Thursday, June 27, 2019

Finally, A Direct Comparison of Smoking and Smokeless Tobacco Use

I have documented how American health authorities refuse to directly compare the health effects of smoking and smokeless tobacco (ST) use.  The results of such an exercise would require them to acknowledge the products’ vast risk differentials.  For years, the American Cancer Society has possessed data that would allow this comparison (here, here, and here), but they refused to run the analysis or provide me with the data (here). I recently explained how FDA officials hid the comparison in a New England Journal of Medicine article (here).

I have spent much of the past 25 years trying to correct this information deficit.  Lacking access to the necessary data, the only comparison I could make was indirect (here), which was less than ideal.

Now, at last, the data are in full view.  Altria scientists in April published the first-ever follow-up mortality study of cigarette smokers and ST users, using national surveys and the National Death Index, all of which are produced by the U.S. Government and publicly available.  The first author of the impressive study, published in Harm Reduction Journal, is Michael T. Fisher. 

The figure at left illustrates the results for all causes of death, all cancers and heart diseases; smokeless tobacco is referenced as SLT.  In each section, hazard ratios – the likelihood of dying compared with never tobacco users – are illustrated for smokers by the first set of black dots/squares in the red circles; former smokers are in the next set; and ST users are in the third set, circled in blue.

Smokers are at more than twice the risk of dying from all causes than never tobacco users.  Former smokers’ odds are about 30% to 50% higher than those of never tobacco users (HR = 1.3 – 1.5).  Current ST users who never smoked died at the same rate as never tobacco users.

Compared with never users, smokers had even higher odds for dying from cancer, from 2.9 to about 4.2.  Former smokers also had higher odds, varying from 1.6 to 2.4.  Once again, ST users died at the same rate as never tobacco users.

Smoking isn’t as big a risk factor for diseases of the heart; other factors, like obesity, diet, physical fitness and diabetes, are also important.  Smokers in this study had odds ranging from 1.2 to 2.2, and not all of these were significant.  ST users had no excess risk.

In summary, this analysis of government data confirms that ST use is vastly safer than smoking.  The FDA and CDC not only had this data, but used it in other mortality studies of smokers and cigar users.  By not publishing the results on ST users, federal officials maintained the illusion that ST “is not a safe alternative to cigarettes.”  It is ironic that cigarette industry researchers produced this pivotal analysis.  Stay tuned to this blog for more results.

Wednesday, June 19, 2019

Smokers: Step Away From the Fire With These Safer Cigarette Substitutes

Most cigarette smokers “say” they want to quit, but that is terribly misleading.  Most smokers answer yes to the quitting question because they know it’s the desired response.  In reality, the vast majority of smokers don’t quit in any given year.  All of them would welcome a healthier lifestyle, but they are unable or unwilling to abandon the immediate benefits of tobacco and nicotine, especially smoking.

If you smoke, here’s your guide to vastly safer substitutes that provide nicotine and tobacco satisfaction.

E-Cigarettes and Vape Products

The best harm reduction options for smokers unable or unwilling to give up nicotine and tobacco are e-cigarettes and vape products.  There are thousands of choices, reflecting the fact that they are the most popular – and most successful – quit-smoking aids

Vape Shops

Smokers can take the first step away from the fire by visiting local vape shops, which are often staffed by former smokers who are knowledgeable about your best options and dedicated to your success.  These shops sell popular products and also cater to vapers who want advanced hardware and special e-liquid flavors.  To locate nearby shops, check out Vaping 360’s online locator.  The Vapetrotter Directory is another valuable source.

For lots of factual information about e-cigarettes and vape products, visit the website operated by Consumer Advocates for Smoke Free Alternatives Association.  And for moral support, visit CASAA’s testimonials webpage containing thousands of success stories.



JUUL has taken the vaping market by storm; it’s making cigarette manufacturers nervous, and for good reason.  JUUL pods contain a satisfying nicotine salt that won’t have you climbing the walls or kicking the dog because you don’t have the nicotine hit you need.  Additionally, the pods are inconspicuous, and easy to use and recharge. 

JUUL products are widely available, although the company is only selling tobacco and menthol flavors in convenience and other brick and mortar stores. Its popular flavors -- mango, cucumber, fruit, and cr̬me Рare available online.


Vuse is another family of vaping products that are available in several hardware choices and a wide variety of flavors, including menthol, mint, mixed berry, melon, fruit-and-cream, chai, nectar, tropical fruit and classic tobacco. 

Vuse is available online and in stores nationwide.

Heat-Not-Burn Products


The FDA recently approved the sale of IQOS heat-not-burn products in the U.S.  They are already available in over 30 other countries, and they have produced an unprecedented decline in cigarette consumption in Japan.  An FDA advisory committee in 2018 concluded that the products significantly reduce smokers’ exposure to toxic chemicals found in cigarette smoke.  I believe IQOS products have the potential to compete with vapor products, as they deliver the tobacco flavor and satisfaction many smokers find lacking in e-cigarettes. 

The first U.S. test market for IQOS will be Atlanta, where it will be available at a dedicated Lenox Square store. 

Nicotine Pouches


ZYN is a discrete new pouch product from Sweden that contains no tobacco, just nicotine and flavor – spearmint, wintergreen, cool mint, coffee, cinnamon or peppermint.  Also note that there are two strengths, ZYN 3 and ZYN 6 (milligrams). 

Originally launched in Western states, ZYN is now available nationwide anywhere cigarettes are sold.  It’s also available from


On! is another nicotine pouch made in Sweden, available in mint, wintergreen, cinnamon, berry, citrus and coffee flavors and in three strengths, 2, 4 and 8 milligrams.

These pouches have been in limited distribution here in the U.S., and they are also available at  However, Altria has just bought a large share of the company, so look for these pouches soon in your local convenience store.

Smokeless Tobacco

Camel Snus

Camel Snus packets come in several flavors: mint, frost (spearmint) and winterchill (wintergreen).  If you prefer more tobacco flavor, try Robust or Mellow.  There are also two sizes, a slim version containing 0.6 gram of tobacco, and a larger pouch with 1.0 gram.  I suggest that smokers start with the small size of their favorite flavor.

Camel snus is available nationwide anywhere cigarettes are sold, and online at

Skoal Snus

Skoal Snus packets come in mint and smooth mint. 

You can find them nationwide in the smokeless tobacco section of convenience stores, and they are available at

Skoal Bandits

In 1995, when conducting the first-ever smoking cessation clinical trial using smokeless tobacco (abstract here), my research group recommended that smokers switch to Skoal Bandits, the only widely available pouched smokeless tobacco product at that time.  They are still available nationwide in wintergreen and mint flavors.

Oliver Twist

Oliver Twist is the planet’s most discrete smokeless tobacco product.  It consists of mini-rolls of tobacco (smaller than a pencil eraser), which are made in Denmark by rolling whole tobacco leaves into a rope, which is then cut into small pieces.  Flavors include original (tobacco), wintergreen, sunberry and tropical.

Oliver Twist can be difficult to find.  Look for stores that sell premium cigars and pipe tobacco, or order it at      

Helpful Tips:

First and foremost, place smokeless products inside your UPPER LIP.  That is the key to minimize tobacco juice and the need to spit.  At first it might feel like a cannonball, but it won't be noticeable.

There are many options, so don’t be discouraged if one product doesn’t fit your lifestyle or taste.

Whatever product you use, get your nicotine buzz, but don’t overdo it. When you inhale cigarette smoke, you get an immediate nicotine kick, and during your smoking career you learned to optimize your buzz. The effect from e-cigarettes or smokeless tobacco may be different, but you’ll learn how to get a similar effect.

Stick to the switch. Although some smokers make the transition quickly, smoke-free tobacco products don’t automatically “cure” your desire for 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.

If your ultimate goal is complete nicotine and tobacco abstinence, stepping away from the fire is a critical first step.  Remember that it’s the smoke that kills, so becoming and staying smoke-free, not necessarily nicotine- or tobacco-free, is your first priority.  It’s the key to a longer and healthier life.

Friday, June 14, 2019

Common Sense Legislation Would Limit Teen Tobacco Access

Senate Majority Leader Mitch McConnell recently introduced legislation to make 21 the legal age for tobacco sales nationwide.  As he elevated the Tobacco 21 debate to the national stage, McConnell said that stemming teenage vaping was a primary objective.

There is no question that vaping is on the rise among teens, but the Food and Drug Administration and other federal agencies have miscast the situation, labeling it an epidemic to provide a rationale for excessive regulations.  Regardless, McConnell’s championing of Tobacco 21 is appropriate, as it would delegitimize tobacco sales to 18-year-old high school students.  While those youths comprise 16% of all high school students, they account for one-quarter of high school smokers and smoker-vapers.    

FDA survey data shows that more than 90 percent of teens who use tobacco products obtain them from social sources.  The Population Assessment of Tobacco and Health (PATH) survey collects detailed information about teen tobacco use. It reveals that fewer than 10 percent of current teen e-cigarette users – defined broadly as having taken at least one puff in the past 30 days – “bought them myself.” While the FDA and other government agencies target retailers, the vast majority of underage teens get e-cigarettes from their friends and relatives.  These sources can’t be regulated.

The Tobacco 21 debate was reignited recently by a proposed FDA rule requiring retailers to have a separate room for flavored e-cigarette products, accessible only to purchasers of legal age.  This is a nearly impossible requirement for convenience, grocery and drug stores.  The rule might be met by vape and tobacco shops, but that won’t solve the problem. According to a recent study, teens purchased vapor products most frequently online (32%) and from vape (22%) and tobacco (16%) shops.  Convenience, gas and liquor store purchases were less frequent (5.6%), as were grocery, drug and other stores (2.2%).  Thus, the proposed rule would have no impact on the most common sources of teen purchases, but it would likely eliminate vapor sales at stores where teens aren’t buying products.  This would be government regulation at its worst. 

While the FDA obsesses over brick-and-mortar retailers, Congress should immediately address online vapor sales.  The 2009 Prevent All Cigarette Trafficking (PACT) Act required online purchasers of cigarettes and smokeless tobacco products to provide proper identification at the point of delivery.  However, the law doesn’t cover e-cigarettes, an omission that would be corrected by the recently introduced Preventing Online Sales of E-Cigarettes to Children Act

Tackling teen smoking and vaping at the federal level is important.  Passing Tobacco 21 and updating the PACT Act to include e-cigarettes are two easily achievable legislative actions that will be far more successful in decreasing underage teen tobacco use than ill-conceived new restrictions and regulations impacting adult access to e-cigarettes.