A Smokeless Alternative To Quitting–Unabridged Version

The New York Times, April 6, 2004

By Sally Satel

For decades, public health advocates have championed harm reduction for people who cannot stop taking health risks – or do not want to. Needle exchange is a classic example. Intravenous drug users get clean needles because, the reasoning goes, contracting and spreading AIDS is worse than making heroin use a little easier.

But harm reduction for hard-core smokers is another matter. It is politically incorrect.

At issue is a form of smokeless tobacco, a popular Swedish product called snus (rhymes with loose) that satisfies smokers’ nicotine addiction with negligible health risks of its own. But to many foes of smoking, it is not a lifesaver, but the devil’s instrument.

Snus, moist oral tobacco, comes in a tiny tea bag. It sits discreetly between lip and gum, releasing nicotine. Because it does not stimulate saliva production, there is no spitting. Even better, there is no smoke.

“It is the tobacco smoke, with its thousands of toxic agents, that leads to cancer, heart disease and emphysema,” says Dr. Brad Rodu, an oral pathologist at the University of Alabama at Birmingham.

Eliminate the smoke, and you significantly reduce the risk. Indeed, Dr. Rodu found that a 35-year-old snus user will live on average as long as a 35-year-old who quits nicotine altogether – eight years longer than a smoker. Snus, or snuff, is especially attractive to smokers – who crave nicotine – because it produces nicotine levels comparable to smoking. Other nicotine replacement products like gum and the patch administer too little nicotine to prevent reliably craving and withdrawal symptoms.

The health benefits are impressive. Forty percent of Swedish men use tobacco products, and that is also the rate for men in the other 14 countries in the European Union. Yet Sweden has the lowest rate of lung cancer by far. Why? Largely because of snus, which represents half of all the tobacco that Swedish men use. (The other half smoke.)

Snus has not caught on with female smokers, though, and they make a morbid comparison group, ranking fifth, behind Denmark, Norway, Britain and the Netherlands.

Smoking opponents, one could argue, should herald snus. But instead, the very notion of harm reduction seems to inflame them.

“It’s like trying to play God trading oral cancer for lung cancer,” said Dr. Gregory Connolly of the Massachusetts Tobacco Control Program.

More than 20 epidemiological studies show that smokeless tobacco is far safer than cigarettes for mouth cancer. Even traditional smokeless tobacco products bring one-third to one-half the risk as smoking.

Users of Swedish snus, which contains very low levels of tobacco-specific nitrosamines, the carcinogens that cause lung cancer, among other diseases, incur a risk of developing oral cancer that is no greater than nonsmokers’.

The five large studies that examine snus in relation to oral cancer “are consistent in finding no increased cancer risk,” according to an article last year in the journal Tobacco Control.

What about gateway effects? Clearly, if using smokeless tobacco turns people on to nicotine and they “graduate” to smoking, it fails as a public health strategy.

This was not the case in Sweden, however.

If snus induced young people to smoke, then Sweden would be expected to have a poor record of smoking reduction. Instead it has the best record in Europe.

Moreover, the proportion of current smokers who are former snus users is far less than the proportion of snus users who were once smokers.

In short, snus has largely been a pathway away from smoking, not vice versa. In the United States, Dr. Lynn T. Kozlowski of the biobehavioral health department at Penn State, found that more than three-fourths of men from 18 to 34 who used smokeless tobacco never went beyond it to cigarettes or had used cigarettes before using smokeless products.

Swedish snus and other brands of smokeless tobacco like Ariva, Exalt and Revel are available in this country but are hard to find. Most smokers have never heard of them, and many doctors are unfamiliar with the products.

The government, rather than clearing the air, is muddying it. Last year, the surgeon general, Vice Adm. Richard H. Carmona of the Navy, told Congress, “There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes.”

This is quite simply wrong in the case of smokeless tobacco in general, and snus in particular.

A set of “Tips for Teens” from the Department of Health and Human Services answers the question, “Isn’t smokeless tobacco safer to use than cigarettes?” with an emphatic – and erroneous – “no.”

“I suppose you could argue that shooting yourself in the leg poses less of a health risk than shooting yourself in the head,” a former president of the American Dental Association, Dr. D. Gregory Chadwick, said. “But do we really need to have that discussion?”

Yes, we do. Public health experts have for years endorsed harm reduction as a pragmatic last resort for hard-core users of heroin, cocaine and alcohol, because the experts are convinced of the relative safety that accrues to the user and society.

No one disputes that quitting is optimal. But in the real world, that is not practical in every case. Snus in particular, and smokeless tobacco in general, provide clear, lifesaving advantages over smoking that antitobacco activists refuse to acknowledge.