American Evidence that Snus Is An Effective Substitute

Scientists from the University of Minnesota Tobacco Use Research Center have just published the results of a clinical trial from 2006-7 showing that RJ Reynolds’ Camel Snus and Philip Morris’ Taboka (a precursor of Marlboro Snus) were viable substitutes for cigarettes. The trial was conducted by Michael Kotlyar and colleagues; the results are published in Cancer Epidemiology and Biomarkers (abstract here).

Kotlyar recruited smokers who were interested in quitting, and assigned them to use one of three products: 4 milligram nicotine gum or lozenge, Camel Snus or Taboka (participants had a choice of various flavors for each product). Participants used only 1 or two products per day during a one-week sampling period; for the next four weeks, they used the product at least 6 to 8 times daily. During week 5, participants were required to reduce consumption of the substitute; by the end of that week they had to be completely tobacco- and nicotine-free.

There were several interesting results. First, all participants in all groups had a reduction in exhaled carbon monoxide, clearly demonstrating that they smoked less than before the study. Participants in all groups had a reduction in the urine concentration of two chemicals that are considered carcinogens, abbreviated here as NNN and NNAL. The reductions were statistically significant except for NNN in Camel Snus users (p = 0.07).

Overall craving and withdrawal scores decreased over the 4 weeks in all groups, with no differences between the groups.

Continuous abstinence rates over the 4 treatment weeks varied from 33% (Taboka) to 43% (Camel Snus). Two weeks after the treatment ended, 39% of the Taboka group, 47% of the Camel Snus group and 56% of the nicotine group were not smoking, but these percentages dropped to 23%, 31% and 33% respectively after ten weeks of complete abstinence.

One possible reason for the precipitous drop in the smoke-free percentages was the insistence on abstinence after 4 weeks. If this philosophy prevails, it will guarantee that smokeless products are no more effective than pharmaceutical nicotine, which has a documented failure rate of 93% (evidence here).

There is evidence that the FDA is starting to think about offering smokers “long-term” nicotine substitution (review a symposium on the topic was held on October 26-27 here), which is a strategy I called “nicotine maintenance” in 1999 (here). I recommend that readers look at the FDA presentations, especially the one by Neal Benowitz (here). He indicates that the best information about the long-term risks of nicotine come from the epidemiologic studies of Swedish snus use.

There were other interesting aspects of the Minnesota study. The Taboka group smoked significantly more than those using nicotine or Camel Snus. It is possible that Taboka, which had very low nicotine levels, simply didn’t satisfy smokers.

A total of 1,159 smokers responded to advertisements for the study. According to the researchers, 800 “were able to be reached and were screened over the telephone,” and 429 qualified and were interested in participating. Another 212 did not show up for the orientation. The attrition didn’t stop there: 211 smokers were enrolled in the study but only 130 were randomized to one of the three groups. Just 80 participants completed the 4-week treatment period and the one-week transition to abstinence.

These numbers represent one of the biggest challenges of clinical trials, especially in the field of risky behaviors like smoking. The 80 participants who completed the study represent only 6.9% of the smokers who originally responded, so they are an especially motivated group. That has been one of the problems with quit-smoking trials: It is impossible to generalize their results because they are from a highly selected population that is not representative of smokers in general.

In the past, I have criticized the Minnesota group for publishing biased and distorted studies about smokeless tobacco (here and here). But this is a fair and balanced report of the potential for smokeless tobacco as a substitute for cigarettes.

Indications from Indy That Snus is a Viable Cigarette Substitute

Indianapolis is the quintessential Midwest American city, and it has served as a test market of Swedish-style snus by the two largest American cigarette manufacturers. In 2006 Philip Morris launched a test market for Taboka snus in Indy (in 2008 it was discontinued when Marlboro snus was launched). In 2007 Indy was one of several expansion markets for RJ Reynolds’ Camel Snus; that product went on to national distribution earlier this year.

Lois Biener and Karen Bogen, from the University of Massachusetts Center for Survey Research, analyzed data from the 2006-7 Indiana Adult Tobacco Survey, and their recently published study provides some valuable information.

Biener and Bogen reported that almost 20% of survey respondents throughout Indiana were aware of snus. Awareness among smokers statewide was 44%, which was 4.5 times higher than awareness among non-smokers.

Awareness among respondents in central Indiana (i.e. around Indianapolis) was 29%. More importantly, about 64% of male smokers in central Indiana had heard about snus, and 20% had tried it. This is evidence that Philip Morris and Reynolds were targeting adult male smokers in their test-market campaigns, and that the manufacturers were fairly successful.

Biener and Bogen also reported that risk perception played an important role in getting people to try snus. Respondents who correctly believed that smokeless tobacco is less harmful than cigarettes were almost 4 times as likely to try snus as those who had been misinformed about the differential risks. Unfortunately, this study revealed that 88% of all respondents had been misinformed, so they incorrectly believed that smokeless tobacco was just as dangerous as cigarettes.

Biener and Bogen offer some perceptive comments on the sad state of smoker misinformation:

“Both marketing and health education messages should include the information that all tobacco products are harmful and that abstinence from all tobacco products is the most healthful choice. At the same time, simply saying that smokeless tobacco is ‘not safe’ is not a sufficient stance for public health communications. There is a recognized continuum of risk along which various tobacco products can be placed, with low-nitrosamine smokeless tobacco products much lower on the risk continuum than combustible tobacco, although it is not harmless. Devising an effective way to inform the public about the continuum should be an important research priority, as currently consumers are woefully incorrect in their assessments of relative risk of various tobacco products. This state of affairs could result in people deciding not to give up smoking in favor of a product lower on the risk continuum because they assume that all tobacco products are equally harmful.”

Biener and Bogen mention that information about differential risks of smokeless and smoking have appeared in the media, and they cite a 2006 article by Kevin Helliker in the Wall Street Journal. That article remains the most well researched and best written description of tobacco harm reduction, and it can be found here.