Tobacco Documents Online

Smokeless tobacco: a life saver? For smokers only: how smokeless tobacco can save your life. Brad Rodu. 'New York: Sulzberger & Graham, 1995. ISBN 0-945819-77-3, pp. 190, $11.99. In the accepted norm of assessing the efficacy of a pharmacological treatmem or be- havioural intervention, an investigator devel- ops a novel hypothesis, designs an appro- priate study to test that hypothesis, and publishes the results in a peer=reviewed journal where the study may be critically evaluated by others. Only after careful con- sideration of the results and quality of the study~ other supporting evidence, and exist- ing alternative intervention strategies, would a responsible clinician recommend the new treatment. Apparently, at least one path- ologist takes a very different approach to the sdentific method: omit the clinical trial, play down the side effects (which may include premature death), discount existing safe and effective treatment modalities, publish opin= ion pieces and die these as evidence of efficacy, and publish a book for the lay public in which the new "treatment" is blatantly advocated. For smokers only represents the result of this alternative "scientific" method. The basic premise of this book is that cigarette smokers with nicotine dependence could substantially reduce their health risks if they were to switch to the use of oral snuff for their nicotine dosage. The first few chapters discuss the health consequences of cigarette smoking and environmental tobacco smoke exposure. The author contends that the 400000 deaths each year in the United States attributable to cigarette smoking could be reduced to 6000 annual deaths due to oral cancer if all smokers were to switch to the use of snuff. Unforamately, the author's pre- dicted mortality could not be achieved unless there was a simultaneous end to smoking initiation in the United States (and even then only after several decades). The relative risk estimates used by the author to compute oral cancer mortality from oral tobacco and cigarette smoking are from very different study designs and populations, and corn= parisons between them are of dubious val- idity. Tbe author also ignores the potential role of snuff use in other cancers and in cardiovascular diseases.L s Even if wc were to accept the author's contention that switching from cigarette smoking to oral snuff use would reduce tobacco users' risk of morbidity or mortality, this method of quitting smoking has littie b~sis in science. According to ~n earlier news repor~ in Tobacco Control 1994; 3: 306-7, the author and his colleagues at the University of Alabama at Birmingham were soliciting study participants. However, this book pre- sents no results from any randomised trial that tested the efficacy of the hypothesis. The chapter entitled "The smokeless tobacco solution" contains a section labelled "Evi- dence that this method works." The total evidence presented in that section is the anecdotes of nine former smokers who bad switched from dgarettes to ors1 tobacco. Virtually all of those persom stopped smok- ing only after experiencing fairly severe respiratory symptoms or frank disease which apptared to render them physically incapable of co.tinning to stooge; this picture is not exactly that of a voluntary cohort of smokies mention of lo~g-te~m quit rates, side effects, or other outcomes that would be reported from a properly conducted clinical trial. The recommendation of oral snuff as a form of nicotine replacement therapy (NRT) at this point in history is curious, considering the established carcinogenidty of snuff and the availability in the United States of two forms of NKT that have been accepted by the Food and Drag Administration (FDA) as safe and effective (nicotine polacrilex gum and nicotine transdennal patch). No mention is made in this book of setting a quit date or defining a finite time period for using snuff, in contrast to the recommended regimen for using established methods of NRT. The book essentially dismisses nicotine gum and patches in two pages. Concerning the gum godu writes, "[W]hile it is more socially acceptable to chew gum than to smoke at many job sites or social occasions, one still runs the risk of looking like a nnulnant cow or a hyperactive adolescent." Aside from misrepresenting the manner in which nicotine gum is intended to be chewed, the author apparently feels that long-term use of a known carcinogenic substance and Lifelong nicotine dependence are more "sodally acceptable" than a short=term method designed to treat the addiction. Although he points out that a meta-enalysis of nicotine patch trials found a smoking qnit rate of just 25 %, Rodu provides no estimate of the success rate of snuff in achieving long- term smoking cessation. Nevertheless, he concludes that "(s)mokelcss tobacco is over- looked as another effective quit-smoking concept.)) A (perhaps) unintended effect of For smokers only is the promotion of oral tobacco use by young people. Several studies have found oral tobacco use by parents or older siblings to be a fairly strong correlate or predictor of use by adolescents (SL Tomar, unpublished).~-v The author recoguises this, but his recommended solution is to"takc the more discreet pouches of snuff that cannot be detected." The low probability of long=term success in hiding oral tobacco use from one's children or siblings, the implicit (and some= times explicit) message in this book that oral tobacco is safe, and the detailed, illustrated step-by-step instructions in this book on initiating snuff use would appear to provide an excellent source of role modelling for the initiation of oral tobacco use by young people. The author's stated goal of having "smokeless tobacco ...be used only by the last generation of nicotine addicted smokers" is, at best, a naive assessment of the likely impact on young people of his highly publi- cised book. It is possible that Rodu is truly guided by an altruistic vision of a world without cigarette smoking, and that he sincerely believes that oral tobacco is the best way to achieve it. However, his final chapter, "PoLitics and pragmatism", appears to in- dicate a considerably larger agenda. In this chapter, he takes shots at the "antitobacco troopers", the US Food and Drag Admin- istration, and tobacco taxation. He applauds the smokeless tobacco industry for launching massive advertising campaigns in the late 1970s and early 1980s to promote theh: products as safer aitertmtives m cigarettes. Redu neglects to note that mint of the gr~th in sales of muff md chewing toba~x-o was were not necessary smokers trying to quit. Rodu's proposal that cigarette smokers switch m using moist snuff mirrors adver- tising campaigns for US Tobacco Company's Skoal and Skoal Bandits (for example, see Tobacco Control 1994; 3: 306-7). Whatever Rodu's motives may be for publishing this book, it is dear that the smokeless tobacco industry stands to reap the benefits. For smokers only provides persons suffering from nicotine dependence a justification for continuing that dependence while continuing to expose themselves to known toxic and carcinogenic products. This scenario is simi- lar to that presented by "low-yield" cigar- ettes, which kept many smokers in the market who might otherwise have quit. The real comparison may not be the number of deaths due to smoking compared with the estimated number of deaths from using oral tobacco, but the increased risk among contemplators who may have quit all tobacco use compared with those kept in the tobacco market by advocates for using snuff. Encouraging smokers to adopt this untested method to quit smoking rather than treating their nicotine dependence by using established methods is professionally irresponsible. SCOTT L TOMAR O.~ee on Smohi~ and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA 1 US Departrnent of Hcalth and Human Services. The health consequences of using smokeless tobacco. A report of the advisory committee to the Surgeon General Bethesda, Maryland: Public Health Service, National Institutes of Health, 1986. (NIH Publication No 86-2874.) 2 Bolinder G, Alfredsson L, Englund A, dc Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am ff Public Health 1994; 84: 399-404. 3 Cohen RY, Sattler J, Felix MRS', Browaell KD. Experimentation with smokeless tobacco and cigarettes by children and adolescents: rela- tionship to beliefs, peer use, and parental use. Am ff Public Health 1987; 77: 1454-6. 4 Hall RL, Dexter D. Smokeless tobacco use and attitudes toward smokeless tobacco among Native Americans and other adolescents in the Northwest. AmJ Public Health 1988; 78: 1586-8. 5 Colburn JW, Cummings K/v~, Michalek AM. Correlates of adolescents' use of smokeless tobacco. Health Educ Q 1989; 16: 91.-100. 6 Glovcr ED, Latin M, Flannery D, Albriuon DL. Smokeless tobacco use among American college students, ff Am Coll Health 1989; 32-" 81-5.