Brave new world of tobacco disease prevention: Promoting dual tobacco-product use?

Abstract

Could snuff be part of the solution to reducing tobacco-caused death and disease or will this form of oral smokeless tobacco help perpetuate the stream of more than 400,000 deaths per year in the United States? The answer cannot be predicted simply on the basis of tobacco product toxicology, but must also be examined through the lens of behavioral epidemiology to determine how snuff is actually used. In this issue of the American Journal of Preventive Medicine, Tomar1 reports an analysis of the relationship between snuff use and cigarette smoking in the United States. This analysis raises questions and provides additional reasons for caution about promoting snuff use to reduce death and disease caused by cigarette smoking. It also raises the specter of a potentially deadlier form of tobacco use becoming more common: persistent dual use of cigarettes and smokeless tobacco products. Moist snuff (e.g., trade names Copenhagen , Skoal , and Kodiak ) is the most popular form of smokeless tobacco in the United States, with rates of use being higher among males (especially adolescents and young adults) than females.2–4 It has been recognized since the 1980s that snuff, along with other oral tobacco products, is addictive and causes cancer and other oral diseases.3,5,6 It may be surprising that a potential beneficial public health role has been contemplated for snuff,7 yet there is a compelling theoretical basis for the possibility. Put simply, cigarette smoking is so extraordinarily deadly and addictive that use of snuff to replace cigarettes is a theoretically feasible approach to reduce disease—even if snuff use persists in former smokers.8 Compared to the toxic effluent of the cigarette, which is inhaled deeply into the lung, smokeless forms of tobacco consumption tend to be less toxic and are associated with a lower risk and narrower range of diseases.5,9,10 Thus, a switch from cigarette smoking to smokeless tobacco would pose a theoretical health benefit compared to continued smoking. The caveat implied by the term “theoretical” is raised because, as discussed in the Institute of Medicine (IOM) report,9 there are not sufficient data to warrant endorsement of any tobacco product as a means of reducing the risk of cigarette smoking. Furthermore, the criteria for harm reduction endorsed by the IOM committee included the effects of use of the product on “total tobacco-related mortality” in the population. For example, a population risk of promoting snuff as a smoking-cessation aid could potentially undermine efforts to prevent the onset of snuff use in young people, just as snuff marketing with a relative safety theme (compared to cigarettes) fueled the epidemic spread of snuff use among adolescent athletes who were resistant to smoking in the United States in the 1970s and 1980s.5,6,11,12 Another potential population risk is illustrated by the “light” cigarette debacle, whereby low-tar cigarette brands were promoted as less harmful ways of smoking and were intended (by their manufacturers) to delay smoking cessation by providing smokers with alternatives to quitting.8,13 In fact, there is little evidence that these cigarette brands actually reduced disease risk among smokers.13 The impact of a product on overall patterns of tobacco use can be as critical as the product itself in disease production or prevention. To address this issue, Tomar1 explored the interrelationship between the use of snuff and cigarettes using the National Health Interview Survey data from 1998. His findings raise both promise and peril, as well as a new potential concern. Tomar found that daily snuff users were more likely than never users to have quit smoking cigarettes in the preceding 12 months; to the extent that these were smokers who would not have quit without the aid of snuff, this finding represents a theoretical reduction in health risk for those smokers. He also found, however, that people who smoked cigarettes and occasionally used snuff were less likely to successfully quit smoking. Furthermore, the odds were greater than 2 to 1 that snuff users will become smokers than the other way around. These findings extend those of previous reports, which demonstrated that in the United States product switching is dominantly in the direction of snuff to cigarettes and not cigarettes to snuff.14,15 Additional data challenge the validity of comparing From the Johns Hopkins University School of Medicine (Henningfield), Baltimore, Maryland; Pinney Associates (Henningfield, Rose), Bethesda, Maryland; and Roswell Park Cancer Institute (Giovino), Buffalo, New York Address correspondence to: Jack E. Henningfield, Pinney Associates, 4800 Montgomery Lane, Suite 1000, Bethesda, MD 20814. E-mail: jhenning@pinneyassociates.com. Information for full text of this commentary is available via AJPM Online at www.ajpm-online.net.