ic and medical publications have acknowledged the dif-ferential risks between the two tobacco products.

In 2002, the Royal College of Physicians of Londonissued a report acknowledging that some ST manufac-turers may want to market their products “as a ‘harmreduction’ option for nicotine users.”

Evidence that ST is an effective substitute for cig-arettes

1. Survey data

A 1991 national survey revealed that one-third of adultST users were former cigarette smokers. According toan earlier survey, young men who had smoked ciga-rettes and subsequently used ST were twice as likely tohave quit smoking as cigarette-only users.

2. Clinical trial data

One clinical trial has been conducted assessing theefficacy of an ST product in helping cigarette smokersbecome smoke-free. Of sixty-three subjects startingthe study, sixteen had successfully quit smoking afterswitching to ST at one-year follow-up; twelve were stillsmoke-free after seven years. Four additional partici-pants had used ST to reduce their cigarette consump-tion by at least 50%.

3. The Swedish tobacco experience

For the past 100 years, cigarette smoking has been thedominant form of tobacco consumption in almost alldeveloped countries. One notable exception isSweden, where smoking rates, especially among men,have been considerably lower than those of compara-ble countries for decades. Over the past fifty years,Swedish men have had the lowest rates of smoking-

related cancers of the lung, larynx, mouth, and bladder inEurope and the lowest percentage of male deaths relat-ed to smoking of all developed countries.

A 2006 study examined data from a 2001-02 nationallyrepresentative Swedish social survey. The data showsthat snus use among men was significantly associatedwith a reduced rate of smoking. They also found thatsnus was the most commonly used cessation aid amongmen (used by 24% of men on their most recent quitattempt). Men who used snus as a quit-smoking aidwere more likely to quit successfully than those usingnicotine gum, which was also true for women.

Conclusion

Despite massive anti-smoking public health cam-paigns over the past forty years, 45 millionAmericans continue to smoke, and far too many diefrom smoking-related diseases. ST has far feweradverse health effects than cigarette smoking andshould be encouraged as one option for tobaccoharm reduction for smokers for whom completeabstinence from tobacco is not attainable.

Dr. Elizabeth Whelan, PresidentACSH, 1995 Broadway 2nd Floor, New York, NY 10023

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A C S H F O U N D E R S C I R C L E

Christine M. Bruhn, Ph.D. University of California, Davis

Taiwo K. Danmola, C.P.A.Ernst & Young

Thomas R. DeGregori, Ph.D.University of Houston

A. Alan Moghissi, Ph.D. Institute for Regulatory Science

Albert G. Nickel Lyons Lavey Nickel Swift, Inc.

Stephen S. Sternberg, M.D. Memorial Sloan-Kettering CancerCenter

Lorraine Thelian Ketchum

Kimberly M. Thompson, Sc.D. Massachusetts Institute ofTechnology

Robert J. White, M.D., Ph.D. Case Western Reserve University

A C S H B O A R D O F T R U S T E E S

Nigel Bark, M.D.Albert Einstein College of Medicine

Elissa P. Benedek, M.D. University of Michigan MedicalSchool

Norman E. Borlaug, Ph.D. Texas A&M University

Michael B. Bracken, Ph.D.,M.P.H. Yale University School of Medicine

James E. Enstrom, Ph.D., M.P.H.University of California, Los Angeles

Jack Fisher, M.D.University of California, San Diego

Hon. Bruce S. Gelb New York, NY

Donald A. Henderson, M.D.,M.P.H.University of Pittsburgh MedicalCenter

Thomas Campbell Jackson,M.P.H.Pamela B. Jackson and Thomas C.Jackson Charitable Fund

Elizabeth McCaughey, Ph.D. Committee to Reduce InfectionDeaths

Henry I. Miller, M.D.The Hoover Institution

Rodney W. NicholsIndo-US Science & TechnologyForum

George F. OhrstromThe Ohrstrom Foundation

Kenneth M. Prager, M.D.Columbia University Medical Center

Katherine L. Rhyne, Esq.King & Spalding LLP

Lee M. Silver, Ph.D.Princeton University

Thomas P. Stossel, M.D.Harvard Medical School

Harold D. Stratton, Jr., J.D.Dykema

A C S H S T A F F

Judith A. D’AgostinoExecutive Assistant

Ruth Kava, Ph.D., R.D.Director of Nutrition

A. Marcial C. LapeñaAccountant

Jennifer LeeArt Director

Molly LeeResearch Associate

Cheryl E. MartinAssociate Director

Tara McTeagueDevelopment Assistant

Gilbert L. Ross, M.D.Executive and Medical Director

Todd SeaveyDirector of Publications

Jeff Stier, Esq.Associate Director

SMOKELESS TOBACCOAS HARM REDUCTION

FOR SMOKERS

SMOKELESS TOBACCOAS HARM REDUCTION

FOR SMOKERS

For more information, visit

www.acsh.org

John Moore, Ph.D., M.B.A.Grove City College, President Emeritus

Frederick Anderson, Esq. McKenna Long & Aldridge

Elizabeth M. Whelan, Sc.D., M.P.H.ACSH

C H A I R M A N V I C E C H A I R M A N P R E S I D E N T

Cigarette Smoking

Prevalence

At first glance, the United States appears to be the quin-tessential example of the slow but substantial decline ofcigarette smoking in the developed world. The smokingrate among men was 52% in 1965 but dropped to 23% by2004. Prevalence among women declined from 34% in1965 to 19% in 2004.

But declining prevalence overshadows the fact that, withpopulation growth, the absolute number of smokers in theU.S. remained relatively constant at 45 to 50 million overthe entire period. Additionally, today’s smoking populationhas a higher proportion of heavy smokers, who are moreresistant to conventional cessation strategies emphasiz-ing tobacco and nicotine abstinence.

Health effects

Cigarette smoking remains thesingle most important avoidablecause of death in the developedworld. The CDC estimates thatsmoking is responsible for438,000 deaths in the U.S.annually.

Cigarette smoking is a risk fac-tor for cancers of the lung,throat, esophagus, bladder, kidney, pancreas, and cervixand for leukemia. It is also a risk factor for cardiovasculardiseases, including heart attacks, strokes, and aorticaneurysms and for lung diseases such as bronchitis,emphysema, and chronic airway obstruction.

Nicotine

Because nicotine is so powerfully addictive, most smokersattempting to quit are not successful. It is estimated that70% of smokers want to quit and 40% make a seriousattempt to quit each year, but fewer than 5% succeed inany given year. What can be done for the remainingsmokers who want to quit? The use of ST may be analternative for these smokers.

ST Use

ST was the dominant form of tobacco used in the U.S.until early in the twentieth century, when cigarettesbecame more popular. Use of all types of ST is mostprevalent in Southern states and in rural areas throughoutthe U.S.

Types of ST

Modern ST productsare neither chewednor spit. ST productsare not burned butinstead are placed inthe cheek or betweenthe lip and gum.Three types of ST are used in the U.S.: powdered drysnuff, loose leaf chewing tobacco, and moist snuff.

In addition to the U.S., Scandinavia has a long tradition ofmoist snuff use, especially Sweden, where “snus” (thegeneric term for moist snuff in Swedish, pronounced“snoose”) is essentially the only type of ST product in use.

One reason for the increased popularity of moist snuff isthat manufacturers have gradually refined the products inthis category to be more user-friendly. Modern moist snuffproducts are sold in pre-portioned pouches similar toteabags but much smaller. Because these productsremain stationary in the mouth and generate very littlejuice, they can be used discreetly without creating a needto spit.

Prevalence

In 2000, in the U.S., about 1 in 23 men and 1 in 330women used ST. About 25% of ST users also sometimessmoke cigarettes, but cigarette consumption is consider-ably lower in these users than in those who smoke exclu-sively.

Health effects

1. Oral leukoplakia

Oral leukoplakia is a term that literally means “whiteplaque,” and it is used to describe areas of the mouth lin-ing that become thickened by ST use or smoking. Thecondition is very uncommon, occurring in less than 1%of the general population, primarily in long-time smokers.Smoking-related leukoplakia most commonly involve theundersurface of the tongue and throat area, locationsthat account for 75% of oral cancer in the U.S. Oralleukoplakia occur in up to 60% of ST users but onlyrarely progress to cancer.

2. Oral cancer

It is widely perceived — both by laypersons and medicalprofessionals — that there is a strong associationbetween ST use and oral cancer. This is false.Epidemiologic studies dating back to the 1950s provideconvincing evidence that most ST products increase oralcancer only minimally. For example, ST has been wide-ly used in Sweden for 200 years, yet Sweden has one ofthe lowest rates of oral cancer in the developed world.

3. Other cancers

As noted above, cigarette smoking is associated withincreased risk for many cancers even in areas of thebody not in contact with cigarette smoke. By compari-son, numerous epidemiologic studies have failed todemonstrate that ST use is associated with risk of can-cer at any site outside the mouth.

4. Cardiovascular diseases

Over the past fifteen years, eight epidemiologic studieshave examined the risk of cardiovascular diseasesamong ST users. Six of the studies found that ST usershad no increased risk for heart attacks or strokes. Theother two reported modestly positive associations.

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Introduction

About 45 million Americans continue to smoke, evenafter one of the most intense public health campaignsin history. Each year over 400,000 smokers die fromsmoking-related diseases.

Many smokers are unable to quit smoking throughcomplete nicotine and tobacco abstinence, and con-ventional quit-smoking programs generally presentsmokers with two unpleasant alternatives: quit or die.

Another approach to smoking cessation, tobacco harmreduction, involves the use of alternative sources ofnicotine, including modern smokeless tobacco (ST)products. Switching from cigarette smoking to usingST reduces the risk of many smoking-related diseases,including oral cancer. Very few smokers realize that itis the inhaled smoke, not nicotine, that is so hazardousto health. A substantial body of research, much of it pro-duced over the past decade, establishes the scientificbasis for the use of ST products as a means of reduc-ing harm from tobacco.