The Heart Association’s rejection of tobacco harm reduction is contradicted by the evidence presented in its review.
Here are the diseases that were reviewed, and the authors’ assessment of the risks among ST users:
Hypertension (high blood pressure): “In summary, data from the majority of studies in this section do not support an increase in the incidence or prevalence of hypertension in ST product users.”
Myocardial Infarction (heart attack): “In summary, data derived from the majority of studies conducted in Sweden, whereby snuff/snus is the major ST product used, have not demonstrated a significant increase risk of nonfatal or fatal MI…Data derived from predominately US populations are equivocal…More research is needed in the United States with currently marketed ST products to assess the potential relationship between ST product use and MI risk in the US population.”
Stroke: “In summary, data from 2 studies (1 from the United States and 1 from Sweden) suggest that ST product use is associated with a slight increase in the risk of stroke mortality…More research is needed in the United States regarding currently marketed ST products to assess the potential relationship between ST use and stroke risk in the US population.”
Other Cardiovascular Risk Factors: “Although the data are limited, most studies have found no relationship between ST use and other biochemical risk factors for [cardiovascular diseases].”
Diabetes and Metabolic Syndrome (a complex disorder involving increases in blood sugar, blood lipids, blood pressure and weight): “Based on data from two of the above studies conducted solely in Swedish populations, heavy use of moist snuff appears to increase the odds of developing [metabolic syndrome] and type 2 diabetes.” This interpretation should be placed in perspective. One Swedish study (abstract here) found that heavy users of snus (5+ cans per week) had modestly elevated risks for metabolic syndrome (odds ratio = 1.5 – 2.0), but moderate users (4 cans or fewer) had no risk. With respect to type 2 diabetes, one Swedish study (here) found an increased risk in users of 3+ cans per week (OR = 2.7, CI = 1.3 – 5.5), while two other studies (here and here) found no risk in snus users; the second study was not included in the Heart Association review. In summary, if the risks are real, they are modest and only present in heavier users.
So, after a comprehensive review, the authors concluded that there were no markedly increased risks for any cardiovascular disease. Yet, on the basis of very limited evidence, “the American Heart Association does not recommend the use of ST as an alternative to cigarette smoking or as a smoking cessation product.”
Each year 118,000 Americans die from cardiovascular diseases attributed to smoking. Why is the Heart Association denying these smokers a vastly safer alternative?
The authors were unable to find any substantially elevated risks related to ST use, yet the Heart Association press release and other materials are decidedly prohibitionist. Here is a media sound bite by first author Mariann Piano: “[Health professionals] need to respond by continuing to emphasize that none of their patients should be using any kind of tobacco product. So that does include all forms and types of ST products. And so they need to absolutely emphasize that their patients should never begin smoking and that smoking cessation, for those who do use cigarettes, or cessation of ST products. We again don’t advocate the use of any tobacco products.”
Piano’s prohibitionist rhetoric is surprising, because in 2001 she was on a Heart Association panel that delivered a balanced message on the impact of alcohol on heart diseases (available here). That report concluded:
“Moderate intake of alcoholic beverages (1 to 2 drinks per day) is associated with a reduced risk of [coronary heart disease] in populations…Although moderate use of wine and other alcohol-containing beverages does not appear to lead to significant morbidity, alcohol ingestion, unlike other dietary modifications, poses a number of health hazards…The American Heart Association maintains its recommendation that alcohol use should be an item of discussion between physician and patient.”
The Heart Association could have issued a similar policy with respect to ST as a substitute for cigarettes, but tobacco prohibition prevailed. The list of authors includes several prohibitionists, most prominently Neal Benowitz, who I discussed previously (here). He has established a clear position against tobacco harm reduction, which is especially disturbing since he is on the FDA’s tobacco products scientific advisory committee.
The Heart Association has rejected ST; what does it recommend for smokers? Its quit smoking website (here) offers smokers these tips, among many others:
• Lie back in a comfortable chair and relax for 10 to 15 minutes. Use a relaxation tape. If you don't have time for a full session, breathe in deeply and slowly while you count to five. Then breathe out slowly for 5 counts.
• Take a short walk.
• Start a hobby that calms you, such as making models, sewing or doing jigsaw puzzles.
• Warn your family and friends that you may be in a bad mood for a few weeks.
• Do something to improve your self-image. For example, shop for clothes to go along with the "new" you, or get a new haircut.
The American Heart Association has rejected tobacco harm reduction for the thinnest of reasons. Yet it wants smokers to manage one of the most powerful of human addictions with a jigsaw puzzle, a relaxation tape or a new haircut. The Heart Association should be expected to take a more positive and compassionate role in preventing the 118,000 cardiovascular disease deaths that result each year from smoking.
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