Smokeless Tobacco Use Does Not Lead to Smoking

A favorite tactic of the Campaign for Tobacco-Free Kids and other anti-tobacco extremists is the gateway allegation – “tobacco use causes _____” (fill in the blank with an undesirable behavior). For example, one of the Campaign’s pamphlets blames smoking for teenage drug and alcohol use (read it here). Extremists rarely provide rigorous proof for such claims. Given this, it is not surprising that they claim that smokeless tobacco use is a gateway to smoking.

UAB epidemiologist Philip Cole and I looked at this issue in a new study, published in Nicotine and Tobacco Research (available here). We used the National Survey on Drug Use and Health (NSDUH), which is sponsored by the federal Substance Abuse and Mental Health Services Administration.

The NSDUH asks survey participants at what age they used cigarettes or smokeless for the first time. Using this information, we classified participants as cigarette initiators (meaning they smoked before they used smokeless), smokeless tobacco initiators, or both; we then determined the prevalence of current smoking among these groups using established criteria (available here). Our analyses were restricted to white men age 18+ years (who are most likely to have used smokeless tobacco). In addition, we looked at white boys aged 16-17 years, since the gateway claim often focuses on teenagers.

Our study showed that the prevalence of current smoking among white men who were cigarette initiators was 35%. In comparison, the prevalence of smoking among smokeless tobacco initiators was only 28%, a significantly lower statistic. If the gateway effect was real, smokeless initiators would have had smoking rates similar to – or higher than – cigarette initiators.

The results for boys were even more impressive. Current smoking among cigarette initiators was 43%, but only 18% of smokeless tobacco initiators smoked. This means that boys who had started with smokeless tobacco were less than half as likely to be smoking at the time of the survey.

A few published studies have looked at the gateway issue in the U.S. In 2003, Tomar claimed that teenage boys who used smokeless were 3.5 times more likely to become smokers than nonusers of tobacco (abstract here). However, a subsequent re-analysis (available here) of Tomar’s data found that he hadn’t considered other well-known predictors of teenage smoking, such as low grades, smoking by a family member or other risky behaviors. After including these factors, smokeless tobacco use was a non-significant risk factor. Another study, by Timberlake and colleagues (available here), found “no evidence for an increased risk of smoking among the [smokeless tobacco] users.”

Anti-tobacco extremists will continue to claim that smokeless tobacco leads to smoking. However, as we conclude in our paper, our results do “not support the hypothesis that [smokeless tobacco] use is a gateway to smoking among American white males of any age, including teenagers. In fact, there is evidence that, compared with cigarette initiators, [smokeless tobacco] initiators are significantly less likely to smoke, which suggests that [smokeless tobacco] may play a protective role.”

Tobacco Harm Reduction: Not During Pregnancy

One of the most common – and challenging – questions regarding tobacco harm reduction is whether it is applicable to pregnant women who smoke.

According to the 2004 Surgeon General’s report, smoking during pregnancy is associated with increased risks for premature delivery, low-birth-weight infants, and stillbirth. Smoking is also associated with increased risk for problems with the placenta (the organ that nourishes the fetus). These problems include growth of the placenta in the wrong location (placenta previa) and separation of the placenta from the mother’s uterus (placental abruption), both of which can place the mother and developing fetus at risk. Paradoxically, pregnant women who smoke have a significantly lower risk of preeclampsia (a form of high blood pressure). But the overall effect of smoking on the developing fetus is decidedly negative.

Can a pregnant smoker who switches to smokeless tobacco benefit her health and that of her developing baby? Only one scientific study has addressed this issue. It reported information on pregnancy outcomes among Swedish women who used snus or smoked, compared with nonusers of tobacco, and it was published in 2003 by a group of investigators from the Karolinska Institute in Sweden and the National Institute of Child Health and Human Development in the U.S. The abstract is available here.

In this study, tobacco users had smaller babies than nonusers, although the reductions were modest. The average baby weight for nonusers was 7 pounds 14 ounces; babies of snus users weighed 7 pounds 13 ounces, while light smokers (1-9 cigarettes per day) and heavier smokers (10+ cigarettes) had babies that weighed less (7 pounds 8 ounces and 7 pounds 6 ounces, respectively).

Women who used snus were more likely than nonusers to have a premature delivery (adjusted odds ratio, aOR = 1.79, 95% confidence interval = 1.27 – 2.52), which was similar to that of light (aOR = 1.56, CI = 1.33 – 1.83) and heavier smokers (aOR = 1.84, CI = 1.53 – 2.21).

This study confirmed that smoking is protective for preeclampsia. The aOR for light smokers was 0.71 (CI = 0.59 – 0.88), and heavier smokers’ risk was even less (aOR = 0.48, CI = 0.36 – 0.64). However, snus users had a somewhat elevated risk for preeclampsia (aOR = 1.58, CI = 1.09 – 2.27).

In summary, pregnant women who use snus are at risk for slightly smaller babies, and they also have modestly elevated risks for premature delivery and preeclampsia. Women who are pregnant should refrain from using all tobacco products.

Note: The original link to the research study abstract was wrong. It was corrected on September 7, 2010.

Pressure on Norway from the World No-Tobacco Organization

The World Health Organization is the United Nations’ health authority. Although WHO has very little presence or direct influence on American health issues, its positions and policies are of considerable significance in other countries. Wielding its influence, WHO has attempted to impose an unnecessary tobacco policy on Norway.

WHO’s Tobacco Free Initiative (TFI) is blatantly prohibitionist. Each year, TFI sponsors “World No Tobacco Day” on May 31, and its 2006 celebration was especially memorable. That year, the theme was “Deadly in Any Form or Disguise,” (read about it here) and the message was simple: “Cigarettes, pipes, bidies, kreteks, clove cigarettes, snus, snuff, smokeless, cigars… they are all deadly.” Tobacco prohibitionists throughout the world sing from the same songbook.

As I wrote in a post last year, snus is available in Norway, and there is evidence that it has had a substantial positive effect on smoking among men. Apparently TFI is not happy; on May 5, its coordinator told the Norwegian government that TFI wants graphic warnings on snus boxes (translated article here).

The response from the Norwegian health ministry was entirely sensible. Secretary Roger Ingebrigtsen, rejecting TFI’s demand, stated “that scientists long have agreed [upon] and documented the harmful effects of cigarettes and rolling tobacco… but the consensus and the documentation is not as unambiguous” for the use of snus (translated link here).

The government of Norway should be commended for putting the health of its smokers ahead of a misdirected and counterproductive WHO campaign against safer cigarette substitutes.

The Proven Positive Effects of Nicotine and Tobacco

In 1994, Jacob Sullum told the following story at a Cato Institute seminar on tobacco use:

“A few years ago when I was working on a story about the antismoking movement for Reason magazine, I interviewed Scott Ballin, chairman of the Coalition on Smoking or Health. I raised the question of why people smoke. ‘There is no positive aspect to it,’ he assured me. ‘The product has no potential benefits.’ Not everyone concurs with that assessment; in a recent column in Vanity Fair, for example, Christopher Hitchens wrote that ‘cigarettes improve my short-term concentration, aid my digestion, make me a finer writer and a better dinner companion, and in several other ways prolong my life.’”

Disparaging tobacco’s value is a familiar theme with tobacco prohibitionists. They claim that the substance is worthless, and that the beneficial effects reported by smokers are only symptoms of relief from nicotine withdrawal. But smokers believe that they derive specific benefits. Who is telling the truth?

A meta-analysis just published in the journal Psychopharmacology reviewed the effects of nicotine and smoking on aspects of human performance (abstract here). The lead author is Stephen Heishman, a scientist at the National Institute on Drug Abuse; he is joined by Bethea Kleykamp of Johns Hopkins University and Edward Singleton of Stevenson University. The study will not please anti-tobacco extremists.

Heishman et al. reviewed 15 years of published studies on the effects of nicotine and smoking on various measures of human performance. They had strict criteria for the studies they accepted; one of the most important was including only nonsmokers or smokers who had not been deprived, in order to eliminate the confounding effects of withdrawal on performance.

Heishman et al. found that nicotine and/or smoking produces positive effects involving fine motor skills, attention and memory. The investigators conclude: “The significant effects of nicotine on motor abilities, attention, and memory likely represent true performance enhancement because they are not confounded by withdrawal relief. The beneficial cognitive effects of nicotine have implications for initiation of smoking and maintenance of tobacco dependence.”

It’s time to be honest with the 50 million Americans, and hundreds of millions around the world, who use tobacco. The benefits they get from tobacco are very real, not imaginary or just the periodic elimination of withdrawal. It’s time to abandon the myth that tobacco is devoid of benefits, and to focus on how we can help smokers continue to derive those benefits with a safer delivery system.

Misinformation from Three Senior FDA Officials

Many federal agencies deal with tobacco. For example, the Agriculture Department monitors tobacco cultivation (example here); the Treasury Department works with the Bureau of Alcohol, Tobacco and Firearms to monitor tax collections (example here); the Federal Trade Commission monitors sales and marketing (sample report here); and the Centers for Disease Control and Prevention tracks prevalence (sample here). In performing their functions, all these agencies distinguish cigarettes and smoking from smokeless tobacco and its use. Why doesn’t the Food and Drug Administration do the same?

Three senior FDA officials have authored a commentary about tobacco regulation for the New England Journal of Medicine (read it here) in which smoking and smokeless tobacco use are never distinguished. Even worse, “smoking” and “tobacco use” are used synonymously.

The FDA leaders are Lawrence Deyton, director of the Center for Tobacco Products, Joshua Sharfstein, principal deputy commissioner, and Margaret Hamburg, commissioner. They write, “Still, tobacco use causes more than 400,000 deaths in the United States annually…” This is just one of eight times in the article where Deyton et al. use the all-encompassing word “tobacco” when they are describing cigarettes or smoking.

Physician/authors Deyton, Sharfstein and Hamburg clearly are pursuing an agenda when they knowingly rely on “smoking” data but still describe “tobacco products” as “the leading cause of preventable death in the United States.”

Muddled terminology has been a hallmark of anti-tobacco extremists for many years, but it has become particularly apparent recently, as more Americans have become aware of the vastly lower health risks related to smokeless tobacco versus cigarettes. It’s all part of the demonization of tobacco users and manufacturers.

Deyton, Sharfstein and Hamburg write, “Although most Americans know that tobacco is harmful, few know specifically how damaging it is to the health of both smokers and nonsmokers.” Although this is a reference to second-hand smoke, it is also true that few Americans know that smokeless tobacco is vastly safer, and a government agency is partially to blame.

The CDC routinely publishes the exact number of deaths from smoking: the current annual estimate is 442,083. But the number of deaths due to smokeless tobacco use is nowhere to be found, despite the fact that the CDC and the American Cancer Society are in possession of the applicable data. Both organizations refuse to release an estimate or share the data with outside investigators.

Deyton et al. write about “tools” that the FDA will use “to ensure that advertising is truthful and not misleading,” in order to counter “tobacco-industry efforts to mislead the public about the safety of tobacco products.”

“Truthful and not misleading” are excellent criteria that should apply not only to the tobacco industry, but to federal agencies and officials charged with tobacco regulation and public health.

Winn’s Legacy: The Fifty Fabrication

In a previous post I explained how Deborah Winn, an epidemiologist at the National Cancer Institute, misinformed the American public and America’s doctors about the oral cancer risks of smokeless tobacco use.
Winn is also responsible for the widespread statement that smokeless tobacco users are 50 times more likely to develop oral cancer. That statement is a complete fabrication.

Winn’s 1981 study in the New England Journal of Medicine is the source for this completely erroneous information. As I discussed previously, Winn reported that the relative risk for oral cancer among powdered dry snuff users was 4. The puzzle is how a relative risk of 4 has been transformed into 50. Here are the keys to the puzzle’s solution.

First, oral cancer is a very rare disease, but smokers and heavy drinkers have considerably elevated risks. The most common sites for oral cancer are the sides of the tongue and underneath the tongue; other surfaces of the mouth are hardly ever affected. There are rare exceptions: oral cancer infrequently occurs among dry snuff users in the location where they place the product -- the gum and cheek. Winn’s 50 number applies only to the gum and cheek, not to the entire oral cavity (for which the number is still only 4). Even a few cases of cancer in the gum and cheek, which are virtually never otherwise involved, can raise the risk calculation.

The second key doesn’t involve Winn’s main findings, but a secondary analysis she performed on the duration of dry snuff use. Winn found that the highest risk for cancer of the gum and cheek was among women who had used dry snuff for over 50 years. That risk number was 47.5, and it was based on only 15 cases (the small number of cases determined that the 95% confidence interval – the range within which the estimate lies – was very wide, from 9 to 250!). Winn rounded up her estimate to “50-fold” in the abstract.

It is important to point out that the 50 and the 4 refer to the same number of oral cancer cases. Here is an example of how these numbers relate to each other. Let’s say that you have $100 in a savings account, and the average savings account in that bank has $25. This means that you have 4 times as much money as the average customer at that bank. But you decide to move your account to another bank, where the average savings account only has $2. Now you can correctly boast that you have 50 times more than the average account holder, even though you still only have $100.

So, Winn’s “50” number (actually 48) is appropriately used only in the following specific description: Women who used powdered dry snuff for over 50 years were 48 times more likely than nonusers to develop a cancer of the gum or cheek where the snuff was placed.

That is not how anti-tobacco extremists use the “50” number. They are eager to portray smokeless tobacco use as life-threatening, so they say that users of any type of smokeless tobacco for any duration have a fifty-fold elevated risk of oral cancer. This is a total canard.

The “50” fabrication continues to be peddled by organizations and government agencies that know better. Here are some examples:

The American Cancer Society (here)

The Centers for Disease Control and Prevention (here)

The University of Iowa (here) and Brown University (here)

State agencies in Kentucky (here), Rhode Island (here) and Wyoming (here).

It appears that Winn’s “50” legacy will persist until Americans demand that organizations and government agencies provide accurate information about the risks of tobacco.

Poisoning Public Health Issues

Anti-tobacco extremists have a big problem with smokeless tobacco. There is virtually no scientific evidence that long-term smokeless tobacco use is associated with ANY disease. So extremists have engaged in a media campaign to vilify these products in exceptionally creative ways.

I previously discussed the specious claim that smokeless tobacco products contained dangerous levels of wintergreen flavor (available here). Now a diatribe from Gregory Connolly, a Harvard University tobacco prohibitionist, has created the illusion that smokeless tobacco products are a major cause of poisoning among American children. The study was published in the journal Pediatrics (see the abstract here). It was tailored to produce a media frenzy, and it did. Here is a typical headline from MSNBC: “Tobacco mints tied to kids’ poisoning: smokeless products 2nd most common source of accidents.”

Most Americans will think that children all over the U.S. are dropping dead from accidental exposure to smokeless products. Connolly and his colleagues at Harvard, the CDC and an Ohio poison control center collected information on 13,705 incidents from the National Poison Data System from three years (2006-2008). Out of context, that appears to be an alarmingly high number.

I can’t provide context on the three-year data they accessed, but I was able to review the 2008 annual report of the American Association of Poison Control Centers (read it here). I think you will find the report informative.

It turns out that tobacco products accounted for only about 1% of the over 684,000 cases of exposure to non-pharmaceutical agents of all kinds in children less than 6 years of age in 2008. That’s 7,310 cases. Here’s a table of the top 20 exposures:


Non-pharmaceutical Exposure Cases Among Children Under 6 Years of Age, 2008

Product Category	Number of Exposures
Cosmetics and personal care products	170,210
Household cleaners	120,295
Foreign bodies	94,792
Pesticides	42,260
Plants	41,842
Arts, crafts, office supplies	28,331
Alcohols	23,569
Deodorizers	20,487
Solvents, oils	14,565
Bites, venom	10,808
Chemicals	10,470
Paint, paint strippers	9,593
Adhesives, glues	7,725
Essential oils	7,334
Tobacco	7,310
Batteries	5,432
Polishes, waxes	4,700
Building, construction products	4,683
Fertilizers	4,579
Food poisoning	4,503
Everything else	51,084
All	684,572

The MSNBC subheadline (“smokeless products 2nd most common source of accidents”) reflects another omission in Connolly’s abstract. He listed smokeless as the second most common TOBACCO source in the abstract, without revealing that it was a distant second. Cigarettes were responsible for 77% of 2006-08 tobacco exposures. In comparison, smokeless tobacco was only responsible for 13% of tobacco exposures.

The 2008 report shows that smokeless tobacco products were responsible for 1,105 of the 7,310 tobacco exposures, or about 15%.

So let’s do the math: in 2008 smokeless tobacco exposures were 0.16% of the 684,000 total exposures among children less than 6 years of age.

There is one more flagrant omission in Connolly’s journal article: he didn’t report the number of exposures involving nicotine medicines. That information is available from poison control reports; in 2008, 589 children under 6 years were exposed to nicotine medicines, slightly more than half of those exposed to smokeless tobacco. It’s another example of Connolly’s extreme selectivity.

Connolly used the results of his study to comment that tobacco manufacturers were “recklessly playing with the health of children.” When put into proper perspective, (exposures like household cleaners, solvents and oils, paint and paint strippers, fertilizers), Connolly’s selective reporting of poison control information is recklessly playing with the tolerance of the American public for honest discussion of important public health issues.

[Originally created on April 19, this entry was updated on April 20.]