Dual Use and Smoking Suppression

Norway has proven that the Swedish tobacco experience can be duplicated in other countries where smokeless tobacco is used (discussed earlier here and here).  Karl Erik Lund, from the Norwegian Institute for Alcohol and Drug Research, and Ann McNeill from the University of Nottingham in the UK, have profiled male dual users (of snus and cigarettes) in Norway in a new report published in Nicotine & Tobacco Research (abstract here).

Drs. Lund and McNeill use Norwegian survey data to show that dual use has been relatively stable at 4-7% over the 25-year period from 1985 to 2010, during which exclusive snus use increased from 3% to 12% and exclusive smoking dropped from about 50% to 20%.  While U.S. tobacco prohibitionists argue that dual use will be problematic if smokers are educated about safer smokeless products, dual use has not been a public health issue in Sweden or Norway.

Another finding in the Scandinavian research is that dual users smoked fewer cigarettes than exclusive smokers (57 vs. 80 per week).  I also reported this fact in my landmark Swedish study published ten years ago (abstract here), and I documented this finding among American dual users (abstract here). 

One finding not discussed by Lund and McNeill was that among all Norwegian men surveyed from 2005-2010, 5.3% were former smokers and current snus users, while only 3.3% were former snus users and current smokers.  This shows that snus was more of a gateway FROM smoking than the reverse.  This contrasts with U.S. experience, where more male smokeless users transition to smoking (documented by me here).  It appears that Norwegian men are better informed about the relative risks of  snus use and smoking, resulting in healthier decisions.

Lund and McNeill conclude: “The increase in snus use among men in Norway has not been paralleled by an increase in dual use of snus and cigarettes.  The prevalence of smoking—the far most dangerous form of nicotine uptake—is quite low among men who use snus everyday but generally quite high among men who use snus on a less-than-daily basis. Use of snus also seemed to lower cigarette consumption.  Dual use did not lessen plans to quit smoking within 6 months but increased expectancies of being smoke-free 5 years into the future.”

An Absorbing Nicotine Lesson

Nicotine uptake from snus, cigarettes and medicinal gum varies significantly, new research shows.

Helena Digard of British American Tobacco is lead author on the work, joined by colleagues from her company and from Sweden’s Lund University; their research was published in Nicotine and Tobacco Research (abstract here).

Dr. Digard provided 20 Swedish dual users of snus and cigarettes with two loose and two pouched snus products with different nicotine levels; nicotine gum; and a cigarette, over the course of six sessions.  Snus was placed in the upper lip for one hour only and not moved; the cigarette was smoked ad lib for 5 minutes or until reaching a prescribed length; the gum was chewed every 2 seconds for 30 minutes, with juices swallowed once every minute. 

The chart from the journal illustrates critical nicotine absorption data:

1.  Cigarettes produced a rapid, but transient, nicotine spike.  Peak blood nicotine levels of around 12 nanograms (ng) per milliliter (ml) were seen seven minutes after starting to smoke, followed by a steep decline.

2.  Snus produced similar nicotine levels much more slowly, but they stayed higher longer.  The products produced varying nicotine levels (~ 10-17 ng/ml) that correlated with their nicotine concentrations; the peak occurred one hour after placement.  Subsequent declines were also slower; after two hours, nicotine levels ranged from 7 to 12 ng/ml.

3.  Nicotine gum produced low blood nicotine levels much more slowly.  The peak (8 ng/ml) at 45 minutes was similar to the cigarette level that had declined by one-third. 

These findings are similar to those reported 24 years ago in the New England Journal of Medicine (reference here); they are particularly relevant for cigarette smokers making the switch to smoke-free nicotine products. 

The big lesson: Snus delivers satisfying doses of nicotine, but not as quickly as cigarettes.  However, slower nicotine delivery means slower decline – a distinct advantage.  Switchers generally use fewer pinches or pouches of smokeless tobacco compared to the number of cigarettes they smoked, as documented in my published research in the U.S. (here and here) and in Sweden (here). 

When unit consumption drops, smokers save money, further incentivizing them to stick with their switch to safer smokeless products.

Snus Prohibition in the EU

Swedish newspaper Dagens Nyheter reports that the European Commission’s health directorate has proposed a ban on the export of Swedish snus (article in Swedish here).

Sweden’s government has been quietly urging the European Union to lift its ban on snus sales in other European countries.  Dismissing the strong scientific and public health rationale for snus as a cigarette substitute, the health directorate’s proposal ensures the complete market dominance of cigarettes in the EU, thereby sentencing millions of smokers to shortened lifespans.

According to Dagens Nyheter, the proposal will also require health warnings to cover 90% of cigarette and snus packages. But for simple black and white tombstone lettering, branding would be eliminated by 2017.

The proposal is subject to review by the EU’s 27 commissioners; the European Parliament can also play a role.  The health directorate hopes to put the proposal into force by 2014.

In related news, the Danish government, threatened with legal action by the EU, announced that it will ban the sale of snus (article here).  Traditional loose snus has been legal and modestly popular in Denmark, just across the Strait of Oresund from Sweden.  The Danish government will present parliament with a bill to prohibit loose snus by March 2013; according to the Copenhagen Post, at least four political parties will oppose the ban. 

With 700,000 smoking-related deaths per year in the EU, the European Commission should embrace the life-saving policy of tobacco harm reduction and eliminate its irrational ban on smoke-free products.

What a Difference the Truth Makes: Researchers Say Government Needs to Get Smokers Facts about Smokeless Tobacco

A new study reveals that telling smokers the truth about smokeless tobacco corrects their misperceptions and increases the likelihood of their trying smokeless products to quit smoking.

Lead author Ron Borland of Australia worked with colleagues in the U.S., U.K. and Sweden; their article was published in Harm Reduction Journal (available here). 

Smokers recruited in the four countries were asked about the relative harmfulness of nicotine and smokeless tobacco versus cigarettes.  Smokers were also asked if they were likely to try these products in their next quit attempt.  Smokers were then given a three-page fact sheet truthfully explaining the different health risks of nicotine or smokeless tobacco and cigarettes.  The Australia fact sheet appears in the article’s appendix; it incorporates much of the information we provided smokers in our Owensboro, Kentucky, cessation program (here).

The results for smokeless tobacco are seen in the table.  Bold numbers in the “After” rows indicate a statistically significant increase from before presentation of the fact sheet. 

Percentage of Smokers With Correct Perceptions of Smokeless Tobacco Harmfulness and Who Are Likely to Try These Products in Next Quit Attempt
	Australia	Sweden	U.K.	U.S.
Smokeless Tobacco vs. Cigarettes
Before Fact Sheet	8%	14%	22%	7%
After Fact Sheet	36%	28%	54%	27%
Likely to Try Smokeless Tobacco
Before Fact Sheet	27%	15%	51%	29%
After Fact Sheet	47%	Not Asked	79%	46%

It is evident that few smokers held correct perceptions of smokeless tobacco before they saw the fact sheet.  Only 7% of American smokers knew that smokeless is far safer than cigarettes; even in Sweden, the home of tobacco harm reduction, only 14% of smokers knew the truth.

It is encouraging that the fact sheets produced statistically significant increases in correct perceptions among smokers in all countries (even though the percentages remained low), and that they also produced significant increases in the percentage of smokers willing to try smokeless tobacco.  (Unfortunately, smokeless tobacco products are banned in Australia and the U.K.)

This study provides “evidence that the provision of information in the form of, say, a cigarette pack onset/insert, might be an effective means to educate smokers about the relative harmfulness of alternative nicotine delivery products such as [smokeless tobacco] and [nicotine replacement therapy]. Given the low levels of knowledge that smokers had about harmfulness of different nicotine delivery products, it would seem to be in the public interest to require such information to be placed on cigarette packs and at the point of sale for tobacco products to ensure that smokers are better informed about the relative harmfulness of smoked and unsmoked nicotine delivery products.”

The authors conclude with a clear call to action:

“The current lack of knowledge would seem to be largely due to the reluctance of governments to ensure that smokers are better informed about the mechanisms by which their dependence on nicotine is harming their health. This could be remedied either by requiring or encouraging manufacturers to publicise this information, and/or by governments doing so themselves through public information campaigns.”