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.

Monitoring the Truth About Tobacco Use in Children

The Monitoring the Future Study, based at the University of Michigan, just released its report on youth tobacco, alcohol and drug use in 2009. In October, I discussed previous findings from the MTF study.

With respect to alcohol use among 12th graders, the new report is very similar to that of the previous year. A whopping 44% of 12th graders had used alcohol, and 27% had been drunk during the past 30 days. Obviously, this put them at immediate and potentially life-threatening risk for alcohol poisoning, motor vehicle and other accidents.

The findings for cigarette use in 2009 were also similar to those from 2008; 20% of 12th graders had smoked in the past 30 days.

In 2009, smokeless tobacco use among 12th graders increased to 8.4% from 6.5% in 2008. At first glance, that appears to be a big jump, but MTF did not find it statistically significant. In fact, MTF did not mention smokeless tobacco in its press release. Despite a paucity of evidence, anti-tobacco fanatics have already decided who is to blame. John Spangler, a tobacco prohibitionist from Wake Forest University who has a National Cancer Institute grant to study smokeless tobacco use among college students, claims that increased marketing of smokeless tobacco likely has had some effect on teenagers.

Matt Myers, president of prohibitionist Campaign for Tobacco Free Kids, is certain that tobacco companies are to blame: “This increase coincides with the introduction of numerous new smokeless tobacco products and a big increase in smokeless tobacco marketing…These new products no doubt appeal to kids because they are easy to conceal, carry the names of youth-popular cigarette brands, and come in candy-like forms and flavors. More than 60 percent of smokeless marketing is spent on price discounts, including coupons, that make smokeless tobacco products more affordable and appealing to price-sensitive youth customers.”

Anti-tobacco fanatics have developed a brilliant strategy for dealing with ANY new research findings about tobacco use: If it’s good, take credit; if it’s bad, blame the industry.

This strategy has an intuitive appeal, and it pits the public health “angels” against the tobacco industry “demons.” But it doesn’t set a very good precedent for the application of scientific principles to public health policy. And it breaks down after applying even a small dose of common sense.

MTF also reported that past 30-day use of marijuana among 12th graders was higher in 2009 than use of cigarettes (20.6% vs. 20.1%). Perhaps anti-tobacco fanatics can answer this question: Which industry is responsible for marijuana use among children?

Any use of drugs, most importantly alcohol, among children is a major problem that should concern every American. We need to better understand the social and behavioral reasons why children experiment and adopt substance use, and we need interventions that are tailored to the relative impact of each substance on children’s health. With these rational guidelines, smokeless tobacco is at the bottom of the priority list.

Polycyclic Aromatic Hydrocarbons in Smokeless Tobacco: Much Ado About Snuffing

In August, I wrote about a report by a prohibitionist University of Minnesota group claiming that one pinch of smokeless tobacco is five times more dangerous than smoking. They reported that smokeless tobacco products contain PAHs, a complex family of chemicals that are formed during the incomplete burning of almost any product, including coal, oil, gas, wood or other organic matter.

The researchers, led by Irina Stepanov and Stephen Hecht, pitched these claims to national media at a press conference sponsored by the American Chemical Society. But they refused to share their results with other scientists, pleading that “we are in process of publishing a full paper on this study.”

That paper has just been published, and it has been pitched again to national media. Again, the headlines scream “high levels of toxins,” and Stepanov et al. portray the results in almost apocalyptic terms: “Our findings render PAHs one of the most prevalent groups of carcinogens in smokeless tobacco. Urgent measures are required from the U.S. tobacco industry to modify manufacturing processes so that the levels of these toxicants and carcinogens in U.S. moist snuff are greatly reduced.”

Are the PAHs really toxins? Are the levels really “high”? Are emergency measures really indicated?

Unproven toxins

Stepanov analyzed smokeless tobacco samples from the U.S. market for 23 PAHs, and the manuscript implies that all of these are proven cancer-causing chemicals (carcinogens). Not even close.

I compared Stepanov’s list with a database maintained by the authoritative International Agency for Research on Cancer. IARC has reviewed several hundred chemicals for cancer-causation, and it has classified them on the strength of the scientific evidence as (Group 1) Carcinogenic to humans, (Group 2a) Probably carcinogenic, (Group 2b) Possibly carcinogenic, and (Group 3) Not classifiable. Groups 2a and 2b are largely based on animal or laboratory studies with no direct human evidence. IARC is a recognized authority, but it is inclined to label chemicals as human carcinogens if there is even a shred of evidence.

Readers will be amazed at how many IARC Group 1 carcinogens are on Stepanov’s list: Exactly ONE. Her list included one chemical IARC calls “probable”, while eight agents are in the still less threatening category of “possible”. More importantly, twelve (over half!) are NOT EVEN CLASSIFIED. (I couldn't find the remaining chemical in any IARC list.)

Low, Low Levels

Stepanov not only misrepresented the number of carcinogens. She implied that levels were dangerously high, stating that “moist snuff can be considered an important source of human exposure to PAHs.” Her data contains virtually no evidence for this statement.

In order to discuss Stepanov’s data, I’ll have to give a short primer or review of the metric system weights. Let’s start with a reference weight 1 kilogram, which is about 2.2 pounds.

1 kilogram = 1000 grams
1 gram = 1000 milligrams
1 milligram = 1000 micrograms
1 microgram = 1000 nanograms

Stepanov reported PAH concentrations in nanograms per gram of (dry) tobacco. A nanogram is one trillionth of a kilogram, or one billionth of a gram, so we are talking about vanishingly small amounts.

A can of moist snuff contains about 30 grams of tobacco, but about 50% of this weight is water, so the effective tobacco content is 15 grams.

The most important PAH on Stepanov’s list is benzo(a)pyrene (BaP), the only IARC Group 1 carcinogen. In Stepanov’s ideal world, no one would consume BaP; but we live in the real world, in which a fundamental tenet of toxicology is: the dose determines the poison. Despite Stepanov’s rhetoric, the level of BaP is very low in her tests, at an average of 56 nanograms per gram. That means that a one-can per day user is potentially exposed to 840 nanograms of BaP per day.

What does this level mean? Fortunately, the federal Environmental Protection Agency (EPA) has information that provides perspective. It says that “BaP is commonly found … in cigarette smoke, in grilled and broiled foods, and … in some water sources.” According to a study published in the Journal of Agricultural and Food Chemistry, a person eating a char-broiled quarter-pound hamburger consumes about 400 nanograms of BaP. The EPA says that water can have 780 nanograms of BaP per gallon and still be acceptable. This means that someone who eats a quarter-pound burger and drinks a half-gallon of water may consume about as much BaP as a can-per-day moist snuff user.

The EPA gives guidance for consumption of 5 other PAHs on Stepanov’s list, which are available in this document from the CDC. In fact, it gives specific consumption levels of these chemicals which are “not likely to cause any harmful health effects.” Using this information, I have estimated the number of cans of moist snuff that can be safely consumed daily by a 110-pound man with respect to these 5 PAHs:

PAH	Stepanov’s Concentration (nanograms per gram)	Number of Cans Per Day That Can Be Safely Consumed
Anthracene	844	1185
Acenaphthene	105	1905
Fluoranthene	1400	95
Fluorene	827	161
Pyrene	1290	78

I have been very conservative in developing these estimates. First, Stepanov used special solvents to get maximal extraction of PAHs from the samples; I have assumed that smokeless users consume those amounts, which is probably a serious overestimate. It is well known that PAHs are not very soluble in water, so it is likely that actual PAH consumption by smokeless users is much lower than the level reported by Stepanov.

One final comment: the EPA has estimated that on average, a person in the U.S. is exposed to about 3 milligrams of all PAHs every day. That’s 3 million nanograms. A person consuming a can of moist snuff per day is exposed to 174,000 nanograms, which is less than 6% of normal daily exposure.

No tobacco product is perfectly safe, but there is very little epidemiologic evidence that using smokeless tobacco, including American moist snuff, is associated with any cancer. Despite this, Stepanov and colleagues chemically characterize these products as major causes of cancer. Their rhetoric is not sustained by their data.

European Experts Continue to Ignore the Swedish Miracle

A new study by cancer epidemiologists clearly provides evidence that snus use among men in Sweden is responsible for the lowest cancer death rate on the European continent. Surprisingly, the authors avoid drawing this obvious conclusion in both their article and their press release.

The study examined cancer mortality trends in 34 European countries over the period 1975-2004. It found that cancer deaths among men throughout Europe declined, mainly due to a drop in “lung and other tobacco-related cancers,” according to co-author Cristina Bosetti. The study shows that men in Sweden have the lowest death rates for lung cancer (less than 50% of the European Union rate) and for all cancers, while rates for Swedish women are at or above EU averages.

These findings are fully consistent with my recently published study of European lung cancer, which I discussed in a recent blog post.

The authors of the new study recognize that differences in cancer death rates among European countries reflect differences in smoking; they conclude that “further reduction of tobacco smoking remains the key priority for cancer control in Europe.” That’s perfectly true. But why did the authors ignore the only legitimate explanation of low cancer rates for Swedish men: the miracle of tobacco harm reduction?

It is important to point out that the difference in cancer rates between Swedish men and the rest of Europe is not a new finding. The first author of the current study, Carlo La Vecchia, is a prolific epidemiologist who previously published a study of cancer in Europe during the period 1955-1989. That study clearly shows that Swedish men have always had the lowest lung cancer rates on the continent.

When that study was published in 1992, there was little appreciation, either in Sweden or elsewhere, of the effect of snus use on smoking. But now there is a wealth of scientific literature on the Swedish miracle. When epidemiologists, tobacco researchers, policy experts and government regulators purposefully avoid talking about tobacco harm reduction, they put their reputations in jeopardy, to speak nothing of the lives of millions of smokers.

It’s a GAS, Take 34

November 19 is the date when American smokers are supposed to experience GAS, which is the American Cancer Society’s annual Great American Smokeout.

The American Cancer Society (ACS) has been producing GAS for 34 years, during which time it has refused to acknowledge that tobacco harm reduction is a legitimate public health option. That’s the main reason GAS is just a lot of hot air.

ACS has even criticized other medical organizations that want to tell smokers the truth. In 2007, the Royal College of Physicians, one of the world’s oldest and most prestigious medical societies, issued a comprehensive report reviewing and corroborating the impressive scientific foundation for tobacco harm reduction. The report concluded “…that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.”

The response from the ACS and its vice president for epidemiology Michael Thun to this thoughtful treatise was a disservice to the millions of inveterate smokers in the U.S. who can not achieve complete abstinence from nicotine and tobacco.

Dr. Thun dismissed the existence of inveterate smokers as a “false assumption,” even though over 13 million Americans have died from smoking-attributable illnesses in the 34-year history of GAS. His solution is to provide all smokers with “sufficient counseling and treatment.”

“Counseling” consists of giving smokers behavioral coping skills. ACS instructs smokers who are in desperate need of nicotine to “Take a walk, go get a drink of water.” In 1991, the National Cancer Institute told physicians to help their patients quit smoking by advising them to: 1) ”Keep your hands busy- doodle, knit, type a letter,” 2) ”Cut a drinking straw into cigarette-sized pieces and inhale air,” and 3) ”Keep a daydream ready to go.” I’ve never met a smoker who could daydream himself out of craving for a cigarette, and I’ve never met a physician who passes along these ridiculous tips.

“Treatment” refers to pharmaceutical nicotine. In a prior post I discussed why these products fail to help smokers. They’re expensive, unsatisfying and most smokers have no interest in using them. If any other medication had the dismal 7% success rate of pharmaceutical nicotine products, the FDA would remove it from the market.

The grim reality is that Dr. Thun’s approach is grossly inadequate. According to the 2006 National Institutes of Health (NIH) Consensus Conference on Tobacco Use, “…fewer than 5 percent [of smokers] succeed [in quitting] in any given year. Effective tobacco cessation interventions are available and could DOUBLE OR TRIPLE SUCCESS RATES…” (emphasis added). This means that providing Dr. Thun’s “conventional treatments” to all 45 million American smokers would help fewer than 15% – no more than 7 million – to quit. Dr. Thun has no plan for the other 38 million adult smokers, except denying them life-saving information about safer smokeless tobacco products.

Dr. Thun understands the difference in risk between cigarettes and smokeless use; he served on a review panel for a National Cancer Institute-sponsored study which concluded that the health risks from the latter are at least 90% lower than those from smoking. However, he withholds this information from smokers because it might “postpone quitting.” He fears that smokeless will repeat the “fiasco of ‘Light’ and ‘Mild’ cigarettes,” which he characterizes as an industry-driven conspiracy. But that is only part of the story.

ACS played a prominent role in the fiasco, publishing research in 1976 showing that light cigarettes were indeed safer. ACS investigators wrote that “total death rates, death rates from coronary heart disease, and death rates from lung cancer were somewhat lower for those who smoked ‘low’ tar-nicotine cigarettes than for those who smoked ‘high’ tar-nicotine cigarettes.” The ACS made a mistake with light cigarettes, but the scientific evidence for smokeless tobacco is unequivocal.

Prohibitionists routinely stifle discussion by transforming every tobacco topic into a children's issue. Dr. Thun’s claim that “apple, peach, and mint” flavored smokeless tobaccos target children sets a new standard of insincerity. If he really believes that these are children’s flavors, Dr. Thun should campaign to eliminate them from alcoholic beverages, another cancer-causing adult-only consumer product. As with alcohol, tobacco manufacturers ought to be free to make their ST products appealing to adult tastes. Carping about flavored tobacco products is not responsible tobacco control; it is unwarranted harassment of adult consumers and the manufacturers who serve them.

Tobacco initiation by young people should be stopped in its tracks, but the relative safety and palatability of ST isn’t a children’s issue. The 8 million Americans who will die from smoking-related illnesses in the next 20 years are not children today; they are adults, 35 years and older. Preventing youth access to tobacco is vitally important, but the Thun/ACS position on tobacco harm reduction effectively condemns millions of smoking parents and grandparents to premature death. If any other consumer product was as dangerous as cigarettes, society would demand safer alternatives. It is scandalous that the Cancer Society is not telling smokers the truth.

Tobacco Prohibition on American College Campuses

The pernicious and unmistakable march toward tobacco prohibition in the United States continues. It is especially depressing that many of the nation’s colleges and universities, institutions that promote themselves as bastions of tolerance and diversity, have implemented not just indoor smoking bans (which have a solid scientific rationale) and outdoor smoking bans (which have virtually no scientific rationale), but universal bans of all tobacco products.

Recently the University of Montana announced that it will impose a school-wide tobacco ban in 2011. The measure is the brainchild of a tobacco task force of misinformed public health activists such as Kari Harris, an associate professor of public health at the university. She said that the ban includes smokeless tobacco because just banning smoking would give students the message that it's safer to use other forms of tobacco. Harris concluded: “Is that the message we want to send?” Heaven forbid an institution of higher learning should provide students accurate information about tobacco use, one of the most important public health issues of our time.

University officials feigned concern over this draconian proposal. Linda Green, director of health enhancement at UM and a Tobacco Task Force member, said she expects - and wants - to hear plenty from students, even if it's outrage. “This is new territory for us… We want to hear their concerns,” she said.

Here are my concerns...

Why are university officials eager to ban smokeless tobacco, a product that is about as safe to use as an automobile?

How can the university enforce a ban on modern smokeless tobacco products, many of which are spit-free and invisible? Will campus police employ tobacco-sniffing dogs at security checkpoints? Will faculty and staff conduct random mouth checks before university lectures? How will the University of Montana resolve the inherent discrepancy between the tobacco ban and its policy on alcohol use (available here), a far more dangerous product?

A comprehensive national review of alcohol use among college students found that 42% (3.8 million) consumed 5 or more drinks on an occasion in the past month. Thirty-one percent of college students (2.8 million) admitted to driving under the influence of alcohol in the past year.

The review also found that over 500,000 college students are unintentionally injured every year because of alcohol and more than 600,000 were hit or assaulted by another drinking student. In total, over 1,700 college students died from alcohol-related motor vehicle accidents and other injuries.

Tobacco prohibition has been endorsed by many colleges and universities. The American College Health Association recommends that institutions of higher learning take the following position “because the improvements to health can be so significant”: Tobacco use is prohibited on all college and university grounds, college/university owned or leased properties, and in campus-owned, leased, or rented vehicles.”

For all the reasons noted above, and more importantly because alcohol consumption is illegal for about three-quarters of undergraduate college-age students, I asked the ACHA whether it had a position on alcohol. According to its communications coordinator, “ACHA does not have any recommendations or a position statement regarding alcohol use on campus.”

In summary, there is virtually no legitimate basis for American colleges and universities to prohibit the use of smokeless tobacco products. Furthermore, the imposition of tobacco bans are feel-good measures by and for health nannies, who neither have the means nor the fortitude to tackle far more important health risks facing our nation’s college population.

How Many Americans Smoke?

The U.S. Centers for Disease Control and Prevention (CDC), provider of “official” statistics on American smokers, has generally reported a downward trend in adult smoking. For example, in 1998 the CDC said 24.1% of the population (47.2 million adults) smoked. By 2005, the CDC said the number had declined to 20.9% (45.1 million).

Are CDC smoking estimates accurate?

UAB epidemiologist Philip Cole and I asked this question in a new study, published in the European journal Public Health. In contrast to the decline reported by the CDC, we found evidence from another federal source that the number of adult smokers in the U.S. has been stable for about a decade. In 2005, for example, the CDC estimate was 45.1 million smokers; our analysis revealed that number could be as high as 54.2 million.

The CDC Counts Smokers Using the National Health Interview Survey

The CDC uses two questions from the National Health Interview Survey (NHIS) to establish the smoking status of participants. The first question is, “Have you smoked at least 100 cigarettes in your entire life?” Subjects who answer “no” are never smokers, and those who answer “yes” are ever smokers. Ever smokers are asked a second question: “Do you now smoke cigarettes every day, some days, or not at all?” Respondents who answer “every day” or “some days” are current smokers; those who answer “not at all” are former smokers.

We Counted Smokers Using the National Survey on Drug Use and Health

We used the National Survey on Drug Use and Health (NSDUH), which is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). Although NHIS and NSDUH survey data on adult smoking have been available for many years, no government agency has ever directly compared them. The Office of Applied Studies at SAMHSA acknowledged differences in the two surveys, but it offered no explanation for the discrepancy.

NSDUH asks a 100-cigarette lifetime question that is identical to NHIS. But NSDUH does not ask about every-day or some-day smoking. Instead, it asks questions about smoking in the past 30 days, which the CDC counts as current smoking. If subjects reported that they had smoked on all 30 days we called them every-day smokers; if they had smoked on 1 to 29 days, we called them some-day smokers.

NHIS and NSDUH Surveys Show Different Pictures of American Smoking

We found that NHIS and NSDUH describe an increasingly divergent picture of smoking in the U.S. over the 1998-2005 period. In 1998, smoking prevalence in both surveys was 24%. By 2005, NHIS prevalence had declined to 21%. But the NSDUH estimate was 25%, suggesting no change. The difference is not trivial: NSDUH’s 4.5% higher estimate in 2005 amounted to 9.1 million more smokers than the NHIS estimate.

Higher smoking prevalence estimates in NSDUH are largely due to much higher estimates for some-day smoking. This is not surprising, because NSDUH surveys included as some-day smokers persons who smoked as infrequently as one day in the past month. In the 2005 NSDUH, one-quarter of 18-34 year old some-day smokers and almost one-third of 35+ year-old some-day smokers smoked only on 1 to 4 days in the past month. If these very occasional smokers had been subjects in the 2005 NHIS survey, perhaps they would not have been counted as smoking at all.

Our findings are consistent with a recent study of college students who smoked at least one cigarette in the past 30 days, 50% of whom denied being smokers. Among the deniers, about 70% smoked on only 5 or fewer days in the past month.

Cigarette smoking has been described in many government publications as “the single most preventable cause of disease and death in the United States.” But in order to estimate accurately the consequences of smoking, it is necessary for the government to count smokers accurately. It is surprising that the CDC counts smokers using only one source, the NHIS survey, and that little research has been conducted to assess its accuracy. Our study raises doubt about the CDC’s claim of a recent decline in smoking. Investigation of this discrepancy by federal survey administrators may lead to better surveys and an improved understanding of American smoking trends.