The Scientific Foundation for Tobacco Harm Reduction, 2006-2011

In 2006, the American Council on Science and Health (ACSH) became the first American scientific organization to formally endorse tobacco harm reduction. Their position was based on a Harm Reduction Journal review article (available here), authored by me and William Godshall, director of Smoke-Free Pennsylvania.

Over the past five years, interest in tobacco harm reduction has expanded exponentially, with a concomitant increase in the number of published studies. ACSH asked me to review and analyze influential contributions to the scientific and medical literature, and to discuss issues that continue to stimulate debate. My review, “The Scientific Foundation for Tobacco Harm Reduction, 2006-2011,” has just been published by the Harm Reduction Journal (available here).

Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks both for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders or with chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks.

In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence; however, they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking.

E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, pending FDA regulation of e-cigarettes as tobacco products is likely to remedy this issue. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates the cigarette handling rituals and cues of cigarette smoking, which suppresses craving and withdrawal that is not entirely attributable to nicotine delivery.

I will end this post with the same quote that ended my review. It is from the outstanding policy paper “Tobacco harm reduction: how rational public policy could transform a pandemic,” by David Sweanor, Philip Alcabes and Ernest Drucker, published in the International Journal of Drug Policy in 2007 (available here):

"The relative safety of ST and other smoke-free systems for delivering nicotine demolishes the claim that abstinence-only approaches to tobacco are rational public health campaigns...Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

E-Cigarettes - No Toxic Effects from Inhaled Propylene Glycol Aerosol

One of the key ingredients in many e-cigarette liquids is propylene glycol (PG), described by Wikipedia (here) as a “colorless, nearly odorless, clear, viscous liquid with a faintly sweet taste…” The entry also explains that PG is used “as a moisturizer in medicines, cosmetics, food, toothpaste, shampoo, mouth wash, hair care and tobacco products…, in smoke machines to make artificial smoke for use in firefighters' training and theatrical productions” and “as a moisture stabilizer (humectant) for snus” among many other applications.

A new study provides valuable information about the toxicological profile of inhaled PG aerosols in laboratory animals; it also provides an excellent general review of the agent. The authors are Michael Werley, a scientist at Altria, and colleagues from Charles River Laboratories (Scotland), WIL Research Laboratories, Battelle Memorial Institute and Virginia Commonwealth University. It was published in the journal Toxicology (abstract here).

The investigators exposed rats and dogs to high concentrations of PG aerosol for up to 28 days, followed by comprehensive systemic evaluations, especially involving the respiratory system.

They report, “In general, these studies confirmed the relatively low toxic potential of [aerosol] PG, administered by various dose routes, including the inhalation route…in the dog, no histopathological effects on the [larynx, trachea and lung] tissues were observed.” The investigators noted decreases in some assessments of red blood cells in dogs treated for 28 days, but “these effects were not clinically significant in the dog and had no effect upon their activity of health”, and “the values still within the normal historical ranges for dogs of this age, strain and sex.”

Werley and colleagues added that, “overall, PG inhalation exposure in rats and dogs produced quite limited toxicological findings, and allowed us to conclude that [aerosol] PG exposures could be conducted safely in man by the inhalation route…”

This study assessed the effects of short-term exposure to PG vapor, but the effects of long-term (months or years) exposure are unknown and unknowable. However, it provides valuable information for e-cigarette users and policy makers. First, even high concentrations of PG vapor don’t have any measurable harmful effects, which is fully consistent with its designation by the FDA as “generally recognized as safe” as a food additive for all food categories up to 2% (here). Just as important, there will be no impact on bystanders from “second-hand” exposure to e-cigarette vapor, if it occurs at all.

How to Use Smokeless Tobacco: A Primer for Smokers

If you have been directed to this page, you want to go to my update on products for smokers here.

This blog is devoted to correcting myths and misconceptions about tobacco harm reduction. Here is some practical advice on to make the switch to smoke-free tobacco products.

1. Pick the right product. Choose a pouch -- a small “teabag” containing tobacco and flavors -- or try one of the other products from this list and decide which works best for you. There are many options, so don’t be discouraged if one product doesn’t fit your lifestyle or taste.

2. If you’re using a pouch, put it in the right place. Place it under your upper lip, near the corner of your mouth. Most smokeless tobacco users put products behind their lower lip – a practice that generates tobacco juice and leads to spitting. In Sweden, snus users tuck the product behind their upper lip, where it’s spit-free and invisible. Simply pop a pouch in your mouth and move it in place with your tongue. Alternatively, pull your upper lip out with your fingers and position the pouch. At first, the pouch will feel like a cannonball. Look in the mirror, and you’ll see that it’s hardly noticeable.

3. Get your nicotine buzz, but don’t overdo it. When you inhale cigarette smoke, you get an immediate nicotine kick. The effect from smokeless tobacco takes longer, but slower nicotine uptake also means slower nicotine decline. One- or two-pack-a-day smokers who switch often need to use only 4 or 5 smokeless pouches… saving money.

Light and ultra light smokers might get too much nicotine from some smokeless products. Choose one that’s satisfying but not overwhelming.

At first, use the smokeless product for only a few minutes. You’ll learn how much time you need to get tobacco satisfaction.

4. Expect the unexpected. You might feel minor burning where you place the tobacco, and your throat might get irritated. This is from the nicotine, and it’s normal. Sipping some water or a beverage can help. You may get the hiccups, feel dizzy or experience an upset stomach, but these minor symptoms will quickly disappear.

5. Stick to the switch. Although some smokers make the transition quickly, smoke-free tobacco products don’t automatically “cure” you of wanting another cigarette. These products will make it easier to quit and they’ll make those cravings less intense, but they don’t entirely replace the smoking ritual. If you’ve smoked for years, breaking the habit can still be a challenge.

Remember, it’s the smoke that kills. Stay committed to being smoke-free.

The Swedish Miracle Confirmed

Investigators from Umeå University and the Karolinska Institute in Sweden have just published a study of tobacco use among the population (40, 50 and 60 year-olds) of Västerbotten County in Northern Sweden over the period 1990 to 2007 (abstract here). The results confirm the findings from earlier published reports (here, here and here), that snus use has been a major influence in low smoking and high cessation rates among Swedish men, and more recently among Swedish women.

This table, adapted from the publication, lists the prevalence (%) of men who used snus, cigarettes, or both products during each period of the study.

Prevalence (%) of Tobacco Use Among Men in Västerbotten County, 1990-2007
	1990-95	1996-2001	2002-07
40 Year Olds
Snus	19	26	28
Cigarettes	20	12	7
Both	8	6	6
50 Year Olds
Snus	12	20	24
Cigarettes	21	16	11
Both	6	6	6
60 Year Olds
Snus	11	14	18
Cigarettes	17	14	13
Both	3	3	4

It clearly shows the transition from cigarettes to snus. Men of all ages made the switch, but the findings are most impressive for 40 year olds: snus use rose from 19% in 1990-95 to 28% in 2002-07, while smoking dropped from 20% to 7%.

Women also made the switch. In 1990-95, 31% of 40 year old women smoked, and only 2% used snus. By 2002-07, 12% smoked and 12% used snus.

The following table, also adapted from the publication, shows that many men used snus to quit smoking.

Percentage of Men Former Smokers Who Were Current Snus Users
	1990-95	1996-2001	2002-07
40 Year Olds	41	49	60
50 Year Olds	26	37	44
60 Year Olds	23	26	31

Once again, the switch was most impressive among 40 year olds. In 1990-95, 41% of former smokers were using snus. By 2002-07 that figure was 60%. Although the percentages were smaller among women former smokers, they were still impressive. In 2002-07, 30% of 40 year old former smokers were using snus -- 16% among 50 year olds, and 7% among 60 year olds.

The study also looked at tobacco use among participants 10 years after they enrolled in the study (Baseline). Here is a breakdown of those results.

Tobacco Use Among Men After 10 Years
	Baseline Tobacco-Free	Baseline Snus	Baseline Cigarettes	Baseline Both
Follow-Up Tobacco
Tobacco-Free	93%	20%	29%	12%
Snus	4	74	13	45
Cigarettes	2	1	51	7
Both	Under 1	5	7	34

Note: Stable use in bold

The important message here is that only 51% of smokers were still lighting up after 10 years, while 29% were tobacco-free, and 13% were using snus. Dual use was even more unstable, with 45% using snus at follow-up. Once again, these findings are similar to previously published research (here).

These results clearly show that snus use has played an important role in low smoking rates. Despite this, the researchers who produced the data argue to the contrary. They write, “If this was a randomized trial it would definitely refute the argument that snus use reduces smoking prevalence…our data is not in support of the claim of smoking reduction of snus…on a population level, snus has played a small role in the decision process to quit smoking.”

The researchers’ anti-tobacco sentiments are clearly at odds with the evidence. Their data simply proves, once again, the reality of the Swedish Miracle. Their jarring analysis underscores the disconnect between the fact-based science of tobacco harm reduction and the obfuscating politics of tobacco prohibitionism.

CDC Propaganda Gets Wide Visibility; National Library of Medicine Assists

The CDC’s dangerously misleading position on smokeless tobacco has been given fresh exposure, thanks to a widely syndicated July 28 news brief from the writers at Health Day (here). Among a broad range of media and web sites republishing the hit piece was the federal government’s National Library of Medicine (here) -- an agency that purports to provide “trusted health information” that is “authoritative,” “reliable” and “up-to-date.” Their seeming endorsement of this anti-tobacco propaganda belies their credibility.

Following is the Health Day screed, interspersed with my factual statements in bold.

Health Tip: Smokeless Tobacco Isn't a Safe Alternative

CDC: It can cause cancer, oral health issues and nicotine addiction

(HealthDay News) -- Some people may think smokeless tobacco is a safer alternative to cigarettes, but experts at the U.S. Centers for Disease Control and Prevention want to nip that idea in the bud.

The CDC acknowledges that it wants to get rid of a concept that is scientifically proven and has the potential to save millions of lives.

The CDC mentions these health issues that can stem from smokeless tobacco use:
Cancer, notably oral cancer.

The oral cancer risk from modern smokeless products is not “notable” at all. It’s insignificant, as documented previously in this blog (here).

Tooth decay, gum disease, receding gums and other oral health problems.

There is “virtually no scientific evidence that smokeless tobacco was an independent risk factor for any dental problem.” It is beyond comprehension that the CDC continues to spew misinformation about dental problems that don’t exist. See my blog entry (here).

If you're pregnant, increased risk of complications, including preeclampsia, low birth weight and premature birth.

This is the only sentence in the release that comes close to being accurate. As I documented previously (here and here), smokeless tobacco use may present risks to the developing baby. All forms of nicotine should be avoided during pregnancy, but the highest risks for a developing baby are associated with maternal smoking.

Fertility problems in men, including abnormal sperm and lower sperm count.

This appears to be another stretch of CDC officials’ imagination. A search of the medical literature reveals two studies relating to smokeless tobacco use and infertility. One, published in 1987 (here), concluded that “tobacco use by chewing or smoking is not associated with impaired semen quality in males selected from an idiopathically hypofertile population.” A second study (here) found some problems among smokeless users in India, data related to a form of tobacco that is neither relevant nor applicable to use of modern Swedish or American smokeless products.

Addiction to nicotine and increased likelihood of becoming a cigarette smoker.

Smokeless tobacco is addictive, and an excellent substitute for cigarettes, but the allegation that smokeless use is a gateway to smoking is a complete fabrication, as I discussed previously (here).

By providing such gross distortions of the truth to smokers and the media, the CDC and NLM undermine their institutional credibility. The public expects these agencies to offer accurate information about infectious diseases, injuries, vaccination, health statistics and more. CDC Director Thomas Frieden ought to be outraged over the distortions and fabrications being promulgated by his personnel.