Wednesday, July 1, 2015

Kaiser Permanente’s Not-So-Negative Take on Smokeless Tobacco



Kaiser Permanente might better call itself Kaiser In Transition.

A week ago I noted that the company’s website provides smokers with three grossly incorrect reasons to avoid e-cigarettes (here).  As it turns out, elsewhere on the same site, Kaiser makes a reasonably good case for the harm reduction potential of smokeless tobacco.

“Smokeless tobacco products include chewing tobacco and snuff.  These products are less harmful than smoking cigarettes,” advises the Good Kaiser.  It’s the first-ever admission by an American corporate health giant that smokeless tobacco use is less harmful than smoking.

After this promising start, Kaiser’s advice is less accurate.  They claim with no scientific basis that smokeless tobacco is “just as addictive as cigarettes.”  In fact, there is some evidence that smokeless tobacco has lower dependence than cigarettes (here).

They correctly note that smokeless tobacco is associated with “[w]hite, leathery patches (leukoplakia) that form on the inside of the cheek or on the gum,”  but the claim that these patches turn into mouth cancer is unfounded.  As I explained in a review article in 1995 (abstract here), white patches from smokeless tobacco use are like calluses on the skin; they almost never turn into cancer.  I have in the past refuted two other of Kaiser’s claims, regarding dental diseases (examples here and here) and pancreatic cancer (here and here). 

Kaiser’s discussion of tobacco harm reduction closes with a stunning admission:

“A type of smokeless tobacco called ‘snus’ seems to have much less risk of harm. But it is not clear whether using snus causes no harm or risk.”

This passage is powerful, because it can be reasonably interpreted to acknowledge that the health risks of snus may be minimal to nonexistent.  I hope this marks the beginning of a new era of truthful and accurate descriptions of smokeless tobacco use and its health effects.        

Wednesday, June 24, 2015

Kaiser Permanente to Smokers: “Say No to E-Cigarettes…Light Incense or a Candle Instead”



Kaiser Permanente, the health care consortium that insures over 10 million Americans, is telling its members, “say no to e-cigarettes…here are 3 good reasons to give them a thumbs down.”  Those reasons, straight from the prohibitionist playbook, are outdated, irrelevant, deceptive and irresponsible.

Reason #1: “Safety concerns.”  KP mentions a six year old FDA study that reported traces of diethylene glycol and tobacco-specific nitrosamines in some e-cig liquid samples.  As I explained, “the FDA tested e-cigarettes for TSNAs using a questionable sampling regimen, using methods that were so sensitive that the results may have no possible significance to users. The agency failed to report specific levels of these contaminants, and it has failed to conduct similar testing of nicotine medicines that have been sold in the U.S. for over 20 years.”  Not only is the study outdated and irrelevant, subsequent studies have failed to find diethylene glycol in e-cig liquids.

Reason #2: “No convincing evidence they will help you quit.”  As I reported earlier this year, ignoring medical literature is not just irresponsible, it’s laughable: There are legions of former smokers who credit e-cigarettes with life- and breath-saving benefits. 

Reason #3: “What’s proven to work still works.”  KP advises that “the most effective way to quit is to use a combination of FDA-approved medications (like the nicotine patch, gum, lozenge, or bupropion) and counseling support,” which works for about 7% of smokers in the general population.  KP urges smokers to use these coping measures to “fight the urge”:

  • ·       Take 10 deep breaths and hold the last one while lighting a match. Exhale slowly and blow out the match. Pretend it's a cigarette and crush it out in an ashtray.
  • ·       Take a shower or bath.
  • ·       Learn to relax quickly and deeply. Visualize a soothing, pleasing situation and get away from it all for a moment. Concentrate on that peaceful image and nothing else.
  • ·       Light incense or a candle instead of a cigarette.
  • ·       Try crossword puzzles, needlework, gardening, or household chores. Wash your hands, do the dishes, or try new recipes.
  • ·       Brush your teeth and use mouthwash.

KP’s e-cigarette advice violates its mission “to improve the health of our members and the communities we serve.”

Friday, June 19, 2015

Research: Camel Snus Reduces Smoking, Promotes Intention to Quit



A small study quietly published last year confirms findings of my 1998 clinical trial: appropriately informed, smokers will embrace smokeless tobacco (ST) as a satisfying and socially acceptable cigarette substitute.



I reported here in 2011 that researchers at the Medical University of South Carolina were conducting a nationwide clinical trial evaluating whether Camel Snus could help smokers quit.  Although the results of that trial are not yet available, the researchers have documented that Camel Snus “can lead to reduced smoking and increased intention to quit.”



Led by Dr. Jessica Burris, MUSC investigators recruited 57 smokers who were unmotivated to quit into one of three groups: (1) a control group of 11 smokers who smoked their own cigarettes; (2) 23 smokers who were given Camel Snus and instructed to use it to cope with smoking restrictions (Snus to Cope); and (3) 23 smokers who were instructed to use Camel Snus to reduce or even eliminate smoking (Snus to Reduce).  Data was collected at the start, midpoint and end of the two-and-a-half week study period.



Although the study numbers were small, the results showed that snus worked, especially keeping in mind that women, who don’t normally use ST, comprised 65% of the snus groups.  Sixty-four percent of the Cope group and 71% of the Reduce group used snus daily.  Daily cigarette use declined by 18% in the Cope group and 38% in the Reduce group.  Compared with the control group, motivation and intent to quit smoking was higher in both snus groups.



After the study, participants in both snus groups “said they liked Camel snus to a moderate degree, but not as much as they liked their usual brand of cigarettes.  Finally, participants in the Cope and Reduce groups perceived low-nitrosamine SLT as having either less (67.4%) or equal (32.6%) risk compared with conventional cigarettes; no one rated [Camel Snus] as having more risk than conventional cigarettes.”



The authors conclude: “This study replicates previous work that shows that low-nitrosamine ST use can lead to reduced smoking and increased intention to quit, and it adds direct evidence to suggest that the function of low-nitrosamine ST use – either to cope with smoking restrictions or to reduce smoking – can have a differential impact on smoking behavior. Overall, the results highlight the importance of messaging and, more specifically, marketing of low-nitrosamine ST to smokers.”



The scientific case for ST as a smoking cessation aid continues to expand.

Thursday, June 11, 2015

San Fran and Cal Smokeless Bans: They’re Yawners



The Campaign for Tobacco Free Kids and other anti-tobacco groups have persuaded the city of San Francisco to ban smokeless tobacco in municipal sports venues (here).  The ordinance takes effect in January 2016, but neither athletes nor fans will likely feel its effect.

CTFK president Matthew Myers wants smokeless products banned everywhere; last week he convinced the California Assembly to pass a state-wide ballpark ban (here); the bill is pending in the state senate.   

If Myers and ballpark barons really wanted to protect children, they wouldn’t let fans drink alcohol and drive.  Most venues sell alcohol; San Fran’s AT&T Park offers beer, wine, Irish coffee and 4,000 parking spaces.      

To be effective, ballpark bans would require full-body searches, including mouth exams, at the gates.  A game’s worth of snus or moist snuff pouches can fit in a zip-lock bag and be tucked in a pocket or purse.  Placement inside the upper lip virtually eliminates spitting, making use of the product invisible.  Even slo-mo replays won’t expose players’ enjoyment of these products on the field.

Laws should not be broken, but as with the failed American experiment of Prohibition a century ago, ballpark bans on smokeless tobacco will only spark civil disobedience.

Wednesday, June 3, 2015

New Eurobarometer Report Supports The Swedish Miracle



How can the European Union continue to deny Sweden’s success in tobacco harm reduction?  I have documented how Swedish snus has contributed to that country’s world record low rates of smoking (here and here) and smoking-related deaths – rates that would translate into hundreds of thousands of lives saved if snus were not banned in the rest of Europe (here and here).  The EU’s  European Commission persists in ignoring this American researcher and a growing number of international tobacco research and policy experts (here).  Perhaps a new report by Eurobarometer, the EU’s official survey organization, will force a policy change.

The 200+ page report (available here) analyzes tobacco prevalence and consumption, including cigarettes, snus and e-cigarettes, across all EU countries.  Its findings substantiate the dire consequences of the EU’s misguided ban on snus. 

The following table of reported key smoking indicators clearly demonstrates the effect of the Swedish snus experience.  Sweden has the lowest smoking prevalence, at 11% -- less than half the 26% prevalence throughout the EU and eight points lower than second-place Finland.  Sweden also leads the EU in prevalence of former smoking, at 35%.  It is the only country in the EU with cigarette consumption among smokers of less than 10 per day.  The reason is obvious: half of Swedes have “ever tried…oral tobacco (snus), chewing or nasal tobacco.”

Intriguing numbers are also supplied from Finland.  That nation has the second lowest smoking rate (19%) and the second highest ever use of smokeless tobacco (14%).  It is widely known that snus use remains popular in Finland.  In fact, snus importation increased last year (here), even though the product has been officially prohibited in Finland since it joined the EU in 1995.  Research shows that Finnish smoking rates would have declined even more if snus sales had not been banned (here).

Some suggest that snus would have no appeal outside of Sweden, but the product is clearly popular in Finland and in Denmark. Last year, the EU sued Denmark for permitting snus sales (here).  Also popular among Danes is a chewing tobacco product, Oliver Twist, another effective cigarette substitute and one that is legal in the EU.  The Eurobarometer numbers show that snus could work in Austria, Estonia and several other countries that have populations with smokeless tobacco experience.   

Keep in mind that the differences in snus and smoking rates noted here would have been much even more impressive if Eurobarometer had separately reported men and women’s numbers.  The snus experience has primarily affected smoking rates among Swedish men, although snus use has also been linked to smoking cessation in Swedish women (here).

The EU should take its head out of the sand and dissolve its unhealthy snus ban.


Tobacco Use in Sweden Versus the Rest of the European Union, 2014
EU CountryCurrent Smoking (%)Former Smoking (%)Cigarettes Per DayEver Tried Oral, Nasal Tobacco (%)
Sweden11359.950
Finland192413.514
Malta201914.81
Luxembourg212212.87
Italy211613.23
Ireland211913.95
Slovakia211612.54
United Kingdom221914.34
Estonia222111.510
Denmark233013.313
Netherlands233111.44
Belgium251914.15
Portugal251214.92
Czech Republic251814.39
Lithuania261812.15
Austria261719.810
Germany272215.39
Romania271314.21
Poland281515.65
Spain291913.72
Slovenia301816.56
Latvia302112.78
Hungary301116.13
Cyprus311519.52
France322213.04
Croatia331616.73
Bulgaria351615.62
Greece382119.51
EU262014.45