Smokeless tobacco products: Unrecognised regulatory and policy opportunities

Abstract

Cigarette smokers are poorly informed about the relative harmfulness of tobacco and nicotine products. Smokers greatly overestimate the risks of using pharmaceutical nicotine and smokeless tobacco (SLT) and underestimate the risks of ‘light’ or ‘low tar’ cigarettes [1–7]. These misconceptions of risk have also been reported among highly educated samples, such as nurses [8] and university students and faculty [9,10], as is shown in the study by Peiper et al. reported in this issue of the journal. The fact that well-educated health professionals are little better informed about the comparative risks of smoked and smokeless tobacco products indicates the need for public education. Some public health professionals oppose this on paternalistic grounds that have been well criticised by Kozlowski [11]. If we accept that smokers and nonsmokers have a right to receive accurate health risk information on tobacco warning labels [11], how should we inform them about lower risk tobacco products? How can we discourage misinterpretation of statements that some products are ‘less harmful’ to mean that they are ‘harmless’? How can we give information about the very different health risks of some smokeless and smoked tobacco products without encouraging young people to use tobacco products, including those of lower risk than cigarettes? Critics argue that accurate risk communication is complicated by the very different cancer risks of different SLT products. Traditional chewing tobacco, such as is used in Asia, causes oral cancer; low nitrosamine SLT (LNSLT), such as Swedish snus, appears to have a much lower oral cancer risk, but levels of carcinogens in SLT products can vary substantially between these two extremes [12–17]. We think that this should be seen less as a challenge than a regulatory opportunity: we can reduce the harm of all SLT products by imposing maximum exposure limits for the most harmful and carcinogenic constituents of SLT, namely, tobacco-specific nitrosamines. Article 9 of the World Health Organization (WHO) Framework Convention on Tobacco Control provides for the regulation of the contents of tobacco products [18] and the WHO's TobReg Working Group has identified the possibility of setting mandated limits on hazardous constituents for SLT products [17]. In the USA, there is now the opportunity to set standards for SLT products under the Family Smoking Prevention and Tobacco Control Act 2009 which gives the Food and Drug Administration the authority to set tobacco product standards to protect the public health [19]. Critics of using SLT for harm reduction are concerned that educating the community about its lower health risks will increase the use of these products among nonsmoking young adults and that some proportion of these users will become cigarette smokers. This does not appear to have happened in Sweden, where SLT use is widespread among men: indeed young men who use snus appear to be less likely to smoke than peers who do not [20]. Some studies in the USA have shown greater uptake of smoking among SLT users [21], but this may be due to shared risk factors for SLT use and smoking in a cultural setting where smokers are encouraged to believe that there are no differences in the health risks of SLT and smoked tobacco [22,23]. Studies in the USA suggest that few smokers are interested in switching to SLT [24], but this too may reflect a lack of knowledge about the lower risk of SLT compared with cigarettes [1]. Many tobacco control advocates are also concerned about the way in which these products are being promoted by the tobacco industry in the USA [25]. As cigarette smoking has declined in the USA and Canada where SLT is legally available, cigarette manufacturers have begun to promote SLT as a tobacco product for use in settings where smoking is banned [26]. Cigarette manufacturers in these countries are marketing SLT products with the same brands as cigarettes, for example Marlboro Snus, Lucky Strike Snus, Camel Snus and other new smokeless products (e.g. Camel ‘Orbs’, ‘Strips’ and ‘Sticks’). These products are explicitly promoted solely as a substitute for cigarettes when smoking is not permitted [26]. This marketing strategy has made public health professionals understandably concerned about the potential for SLT to deter smokers from quitting [25,27]. As we have argued elsewhere [28], these marketing practices provide a strong justification for the regulation of all tobacco products rather than a ban on SLT products. Authorities should, for example, prohibit the use of cigarette brand names on SLT products, and ban all remaining tobacco industry marketing, including use of ‘word of mouth’ promotions, and video sharing and social networking websites [29]. It should not be beyond human ingenuity to use regulation to separate the markets for smoked and smokeless tobacco products, by requiring tobacco companies that market LNSLT products to phase out the production and sale of smoked tobacco products over a period of 10–15 years. More ambitiously, we could encourage all tobacco companies to abandon the production of cigarettes in favour of non-smoked nicotine products, such as LNSLT and clean pharmaceutiucal nicotine products by regulation and controls that make smoked tobacco products unattractive to market [30]. C. G. is supported by a NHMRC postdoctoral research fellowship and W. H. is supported by a NHMRC Australia Fellowship.