- Email: [email protected]
In response to Dr. Ross
Letters to the Editor
Response to the 2002, Vol. 23, Issue 3 Article Entitled
Snuff Use and Smoking in U.S. Men: Implications for Harm Reduction To the Editor: he data in the article by Dr. Tomar1 do not support the position taken that snuff (or smokeless) tobacco is unlikely to help men quit smoking cigarettes. It is both well known and intuitively obvious that those men who use snuff are more likely to become cigarette smokers than men who have never used tobacco. That, however, is not the correct question. To assess the potential efficacy of snuff-smokeless in getting men off cigarettes, we need to know how many are able to quit smoking while using smokeless, as compared with those who try other methods of cessation, with or without nicotine replacement therapy (NRT). Tomar’s data support a use for smokeless in this regard: He found that current smoking was lowest among those who used snuff every day (19.2%) and that daily snuff users were significantly more likely than never-users to have quit smoking in the preceding 12 months (OR⫽4.23). To interpret these data as showing no usefulness for snuff-smokeless in quitting the much more dangerous smoking of cigarettes is sending the wrong message to smokers desperately seeking some help in quitting a most addictive behavior. Abstinence is best, of course, and other modalities (NRTs, Zyban) are less potentially harmful than smokeless, which has its own risks. But the fact is that only a minority of smokers are able to quit, and any assistance may make a real difference.
T
Gilbert Ross, MD Medical/Executive Director American Council on Science and Health New York, New York
Reference 1. Tomar SL. Snuff use and smoking in U.S. men: implications for harm reduction. Am J Prev Med 2002;23:143–9.
In Response to Dr. Ross To the Editor:
I
share Dr. Ross’ concern that very few smokers quit each year. However, Dr. Ross misrepresents my conclusions. I did not conclude that snuff is unlikely to help men quit smoking and did not state that
there is no potential usefulness of a harm-reduction approach in lessening the societal effect of tobacco. The second sentence of the Discussion states “. . . snuff may serve as an alternative form of nicotine dosing for smokers who will not or cannot overcome their nicotine dependence, and perhaps can help smokers to quit.”1 As I noted in the Introduction, however, there are no published data on the efficacy or feasibility of this approach, and the present cross-sectional study cannot provide them. It is, therefore, premature for the American Council on Science and Health, or others who wish to base their public policy recommendations on sound science, to recommend snuff use as an efficacious or effective method to quit smoking. Dr. Ross would like to separate the issue of snuff as a starter product for nicotine addiction and subsequent smoking from the issue of snuff as a smoking-cessation device. My point was that public policy needs to consider unintended consequences as well as intended consequences of recommendations from the health community or tobacco manufacturers to adopt snuff use. That position is consistent with the conclusions reached by the Institute of Medicine’s expert panel that examined the potential role of harm reduction in tobacco control.2 Although some men in this study had quit smoking and had become snuff users, more then 2.5 times as many had switched from snuff to cigarettes, and more men were dual users of the products than were former smokers who currently used snuff. As Henningfield et al.3 noted in their accompanying editorial, U.S. smokeless-tobacco manufacturers are marketing their products to smokers as a way to cope with smoking restrictions, which could perpetuate their smoking or delay cessation. So, if unregulated smokeless-tobacco marketing with implicit, if not explicit, health claims leads to an increase in snuff-induced nicotine addiction among young people who subsequently become smokers, and keeps more smokers from quitting than it helps to quit, is that a net public health benefit? This is a very real policy concern because smokeless-tobacco companies are taking legal action to allow them to market their products in European Union nations where these products have been banned since 1992 (except for Sweden). If the smokeless-tobacco companies succeed in opening those markets, it is unknown whether we will see a move toward “harm reduction” by current smokers or the uptake of these addictive products by young people.
Am J Prev Med 2003;24(3) © 2003 American Journal of Preventive Medicine • Published by Elsevier
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(02)00595-0
285
The U.S. experience strongly points to the latter scenario. Scott L. Tomar, DMD, DrPH University of Florida College of Dentistry Division of Public Health Services and Research E-mail: [email protected]
286
References 1. Tomar SL. Snuff use and smoking in U.S. men: implications for harm reduction. Am J Prev Med 2002;23:143–9. 2. Institute of Medicine, Stratton K, Shetty P, Wallace R,Bondurant S. Clearing the smoke: assessing the science base for tobacco harm reduction. Washington, DC: National Academy Press, 2001. 3. Henningfield JE, Rose CA, Giovino GA. Brave new world of tobacco disease prevention: promoting dual tobacco-product use? Am J Prev Med 2002;23: 226 –8.
American Journal of Preventive Medicine, Volume 24, Number 3
Response to the 2002, Vol. 23, Issue 3 Article Entitled
Snuff Use and Smoking in U.S. Men: Implications for Harm Reduction To the Editor: he data in the article by Dr. Tomar1 do not support the position taken that snuff (or smokeless) tobacco is unlikely to help men quit smoking cigarettes. It is both well known and intuitively obvious that those men who use snuff are more likely to become cigarette smokers than men who have never used tobacco. That, however, is not the correct question. To assess the potential efficacy of snuff-smokeless in getting men off cigarettes, we need to know how many are able to quit smoking while using smokeless, as compared with those who try other methods of cessation, with or without nicotine replacement therapy (NRT). Tomar’s data support a use for smokeless in this regard: He found that current smoking was lowest among those who used snuff every day (19.2%) and that daily snuff users were significantly more likely than never-users to have quit smoking in the preceding 12 months (OR⫽4.23). To interpret these data as showing no usefulness for snuff-smokeless in quitting the much more dangerous smoking of cigarettes is sending the wrong message to smokers desperately seeking some help in quitting a most addictive behavior. Abstinence is best, of course, and other modalities (NRTs, Zyban) are less potentially harmful than smokeless, which has its own risks. But the fact is that only a minority of smokers are able to quit, and any assistance may make a real difference.
T
Gilbert Ross, MD Medical/Executive Director American Council on Science and Health New York, New York
Reference 1. Tomar SL. Snuff use and smoking in U.S. men: implications for harm reduction. Am J Prev Med 2002;23:143–9.
In Response to Dr. Ross To the Editor:
I
share Dr. Ross’ concern that very few smokers quit each year. However, Dr. Ross misrepresents my conclusions. I did not conclude that snuff is unlikely to help men quit smoking and did not state that
there is no potential usefulness of a harm-reduction approach in lessening the societal effect of tobacco. The second sentence of the Discussion states “. . . snuff may serve as an alternative form of nicotine dosing for smokers who will not or cannot overcome their nicotine dependence, and perhaps can help smokers to quit.”1 As I noted in the Introduction, however, there are no published data on the efficacy or feasibility of this approach, and the present cross-sectional study cannot provide them. It is, therefore, premature for the American Council on Science and Health, or others who wish to base their public policy recommendations on sound science, to recommend snuff use as an efficacious or effective method to quit smoking. Dr. Ross would like to separate the issue of snuff as a starter product for nicotine addiction and subsequent smoking from the issue of snuff as a smoking-cessation device. My point was that public policy needs to consider unintended consequences as well as intended consequences of recommendations from the health community or tobacco manufacturers to adopt snuff use. That position is consistent with the conclusions reached by the Institute of Medicine’s expert panel that examined the potential role of harm reduction in tobacco control.2 Although some men in this study had quit smoking and had become snuff users, more then 2.5 times as many had switched from snuff to cigarettes, and more men were dual users of the products than were former smokers who currently used snuff. As Henningfield et al.3 noted in their accompanying editorial, U.S. smokeless-tobacco manufacturers are marketing their products to smokers as a way to cope with smoking restrictions, which could perpetuate their smoking or delay cessation. So, if unregulated smokeless-tobacco marketing with implicit, if not explicit, health claims leads to an increase in snuff-induced nicotine addiction among young people who subsequently become smokers, and keeps more smokers from quitting than it helps to quit, is that a net public health benefit? This is a very real policy concern because smokeless-tobacco companies are taking legal action to allow them to market their products in European Union nations where these products have been banned since 1992 (except for Sweden). If the smokeless-tobacco companies succeed in opening those markets, it is unknown whether we will see a move toward “harm reduction” by current smokers or the uptake of these addictive products by young people.
Am J Prev Med 2003;24(3) © 2003 American Journal of Preventive Medicine • Published by Elsevier
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(02)00595-0
285
The U.S. experience strongly points to the latter scenario. Scott L. Tomar, DMD, DrPH University of Florida College of Dentistry Division of Public Health Services and Research E-mail: [email protected]
286
References 1. Tomar SL. Snuff use and smoking in U.S. men: implications for harm reduction. Am J Prev Med 2002;23:143–9. 2. Institute of Medicine, Stratton K, Shetty P, Wallace R,Bondurant S. Clearing the smoke: assessing the science base for tobacco harm reduction. Washington, DC: National Academy Press, 2001. 3. Henningfield JE, Rose CA, Giovino GA. Brave new world of tobacco disease prevention: promoting dual tobacco-product use? Am J Prev Med 2002;23: 226 –8.
American Journal of Preventive Medicine, Volume 24, Number 3