Would A Switch from Cigarettes to Smokeless Tobacco Benefit Public Health? No
Would A Switch from Cigarettes to Smokeless Tobacco Benefit Public Health? No
Recently, it has been proposed that all cigarette smokers in the United States switch to smokeless tobacco rather than use proven methods to help them quit using tobacco completely. But a switch to smokeless tobacco would not be the panacea its proponents envision; it would merely result in continued nicotine addiction, additional tobacco-related diseases and deaths and a probable increase in the number of young people who begin using tobacco. Any suggestion by a health-care professional that smokers switch to smokeless tobacco instead of quitting tobacco use altogether is unethical, misleading and has no basis in science.
Smokeless tobacco products, which include snuff and chewing tobacco, cause cancer in humans. Smokeless tobacco contains at least 28 known carcinogens, including nitrosamines, benzo[a]pyrene, formaldehyde and polonium-210. Users of smokeless tobacco are at least four to six times more likely than nonusers to develop cancer of the oral cavity or pharynx and are up to 50 times more likely to develop cancer of the gums and the lining of the cheeks. Several studies suggest that smokeless tobacco users may also be at increased risk for other cancers. The high prevalence of smokeless tobacco use among African-American men in past decades probably accounts for a considerable portion of their death rate from oral and pharyngeal cancers, a rate that since 1980 has been more than double the rate for white men. Further, we may soon see an increase in overall oral and pharyngeal cancer rates due to the explosion in the popularity of smokeless tobacco that began a decade or so ago among young white men.
Smokeless tobacco products are highly addictive because of their high levels of nicotine. Smokeless tobacco users may, in fact, receive an even higher daily dose of nicotine than do smokers. There is also strong evidence that manufacturers of smokeless tobacco are able to manipulate the nicotine dosage that the user gets, which may facilitate the addiction process. Cessation studies conducted among smokeless tobacco users typically report lower success rates than do studies conducted among smokers. Studies conducted at the CDC's Office on Smoking and Health have found that 75 percent of young daily users of smokeless tobacco showed symptoms of nicotine addiction. Among users who tried to quit smokeless tobacco, more than 90 percent showed symptoms of nicotine withdrawal. Smokers who switch to smokeless tobacco could develop an even more severe nicotine dependency.
Tobacco use carries cardiovascular risks, not all of which are due to smoke. A recent study conducted among Swedish construction workers and published in the American Journal of Public Health found that smokeless tobacco users may be up to twice as likely as persons who do not use tobacco to die from a cardiovascular disease. In the study, smokeless tobacco use was associated with increased blood pressure and other negative cardiovascular effects -- evidence that puts another kink in the argument that smokers would benefit from a switch to smokeless tobacco. Critics of this study (the same persons who advocate a switch to smokeless tobacco) say that the construction workers who used smokeless tobacco should not have been compared to construction workers who did not use tobacco, but rather to the general Swedish population. This argument flies in the face of an accepted epidemiological principle for investigating the health effects of a suspected toxic substance; a comparison group ideally should resemble the exposed group in all characteristics other than exposure to the substance.
An unintended side effect of switching to smokeless tobacco rather than giving up tobacco entirely is the implicit message to young people that smokeless tobacco is safe. Use of smokeless tobacco by a parent is one of the strongest predictors of subsequent use by a child. One smokeless tobacco advocate's solution to this problem is for persons using smokeless tobacco to hide it from their children. Most of us who are parents, know, however, that young children are often far more perceptive than we might have expected. Despite all attempts at discretion, it is unlikely that a father could dip snuff for long before his children would discover it. A parent, teacher or coach trying to quit tobacco completely would be sending a far more positive message to children than would an adult continuing his or her nicotine addiction, albeit in a smokeless form.
Safe and Effective Forms of Nicotine Replacement Therapy
Even if we were to accept the hypothesis that lives might be saved if smokers switched to smokeless tobacco, by far the greatest number of lives would be saved by treating the nicotine addiction and helping smokers to become tobacco free. In a recently published book, For Smokers Only, Dr. Brad Rodu of the University of Alabama largely dismisses the use of existing nicotine replacement therapies that the Food and Drug Administration (FDA) has established as safe and effective methods to quit smoking. In comparing the use of nicotine replacement therapy with the use of smokeless tobacco, Dr. Rodu ignores the fact that the goals of these two approaches are vastly different. The goal of nicotine replacement therapy, which includes the use of nicotine gum or transdermal patches, is to treat the nicotine addiction and help individuals become tobacco free. Dr. Rodu, on the other hand, proposes to keep smokers addicted indefinitely to known cancer-causing substances and perhaps even to increase the severity of their addiction. Dr. Rodu's contention that nicotine gum or patches cost too much when compared with smokeless tobacco is patently false when one considers the long-term cost of feeding a nicotine addiction with snuff and the probability of increased health-care costs associated with remaining a tobacco user. The argument that nicotine gum users run "the risk of looking like a ruminant cow or hyperactive adolescent," as Dr. Rodu phrases it in his book, ignores the fact that the gum is not to be chewed in the same fashion as ordinary chewing gum and is only intended for use over a finite time period, usually less than six months. Those who switch to smokeless tobacco would need to continue its use for the rest of their lives. Furthermore, the FDA is now considering allowing the sale of nicotine gum without a prescription, which should help reduce the cost and increase the accessibility of this proven method of quitting tobacco. With the availability of safe and effective methods of becoming tobacco free, there is little justification for recommending a tobacco alternative that carries serious health risks.
Where's the Evidence?
To date, there is no scientific evidence that the proposal to switch smokers to smokeless tobacco can work. Despite advertisements in local newspapers that solicited study participants, no data have been published on the efficacy of this plan. The only published "evidence" has been anecdotal: a handful of accounts of individuals who switched from smoking to smokeless tobacco and were referred to a dental school oral pathology clinic "for evaluation" (perhaps for suspected oral cancer?). We know nothing about how many smokers may have tried switching to smokeless tobacco and then returned to smoking, or about how many may have become addicted to both forms of tobacco. Even if we were to buy the argument that smokeless tobacco is an acceptable substitute for smoking, there is no evidence that the switch works.
Health-care professionals have an ethical (and ultimately a legal) obligation to protect the health of their patients by recommending the best course of prevention or treatment. The suggestion that smokers switch from cigarettes to smokeless tobacco fails to meet that standard, since better and safer methods of treatment exist. The switch-to-smokeless plan is clearly outside the norm of practice of physicians, dentists and substance-abuse counselors. Indeed, the only major proponent of this switch from cigarettes to smokeless tobacco, other than a small coterie of academics, is the smokeless tobacco industry: The United States Tobacco Company has long used the advertising slogan "Take a pouch instead of a puff" to market its Skoal Bandits. The idea of switching smokers from cigarettes to smokeless tobacco has been soundly rejected by the U.S. Centers for Disease Control and Prevention, the National Cancer Institute, the American Cancer Society, the American Academy of Otolaryngology-Head and Neck Surgery and the Massachusetts Tobacco Control Program. This opposition to the switch-to-smokeless hypothesis is not a knee-jerk reaction to a new and different idea; it is the result of a consideration of the science. A physician or dentist who recommends the use of a known cancer-causing agent is violating the ethical standards of his or her profession. If a patient switches from cigarettes to smokeless tobacco on the advice of his or her health-care provider and ultimately develops cancer, the provider would likely be held liable for damages.
Although it is always easier to justify maintaining an addiction than to combat it, the fact remains that the only safe alternative to smoking is to overcome the addiction to nicotine and quit tobacco completely. We would not consider it a public health success if we got all crack-cocaine smokers to switch to snorting powder cocaine or got all alcoholics to switch from liquor to beer. Neither should we consider it a success to get nicotine-addicted smokers to switch from cigarettes to smokeless tobacco. Knowing that smokeless tobacco is dangerous and highly addictive, and that the proposed plan is of unknown efficacy, we should not recommend smokeless tobacco as an acceptable substitute for cigarettes.
American Council on Science and Health, Inc.
By Scott L. Tomar