Measuring Smokers’ Preferences for Smokeless Tobacco Products

Most of America’s 45 million smokers have never considered switching to a smokeless tobacco product.  They have plenty of options, but we have little information about smokers’ product preferences.

A new study gauges smokers’ perceptions of five smokeless products: General Snus from Swedish Match, Camel Snus from Reynolds, Marlboro Snus from Phillip Morris, and Stonewall and Ariva dissolvable pellets (which are no longer marketed) from Star Tobacco. 

The study, appearing in Nicotine & Tobacco Research (abstract here http://www.ncbi.nlm.nih.gov/pubmed/23239843 ), was authored by Dorothy Hatsukami, a tobacco researcher from the University of Minnesota and former member of the FDA Tobacco Products Scientific Advisory Committee, and colleagues from Roswell Park Cancer Institute and the Oregon Research Institute. 

Dr. Hatsukami recruited 97 smokers interested in quitting.  After not smoking for five hours, the subjects sampled each of the five products on separate days over a two-week period (brand names were hidden).  They then answered 21 questions about satisfaction, psychological reward, aversion (dizziness, nausea, other bothersome side effects), relief of craving/withdrawal, ease of use, comfort and dependence concerns.  Answers were based on a Likert scale ranging from 1 (not at all) to 7 (extremely); 4 is neutral.  At the end of the sampling period they were asked to pick a product to use during two weeks of smoking abstinence. 

Average Smokers’ Scores For Smokeless Tobacco Products During Sampling Period
Product (Nicotine Content, mg)	Satisfaction	Psychological Reward	Aversion	Relief	Ease of Use	Comfort	Dependence Concern
General Snus (3.4)	1.8	2.2	2.7	3.4	4.8	3.9	1.5
Camel Snus (1.8-2.0)	3.6	2.6	1.9	3.8	5.7	4.9	2.0
Marlboro Snus (0.1-0.4)	3.6	2.5	1.7	3.7	5.5	4.8	1.9
Stonewall (0.3-0.6)	3.3	2.4	1.9	3.6	5.8	5.6	1.8
Ariva (0.2)	3.4	2.4	1.6	3.5	5.9	5.4	1.8

Average scores for the products are seen in the table.  Camel and Marlboro snus had the highest scores for satisfaction and relief of craving/withdrawal, even though they had vastly different levels of free nicotine, the form that is readily absorbed in the mouth.  The dissolvable products scored highest for ease of use and comfort.

Smokers’ individual product scores were correlated with their preferred product for the smoke-free period.  Camel snus was picked by the largest percentage (28%), followed closely by Stonewall and Ariva (24% each), and Marlboro snus (23%).  No one picked General snus, probably because of its high nicotine content, which accounted for higher aversion scores.   

The research leaves a few questions unanswered.  Information on cigarette and smokeless consumption during the smoke-free period was collected, but not reported.  Two-thirds of the subjects in this study were female, but the authors did not comment on the effect of gender on the scores.  Women have considerably different perceptions of smokeless tobacco than men.

These shortcomings aside, the Hatsukami study provides valuable data on smokers’ preferences for various smoke-free products.

Smokeless Tobacco Labeling Matters: Impact of Warnings and Relative Risk Info

A study published in Nicotine & Tobacco Research (abstract here) reveals “high levels of appeal for ST [smokeless tobacco] among young adult Canadian cigarette smokers,” despite the fact that “more than one quarter (28%)…were unaware that using ST is less harmful than smoking.”  The lead author was William E. Callery at the University of Waterloo in Ontario, with co-authors from Roswell Park Cancer Institute and the Ontario Institute for Cancer Research.

Callery and coworkers recruited 611 Canadian smokers age 18-30 years old to participate in an online survey viewing photographs of four ST packages (duMaurier snus, Marlboro snus, Copenhagen moist snuff and Ariva dissolvable tobacco), altered to contain a mix of text or pictorial health warning labels tested by Health Canada, the federal health agency.  The ST packages were also altered to contain relative health risk messages that truthfully explained the difference in risk between ST products and cigarettes.

Callery  et al. found that “43.6% of respondents indicated that they were likely to try at least one of the ST products”; the preferred product was Ariva.  The pictorial warning labels significantly reduced the likelihood of trying the ST products, while the relative risk messages doubled the prospect of trial.  In other words, picture warnings increased the scare factor, while relative risk messages increased the chances of switching.

The young adults came in to the study grossly misinformed about the relative risks of ST products.  Callery observed that “between 30% and 47% of respondents incorrectly believed that ST and cigarettes are equally harmful, and a small proportion incorrectly believed that ST is more harmful than cigarettes.”  As one might expect, warning labels enhanced the misperceptions, while participants who saw the truthful relative risk messages “had higher odds of reporting correct beliefs about the health risk of ST compared with cigarettes.”

Callery and coworkers concluded that their study showed “relatively high levels of appeal for ST products and openness to trying ST products among young adult cigarette smokers in Canada.  Further research is needed to determine if the high level of openness to trying ST found in this study will translate into actual use and, if so, whether increased ST use might alter cigarette consumption.  The current study also suggests that pictorial warnings on ST products increase overall perceptions of risk and discourage use as intended.  However, pictorial warnings also exacerbated the false belief that smokeless products are equally as harmful as conventional cigarettes.  Regardless whether ST products serve as a harm-reduction product at the population level, greater efforts should be undertaken to promote more accurate perceptions of [the relative health risks] between tobacco products.”

The Canadian findings directly relate to tobacco regulation in the U.S.  The FDA should act on the petition filed nearly a year ago to change the misleading warning that smokeless tobacco “is not a safe alternative to cigarettes.” (discussed here)  Furthermore, the U.S. Centers for Disease Control, the National Cancer Institute and other federal agencies should “promote more accurate perceptions of [the relative health risks] between tobacco products.” 

In short, tell smokers the whole truth.

Smokeless Reduces Smoking in Small Clinical Trial

Dr. Dorothy Hatsukami and colleagues have published a small clinical study documenting that smokeless tobacco products appeal to and satisfy smokers, reducing smoking and promoting abstinence.  The research was conducted at the University of Minnesota and the Oregon Research Institute; it appears in Drug and Alcohol Dependence (abstract here). 

Smokers of at least 10 cigarettes a day were recruited in the Minneapolis and Eugene, OR areas; 99 smokers formally entered the intensive 5-week trial (65% were men) and 91 completed it. 

Over two weeks, smokers sampled five products (and flavors): Stonewall dissolvable tobacco (wintergreen, java, natural), Camel snus (frost and mellow), Ariva dissolvable tobacco (wintergreen, java), Marlboro snus (spearmint, peppermint, rich), and General snus portions (unflavored).  A sampling protocol was followed in order to collect information “on relief from withdrawal, relief from craving, ease of use, and general satisfaction and likeability.” 

In the following two weeks, subjects were instructed to quit smoking but were told they could use a preferred smokeless product; three clinic visits were required, for data collection purposes.  A final clinic visit occurred one week later, and a follow-up phone call completed the study at week nine.  During visits, abstinence was verified with an exhaled carbon monoxide test.  Subjects were paid up to $300. 

No subjects chose General for the treatment period; the other four products were each preferred by about a quarter of participants.

At the start of the treatment period, subjects used on average about seven smokeless products daily, and smoked 1-3 cigarettes.  After two weeks, smokeless use dropped to 4-6, while cigarette use was 1-4 daily, depending on the smokeless product.  Camel snus use correlated with the lowest cigarette use.

 

The following table shows the key trial results.  Almost 60% of Camel snus users were cigarette-abstinent during the treatment period, and their continued use of smokeless products was high.  Other products were accompanied by lower abstinence and smaller rates of continued use.  This may be due to Camel’s higher level of available nicotine (1.7 to 2.0 mg. per portion) as measured by Hatsukami, compared to Marlboro (0.1 to 0.4), Stonewall (0.3 to 0.6) and Ariva (0.2).  Camel snus users also had the highest satisfaction scores and the lowest craving scores.

Smokeless Tobacco as a Cigarette Substitute
Product	Abstinent During Treatment Period (%)	Continued Use After Treatment (%)	Continued Use At Week Nine (%)
Camel snus	59	67	48
Marlboro snus	30	26	17
Stonewall dissolvable	29	46	21
Ariva dissolvable	25	38	25

Dr. Hatsukami concluded that “smokers who chose the [Camel] snus product with higher nicotine levels tended to report greater craving and withdrawal relief, more satisfaction, smoking less cigarettes and achieving greater short-term abstinence.”  These are important findings, since they validate the effectiveness of smokeless tobacco products as temporary cigarette substitutes. 

This is an excellent study, but one question remains: Were subjects given complete and accurate information about health risks from smokeless tobacco use and smoking?  Institutional Review Boards require full disclosure of this information to research subjects of clinical trials, and the substance and style of this disclosure could have profound effects on the outcome.  A description of this disclosure would have been informative.

Evidence from this clinical trial will be valuable when the FDA reviews applications for modified risk tobacco products.  Dr. Hatsukami is a member of the FDA Tobacco Products Scientific Advisory Committee, adding to the work’s credibility.