How Many Americans Use Smokeless Tobacco?

I recently described how the federal government is all thumbs when it tries to count how many Americans smoke (here).  Further evidence of the government’s ineptitude is seen in the fact that the National Health Interview Survey (NHIS), the CDC’s official source for smoking statistics, only measures smokeless tobacco use every five years or so.  That leaves the National Survey on Drug Use and Health (NSDUH) as the government’s only annual source of data on smokeless use.

I analyzed NSDUH data from 2012 and found that 7.1% of adult men (roughly eight million) use smokeless tobacco, and the prevalence of smokeless use among women is minuscule (about one-half of one percent).  For obvious reasons, I’ll limit this discussion to men.   

NSDUH asks participants if they use “chewing tobacco” or “snuff.”  Over two-thirds of smokeless users in the survey, about 5.5 million, said they used only snuff, 1.2 million used only chewing tobacco, and 1.4 million used both.  However, participants’ responses to questions about smokeless brands used most often suggest that NSDUH misclassified some users.  The problem stems from the fact that consumers of smokeless products often use the terms “chew” or “dip snuff” interchangeably.

The most common brands among “snuff” users were Copenhagen (29%), Skoal (26%) and Grizzly (25%).  Other than Red Seal (4%) and Kodiak (4%), no other brand registered above 2%.  It is interesting to note that Camel Snus, the first pouched product that introduced the Swedish experience to American smokers, was the preferred brand for 1.7% of snuff users.

The misclassification problem is evident because 16% of “chewing tobacco” users favored Skoal, 11% picked Grizzly and 7% listed other moist snuff brands.  Red Man (25%), Levi Garrett (10%) and Beech-Nut (5%) were the top chewing tobacco brands.

Although 35% of smokeless users in this survey never smoked and 27% are former smokers, it is a tragedy that 38% are current smokers (a figure that is consistent with my previous research (discussed here).  That percentage means that 2.8 million smokeless tobacco users don’t recognize or are ignoring the significantly greater hazards of smoking.  Any ignorance on their part may be traced to the deliberate campaign by the CDC, FDA NIH and other tobacco prohibitionists to deny Americans vital facts about the relative risks of smoking and smokeless use.  This misinformation campaign conflates risk data to damn equally all forms of tobacco. The FDA declares, (here) “Tobacco products are harmful yet widely used consumer products that are responsible for severe health problems…[including] cancer, lung disease, and heart disease, which often lead to death.” The CDC asserts, (here) “Tobacco use is the leading preventable cause of death in the United States.”

Lies of omission like these tell eight million American smokeless users: “You might as well smoke.”  That is a travesty.

The Tide Is Turning: More Scientific Support for E-Cigarettes

E-cigarettes get a positive health review in the new issue of the journal Addiction (here).  Quoting from the abstract:

[Electronic cigarettes, EC] aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower.  Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders.  EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children.  EC enable some users to reduce or quit smoking.

Conclusions: Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality.  Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence.  Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.

The study confirms what I and others (here) have documented about bogus claims regarding toxicants, poison episodes and gateway.  Here are excerpts:

Claim: Chemicals in EC cause excess morbidity and mortality.

Evidence: Long-term use of EC, compared to smoking, is likely to be much less, if at all, harmful to users or bystanders.

Claim: Smokers who would otherwise quit combine EC and cigarettes instead of quitting and maintain a similar smoking rate.

Evidence: EC use is associated with smoking reduction and there is little evidence that it deters smokers interested in stopping smoking tobacco cigarettes from doing so.

Claim: Young people who would not try cigarettes otherwise start using EC and then move on to become smokers.

Evidence: Regular use of EC by non-smokers is rare and no migration from EC to smoking has been documented...The advent of EC has been accompanied by a decrease rather than increase in smoking uptake by children.

Claim: EC use will increase smoking prevalence indirectly, e.g. by making smoking acceptable again in the eyes of people who cannot tell the difference between EC and cigarettes, via machinations of the tobacco industry, or by weakening tobacco control activism.

Evidence: There are no signs that the advance of EC is increasing the popularity of smoking or sales of cigarettes.

In other words, the far-fetched claims by anti-tobacco zealots are derived from thin air, not vapor.

The article is authored by established tobacco harm reduction advocates Peter Hajek, Jean-Francois Etter and Hayden McRobbie; and two Americans – Tom Eissenberg, a member of the FDA advisory panel on tobacco with a moderate record on e-cigarettes and tobacco harm reduction, and Neal Benowitz.  The latter is a surprise, as Benowitz has previously opposed tobacco harm reduction (here and here) and last year endorsed gateway speculation about smokeless tobacco (here).  It is welcome news that he has aligned his view on e-cig vapor with his position on marijuana vapor.

Drs. Benowitz and Eissenberg acknowledge research support from the National Institutes of Health and the FDA and note that the review “…does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.”

But it should.

New York Times’ Call for Marijuana Legalization Advances Harm Reduction

A milestone in the fight for harm reduction was reached on July 28, when the New York Times formally endorsed the legalization of marijuana.  A Times editorial, “Repeal Prohibition, Again,” called for reversal of the government’s 40-year ban on the popular weed (here).  Legalization is overdue, as use of this psychoactive substance that is less dangerous than alcohol has led to the senseless prosecution of hundreds of thousands of Americans.

In 1994, as I was developing my tobacco harm reduction strategy, I read a brilliant article on drug policy reform in the prestigious scientific journal Science.  Entitled “Drug prohibition in the United States: costs, consequences, and alternatives” (abstract here), the article was written by Ethan Nadelmann, a pioneer in drug harm reduction.  Later that year, I described my strategy in a letter to Whitney Taylor of the Drug Policy Foundation (now the Drug Policy Alliance, here):

“Thanks for taking my recent phone call.  First, the proposal: that smokers unable or unwilling to quit consider switching to smokeless tobacco, which is far safer than smoking.  Smoking-related cancers, heart diseases and lung disorders are responsible for 419,000 deaths every year in the U.S.A.  In contrast, if all 46 million American smokers instead used smokeless tobacco, annual tobacco-related deaths (from a small risk of oral cancer) would number only 6000 [references here and here].  In fact, smokers who switch to smokeless tobacco reduce their risk for all smoking-related illnesses, including oral cancer.  Newer smokeless tobacco products deliver the nicotine kick smokers crave and they can be used almost invisibly; spitting, once the stigma of smokeless tobacco use, is minimal or nonexistent with these products.  Smokeless tobacco is already working for many Americans.  Statistics from the Centers for Disease Control and Prevention (CDC) show that 1.5 to 2 million former smokers have chosen this option on their own [reference here].

“I realize that your organization is only concerned with illicit drugs.  However, the current tirade against tobacco use(rs) demonstrates alarming parallels to the long-term crusade against other drugs.  First, as tobacco use is increasingly characterized as not just unhealthy but immoral and criminal, users are now experiencing an alienation process similar to that of narcotics users in the first three decades of the century.  Health professionals with ideas on the medical management of nicotine addiction are being ignored or attacked.  A cadre of prohibition-minded anti-tobacco activists has insisted on increased federal regulation (FDA, OSHA, EPA etc.) of tobacco use, which is endorsed without a hint of dissent by all major medical organizations.  In fact, tobacco use is the only major medical issue in which there is no debate whatsoever.  Prohibition may not be imminent, but smuggling from low to high tax states and the disastrous effects and ultimate reversal of the recent Canadian tax increase offer a great preview of where the crusade is headed and what the consequences will be.

“This proposal has much in common with harm reduction models proposed for illicit drug use with one important exception: smokeless tobacco is legal.  No new regulatory or legislative measures will be required.  Only interested and informed smokers.”

Mr. Nadelmann invited me to share my observations at drug policy reform conferences in 1999 and 2001.  Tobacco harm reduction has been explored at various other drug policy meetings over the last decade. 

The Times editorial board echoed the principals of harm reduction in its marijuana statement, as it weighed the relative risks of using various substances: “We believe that the evidence is overwhelming that addiction and dependence are relatively minor problems, especially compared with alcohol and tobacco.  Moderate use of marijuana does not appear to pose a risk for otherwise healthy adults.  Claims that marijuana is a gateway to more dangerous drugs are as fanciful as the ‘Reefer Madness’ images of murder, rape and suicide.  There are legitimate concerns about marijuana on the development of adolescent brains. For that reason, we advocate the prohibition of sales to people under 21.”

Advocates of tobacco harm reduction will recognize several themes in this passage.  First, there are no apparent health risks for moderate marijuana use (and even fewer health risks for smoke-free forms versus combusted), just as there are no significant risks related to the use of smoke-free nicotine/tobacco products.  Second, the “fanciful” gateway claim is as illegitimate for smoke-free tobacco as it is for marijuana.  Finally, while it is appropriate to protect children from substance use, there is no credible reason to deny adults access to alcohol, tobacco or marijuana.   

The Times has effectively advanced the cause of harm reduction, perhaps to the ultimate benefit of tobacco users and of public health generally.

               

Federal Judge to FDA: Tobacco Advisory Panel Tainted by Conflicts of Interest

“The presence of conflicted members on [FDA Tobacco Products Scientific Advisory Committee, TPSAC] irrevocably tainted its very composition and its work product” and “the Committee’s findings and recommendations…are, at a minimum, suspect, and, at worst, untrustworthy.”  So ruled federal judge Richard Leon this week (here).

A lawsuit by Lorillard et al. claimed that the FDA appointment of TPSAC members Neal Benowitz, Jack Henningfield and Jonathan Samet was “arbitrary, capricious, an abuse of discretion, and otherwise not in compliance with the law” because they had conflicts of interest.  The evidence was abundant and uncontested.  Here are excerpts from the judge’s opinion:

“Since the 1980s, Dr. Benowitz has consulted for numerous pharmaceutical companies about the design of the NRT and other smoking-cessation drugs.  He consulted for affiliates of Pfizer, Inc. and GlaxoSmithKline (GSK) as to such products, even while serving on the TPSAC…Dr. Benowitz has also served as a paid witness for lawyers suing tobacco-product manufacturers.  He testified as a paid expert witness while serving on the TPSAC, and…he was designated to testify in 585 pending tobacco cases.”

“Before and while serving on the TPSAC, Dr. Henningfield consulted for GSK and other drug companies as to NRT and other smoking-cessation drugs.  He also had ownership interest in a company that was developing a patented NRT drug.  Dr. Henningfield has testified as an expert for GSK and for lawyers suing tobacco-product manufacturers… he was designated to testify in 350 pending tobacco cases.”

“Dr. Samet received grant support from GSK at least six times, including in 2010.  He also led the Institute for Global Tobacco Control, funded by GSK and Pfizer.  Dr. Samet also testified for lawyers suing tobacco-product manufacturers…he was designated to testify in two pending tobacco cases.”

Judge Leon’s ruling notes that the composition of TPSAC is different from other FDA advisory committees, because the enabling legislation bans any expert “who received ‘any salary, grants, or other payment or support’ from any tobacco company in the 18-month period prior to serving on the TPSAC.”  

TPSAC was structured to exclude qualified authorities who have had industry support.  Experts with industry support are not precluded from serving on other FDA advisory committees, in which scientific issues are more important than industry demonization.   

Judge Leon noted that the provision should apply evenly to any conflict of interest: “If Congress deemed that past remuneration from tobacco companies constituted a conflict of interest, it stands to reason that past remuneration from direct competitors of those companies, such as manufacturers of smoking-cessation drugs, would also constitute a conflict of interest.”

Judge Leon’s ruling bars the FDA from using a 2011 TPSAC report on menthol, and it also “enjoins the FDA to reconstitute TPSAC’s membership so that it complies with the applicable ethics laws.”  Dr. Samet is the only conflicted member remaining on TPSAC, as chair (until 2016).  Another member, Claudia Barone, may have a conflict, because she received a Pfizer Educational Grant through 2013 and was appointed to the TPSAC on April 1, 2014 (here).

Although the ruling applies specifically to committee actions on menthol cigarettes and dissolvable products, it is relevant to all TPSAC activities until conflicted members are removed.

It is common for experts to be co-opted by financial support from organizations committed to a tobacco free society, a euphemism for the obliteration of the tobacco industry (an objective that is at odds with the principle of regulation).  Any individual who is funded by organizations such as the American Cancer Society, the American Heart Association, the American Lung Association, the National Cancer Institute, the Centers for Disease Control and Prevention, or the Robert Wood Johnson Foundation should be ineligible for membership on TPSAC.

(Updated July 23)

How Many Americans Smoke?

This blog answered that question a few years ago, saying it was “either 45.3 million or 52.7 million in 2010, depending on which federal agency does the counting. This wide variance [among adults 18+ years] of age underscores the discordant findings from government smoking data.” (here)

I wrote, “It is unacceptable that two federal surveys differ by over 7 million in their adult smoking counts. Even worse is the way the government uses the divergent data to spin different stories about smoking.  They use the lower [National Health Interview Survey] numbers [43.5 million] to boast about declining smoking rates, which they attribute to higher taxes and smoking bans. They use the higher [National Survey on Drug Use and Health] numbers [52.7 million] to argue for even more onerous anti-tobacco measures.”

The irregular counting continues today, and the discrepancy between NHIS and NSDUH is actually growing.  Earlier this year the CDC released its count for 2012, which is 42.1 million (here), based on NHIS.  My analysis of the 2012 NSDUH, which is sponsored by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), indicates that there are at least 51.6 million adult smokers.  That’s a difference of nearly 10 million smokers! 

My research sheds light on this discrepancy (here).  It’s time for the federal government to acknowledge their data conflict, and resolve it.