Weight! Quit Smoking Without the Gain

It is well established in the scientific literature that smokers generally weigh less than nonsmokers, and that smokers who quit are at risk for weight gain. A recent article in the journal Science (abstract here) reported that nicotine activates specific nerve cells in the section of the brain called the hypothalamus. This interaction may be responsible for decreased appetite; it is different from nicotine’s trigger of reward and satisfaction in the brain. This complex research was conducted in mice, so the results will need confirmation in human studies. Still, they substantiate two dreaded downsides to quitting smoking: the loss of the powerfully rewarding and satisfying activity, and the gain of unwanted pounds.

We already know that switching from cigarettes to smokeless tobacco keeps smokers satisfied while giving them almost all of the benefits of complete tobacco/nicotine abstinence. But does switching keep the weight off?

In 2004, I published the first and only research article answering this question (abstract here). Along with colleagues from Umeå University in Sweden, I used a World Health Organization dataset to evaluate weight gain among nearly 3,000 men in Northern Sweden.

Weight Gain Over Nine Years Among Men in Northern Sweden
Tobacco Category	Average (lbs)
Nonusers (Referent group)	7.0
Smokers	5.1
Smokers who quit completely	15.0*
Smokers who switched to snus	7.9
Snus users	6.8
Snus users who quit completely	11.2*
*significantly elevated compared with nonusers

The big gainers were smokers and snus users who became completely abstinent from nicotine and tobacco. But snus users and smokers who switched to snus didn’t gain any more weight than nonusers. This is important news for smokers who are concerned about putting on pounds when attempting to quit smoking.

I also noted that the rate of overweight at the start of the study was 32% among those who didn’t use tobacco, 29% among smokers, and 42% for ex-smokers. These percentages are somewhat lower than other reports because our group defined overweight as a body mass index (BMI) of 27 or higher. The standard definition of overweight starts at a BMI of 25. For more information about BMI, go to this website at the federal National Heart Lung and Blood Institute.

Fear of gaining weight should not deter smokers from quitting. Research shows that a switch to smoke-free tobacco can leave them healthier with no added pounds.

The Truth About Federal Warnings on Smokeless Tobacco Products

Cigarette smokers who are considering a switch to vastly safer smokeless tobacco are confronted with confusing government-ordered warning labels. Most would be surprised to learn that three of the four mandated warnings were fabricated by tobacco prohibitionists and codified into federal legislation in 1986 by a misinformed U.S. Congress. Despite their obvious flaws, the original warnings were re-confirmed in the 2009 Tobacco Act and a fourth was added.

Here are the underlying facts and fallacies related to the four warnings:

1. “This product can cause mouth cancer.” This warning was mandated in 1986, five years after Dr. Deborah Winn egregiously misinformed Americans about the magnitude and scope of mouth cancer risk from smokeless tobacco (discussed previously in this blog here and here). This warning is highly misleading. Contemporary American and Swedish smokeless products confer vanishingly small risk for mouth cancer. Now that the FDA has been given authority over the warnings, I hope the agency will provide comprehensive information about all health risks, as I did in this blog (here and here).

2. “This product can cause gum disease and tooth loss.” In 1986, prohibitionists were desperate to blame smokeless tobacco for causing something besides mouth cancer, but twenty-five years ago there was virtually no scientific evidence that smokeless tobacco was an independent risk factor for any dental problem. The same is true today. A comprehensive review of the subject was published by Kallischnigg and colleagues in BMC Oral Health in 2008 (available here). The risk for all dental problems is either very low or nonexistent among smokeless tobacco users.

3. “This product is not a safe alternative to cigarettes.” The purpose of this 1986 warning was to deceive smokers into believing that smokeless tobacco was just as dangerous as smoking. As I wrote in my 1995 book, For Smokers Only: How Smokeless Tobacco Can Save Your Life (link), this warning “is simply ludicrous…Not even potato chips or nature hikes are ‘safe.’ If we look at ‘safe’ to mean relatively safe or ‘safer,’ something the government warnings inanely avoid here, then use of smokeless tobacco products is far safer than cigarette smoking.”

To apply an absolute standard of safety to any product or activity is preposterous. It’s worse to use this standard to deny smokers access to life-saving smokeless products and information.

4. “Smokeless tobacco is addictive.” This was added in the 2009 legislation, and it’s the only warning with a legitimate scientific rationale. It is entirely appropriate for consumers to be warned that any product containing nicotine is addictive. But the warning also reinforces what switchers already know -- that smokeless tobacco can be a satisfying cigarette substitute precisely because it provides satisfying doses of nicotine.

Congress was misinformed in 1986, when it dictated the mouth-cancer, gum-disease and not-safe warnings for smokeless tobacco. In view of the extensive relative risk data published since then, Congress should have revised the warnings to reflect the facts, rather than just rubber-stamp them in 2009.

The FDA prides itself on being science-driven; that provides some hope that smokeless tobacco warnings will some day be appropriately and accurately revised. In the meantime, the mouth-cancer, gum-disease and not-safe warnings exaggerate and distort the vanishingly small health impact of smokeless tobacco. Medical ethics and principles of public health dictate that smokers and smokeless tobacco users should not be subject to such health-endangering deception.

The True Impact of Snus in Sweden: Smoking Cessation Up, Initiation Down

It is a widely accepted myth that snus use among men in Sweden has only served as a quit-smoking aid. While my published studies from 2002 to 2005 (described here, here, and here) and many others (here, here, and here) have documented that male smokers in Sweden have used snus as a gateway to a smoke-free life, that is only part of the story.

Snus use has also played a valuable role in steering tobacco initiators away from more dangerous cigarettes. In 2005, I authored a study of tobacco use among Swedish boys and girls age 15-16, which was published in Tobacco Control (here). The results are impressive: “During the period 1989 to 2003, the prevalence of tobacco use [in Sweden] declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.”

I also observed that “…specific patterns of tobacco use differ strikingly between Swedish boys and their EU counterparts…In 2002 the World Health Organization reported that the average prevalence of daily smoking among 15 year old boys in 25 European countries (excluding Sweden) was 18%.7. In that report boys in Sweden had the lowest smoking prevalence of all countries (5.7%), at about one third of the EU average. The next highest prevalence was in Greece (9.2%). All other countries reported prevalences from 12% (Wales) to 27% (Lithuania). Thus, high prevalence of snus use by Swedish boys may be a factor in low smoking prevalence.

“In contrast, smoking rates among 15 year old girls in Sweden do not differ from those among girls in other European countries. In the 2002 WHO report smoking prevalence among Swedish girls was the fifth lowest in Europe (14%), but still close to the average for all other countries (19%, range 11% in Greece to 29% in Germany).”

I want to be absolutely clear: I strongly support all measures to keep tobacco away from children. However, a tobacco-free world, for adults and children, is as likely as an alcohol-free world was in 1920 (here). Teenagers will use tobacco, no matter what measures are taken to stop them. The remarkable story from Sweden is that most boys choose snus, the product their fathers use. This fact is well-received by health and policy professionals who understand that snus users lead lives that are virtually indistinguishable (in measures of years and health) from those of their abstinent peers.

Finally, the “Swedish Snus Experience” is not only about men. Recently, more women in Sweden are also using modern snus products (evidence here), which are spit-free and socially acceptable. This may represent the first time in recorded history that women have adopted a healthier behavior – from their husbands.

Tobacco Harm Reduction as the Basis for Tax Policy in Indiana & Kentucky

On April 29, 2011, Indiana became the second state in the U.S. to officially recognize tobacco harm reduction. Governor Mitch Daniels signed into law HB 1004 (available here), which states: “The Indiana general assembly finds that the tax rate on smokeless tobacco should reflect the relative risk between such products and cigarettes.”

This is a landmark event. It sets the stage for the state to develop a rational excise tax policy for tobacco products -- something I have advocated since 2003. That year, I proposed that smokeless tobacco products and cigarettes should be taxed according to risk, in order to provide an economic incentive for smokers to transition from high risk/high tax cigarettes to very low risk/low tax smokeless products. My commentary was published by newspapers in Tallahassee and Tampa, Florida (here and here and St. Louis (here).

On March 23 of this year, I provided expert testimony at a hearing of the Indiana Senate Committee on Public Policy, which was considering HB 1405, a bill to appropriately classify dissolvable tobacco products. That legislation (here) was also passed by the legislature and signed by the governor. My prepared testimony is available here.

Indiana is the second state to recognize the roles that tobacco harm reduction and tobacco excise tax policy can play in promoting public health. In 2005, the Kentucky General Assembly passed and Governor Ernie Fletcher signed into law a bill recognizing that:

“increasing taxes on tobacco products should reduce consumption, and therefore result in healthier lifestyles for Kentuckians. The relative taxes on tobacco products proposed in this section reflect the growing data from scientific studies suggesting that although smokeless tobacco poses some risks, those health risks are significantly less than the risks posed by other forms of tobacco products. Moreover, the General Assembly acknowledges that some in the public health community recognize that tobacco harm reduction should be a complementary public health strategy regarding tobacco products. Taxing tobacco products according to relative risk is a rational tax policy and may well serve the public health goal of reducing smoking-related mortality and morbidity and lowering health care costs associated with tobacco-related disease.”

The idea of a rational risk-based tobacco tax is clearly gaining momentum in policy circles. Earlier this year, the National Center for Policy Analysis, a nonprofit, nonpartisan public policy research organization, issued a report titled “Taxing Tobacco By Risk.” That document, available on the NCPA website (here), discusses tobacco harm reduction as a basis for tax policy and concludes: “States that wish to pursue a consistent and science-based tobacco harm reduction strategy should examine the way in which they tax tobacco products and the amount of tax levied on these products.”

In 2003, I wrote: “When it comes to taxes there are no easy answers. But a rational tobacco tax strategy based on risk is as compelling as it is innovative, because it allows lawmakers to meet their fiscal responsibility while fulfilling their moral obligation to help smokers who are desperate to quit.”

Indiana and Kentucky have admirably adopted this compelling and innovative strategy; other states will be wise to follow.

Misinformation from the Dana-Farber Cancer Institute and the Massachusetts Dental Society

The list of prestigious medical organizations that exaggerate and distort the risks of smokeless tobacco is growing longer. On May 12, the Dana-Farber Cancer Institute, “a principal teaching affiliate of the Harvard Medical School and… among the leading cancer research and care centers in the United States,” and the Massachusetts Dental Society, “a 5,000-member professional association… dedicated to improving the oral health of the public in the Commonwealth,” released demonstrably false information about smokeless tobacco risks (article here).

The Dana-Farber article says that these organizations “are partnering to spread the word that chewing tobacco, otherwise known as spit, dip, chew, or smokeless tobacco, is not a safe alternative to smoking.” Using an “absolutely safe” straw-man standard is now standard fare among smokeless prohibitionists.

The most egregious misinformation comes from Dr. David P. Lustbader, an oral surgeon: “Chewing tobacco is the most dangerous form of tobacco because it comes in contact directly with the oral mucosa.” Dr. Lustbader ignores the reams of medical literature irrefutably identifying cigarettes as “the most dangerous” of tobacco products.

Dana-Farber’s Dr. Marshall R. Posner does no better, saying, “Nicotine and the other tars in chewing tobacco change the cells throughout the mouth and tongue and lead to cancer.” First, nicotine does not “lead to cancer.” Second, nicotine is not a “tar.” Third, there are no “tars” in chewing tobacco. What was he smoking?

I emailed the director and associate director of media relations at the Dana-Farber Cancer Institute, detailing the misinformation in the press release and requesting a correction. No response or correction was forthcoming.

Dana-Farber (here) claims to “pursue excellence relentlessly and with integrity in all that we do, adhering always to the highest standards of conduct,” and the Massachusetts Dental Society is dedicated to “promotion of the highest professional standards.” These values are betrayed by the pernicious pronouncements about smokeless tobacco by their purported experts.

National Cancer Institute Funds Camel Snus Quit-Smoking Study

Opponents of tobacco harm reduction have portrayed that public health strategy as a marginal approach to smoking cessation that is neither legitimate nor credible. Finally, that specious position may be convincingly undermined, by no less an authority than the National Cancer Institute. The NCI is funding a study, based at the Medical University of South Carolina, that will evaluate the impact of Camel Snus in a nationwide randomized clinical trial among 1,250 smokers who are not motivated to quit.

The trial will run for one year, although the grant is active until 2016 (description here); the NCI has provided over $400,000 for the current fiscal year. The research is being directed by Matthew Carpenter, a psychiatrist at MUSC who previously published a pilot study demonstrating that Ariva and Stonewall dissolvable tobacco products are effective cigarette substitutes (described in this blog last January, here).

As with any clinical trial, outcomes will depend on the trial’s design; so far, few details are available. Will participants be provided with accurate information about the vastly lower health risks of Camel Snus? The answer isn’t clear, because the public description of the trial uses ambiguous terms. For example, Carpenter states that “a comprehensive risk profile [for smokeless tobacco] remains unclear”, despite numerous epidemiologic studies documenting minimal risks. In addition, he states, “The tobacco industry has developed a number of novel smokeless tobacco products that are purported to offer reduced health risks as compared to conventional cigarettes.” This implies that “reduced health risks” are unsubstantiated industry allegations; in fact, they are established scientific fact.

Carpenter describes the trial: “A population-based, nationwide sample of smokers will be proactively recruited through established methods, consented to enroll in a telephone-based cessation induction trial, and randomized to either a) provision of Camel Snus, or b) not.”

We don’t know how smokers will be recruited or enrolled, but we do know they will be randomized to receive Camel Snus, or not. While it is routine to offer one “treatment” in a clinical trial, this presents many problems when the outcome is a behavior. How do you study a product that is already available in stores nationwide? Will smokers who don’t receive Camel Snus be denied a product that is 98% safer than cigarettes? Will smokers who receive Camel Snus know its name? Will the products be provided free, or will smokers have to buy them? Which flavor of Camel Snus will be used? What happens if participants prefer another flavor, or prefer another smokeless product?

Previously, Carpenter found that Ariva and Stonewall had great potential as smoking cessation aids, but now only Camel Snus is being tested. If this trial is not a success, it may mean only that smokers are not enamored of Camel Snus.

Despite these questions, this trial is a landmark development for tobacco harm reduction. Its funding by the National Cancer Institute sends an unequivocal message that informing smokers about safer smokeless substitutes is ethical, credible and worthy of serious consideration.

Huffington Post Suppresses Tobacco Truth

In his Huffington Post blog on April 18, Dr. Glenn Braunstein penned “Chew on This: The Real Dangers of Smokeless Tobacco.” (available here) Dr. Braunstein is professor and chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles.

The “dangers” he described are demonstrably fictitious. Compounding this offense, Dr. Braunstein subsequently violated HuffPo blog moderating rules by removing my April 19 reasoned and fact-driven comment, which read:

“It is regrettable that Dr. Braunstein used the Huffington Post to misinform Americans about smokeless tobacco.

“Dr. Braunstein: ‘Contrary to popular belief, ingesting [smokeless] tobacco carries risks just as serious and severe as smoking.’ This ignores numerous scientific studies documenting that smokeless tobacco use is 98% safer than smoking. Smokeless does not cause lung cancer, heart disease or emphysema, and the risk for mouth cancer is far lower than with cigarettes. Statistically, smokeless users have about the same risk of dying from mouth cancer as automobile users have of dying in a car wreck.

“Dr. Braunstein goes even further, suggesting that ‘…ingested tobacco may be even more dangerous than cigarettes...’ because of nicotine. This is grossly misleading. All tobacco products have roughly the same nicotine content and produce about the same blood levels. More importantly, nicotine does not cause any smoking-related disease.

“Dr. Braunstein’s comments are at odds with the viewpoint of prominent tobacco research and policy professionals. A group of leading tobacco experts in 2004 concluded: … ‘[smokeless] products pose a substantially lower risk to the user than do conventional cigarettes. This finding raises ethical questions concerning whether it is inappropriate and misleading for government officials or public health experts to characterize smokeless tobacco products as comparably dangerous with cigarette smoking.’

“The established scientific and medical literature on tobacco harm reduction clearly refutes the major objections raised by Dr. Braunstein concerning modern smoke-free tobacco products.”

My comment appeared just long enough on HuffPo to elicit a supporting comment from another reader: “I agree with Dr. Rodu. I'd like to see Dr. Braunstein's reponse to Dr. Rodu's points, though we probably won't. As a dentist, I encourage those who use smokeless to quit, but not by giving them false information. The information in this article is very very misleading.”

According to Dr. Braunstein’s HuffPo biography, he is an endocrinologist with an interest in the treatment of thyroid cancer and in male and female reproductive endocrinology; he has no apparent expertise in tobacco issues. His blog entry on the subject closely aligns with smokeless tobacco misinformation issued in the past by the leading tobacco-prohibitionist organizations (Campaign for Tobacco Free Kids and others).

HuffPo says on its site that its mission is “to promote an open and transparent conversation.” But allowing Dr. Braunstein to erase a fair and factual rejoinder to his unfounded remarks violates that tenet, and disserves the public interest.