Evidence that Smokeless Tobacco Is an Effective Substitute for Cigarettes

Evidence From the U.S.

1.  Population-level evidence from the U.S. National Health Interview Survey

In 2008 Rodu and Phillips provided the first population-level evidence that American men have quit smoking by switching to ST (1).  Using data from the 2000 National Health Interview Survey, which the CDC uses to estimate smoking prevalence in the U.S., Rodu and Phillips estimated that 359,000 American male smokers had tried to switch to ST during their most recent quit attempt.  Of these smokers, 73% (261,000, termed switchers) were former smokers at the time of the survey, representing the highest proportion of successes among all methods.  In comparison, the nicotine patch was used by an estimated 2.9 million men in their most recent quit attempt, but only 35% were former smokers at the time of the survey.  Of the 964,000 men who had used nicotine gum, 34% became former smokers. Of the 98,000 men who used the nicotine inhaler, 28% quit successfully.  None of the estimated 14,000 men who had tried the nicotine nasal spray became former smokers.  Forty-two percent of switchers reported quitting smoking all at once, which was higher than among former smokers who used medications (8–19%). Although 40% of switchers had quit smoking less than 5 years before the survey, 21% had quit over 20 years earlier. Forty-six percent of switchers were current ST users at the time of the survey.

*Men in the U.S., 2000. Numbers in millions.

Rodu and Phillips showed that switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. The results of this study show that tobacco harm reduction is a viable cessation option for American smokers.

2.  A Clinical Trial With 7 Years of Follow-up

In 1995, an open-label, nonrandomized pilot study was conducted assessing the efficacy of an ST product in helping cigarette smokers become smoke-free (2,3).  The investigators used a low-intensity approach, consisting of a 20-minute lecture about the health effects of all forms of tobacco use, followed by information about and samples of pre-portioned single-dose tobacco packets available throughout the U.S.  The investigators used exhaled carbon monoxide levels to validate participant self-reports regarding smoke-free status at the conclusion of the original study after one year (2) and after seven years of follow-up (3).  Of 63 subjects starting the study, 16 had successfully quit smoking by switching to ST after one year, and 12 were still smoke-free after seven years. 

3. Other Clinical Trials

In 2007 Mendoza-Baumgart et al. conducted small pilot trials focused on two ST products (either Exalt snus or Ariva dissolvable) versus a nicotine lozenge (4).  They evaluated toxicant exposure, subjective responses and product preferences among smokers using a cross-over design.

Mendoza-Baumgart et al. found that, compared with baseline smoking, all products produced significant reductions in 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), and all produced comparable effects on withdrawal and craving.  Ariva was the preferred product, followed by the nicotine lozenge and Exalt.  The authors concluded that “These findings make it difficult to ignore the potential of some ST products, specifically Ariva, to reduce exposure to tobacco-specific nitrosamines, particularly NNK…”

In 2010 Carpenter and Gray published a small, but persuasive, study documenting that dissolvable tobacco products “led to a significant reduction (40%) in cigarettes per day, no significant increases in total tobacco use, and significant increases in two measures of readiness to quit, either in the next month or within the next 6 months.” (5) 

Carpenter and Gray randomly assigned 31 smokers who were uninterested in quitting to receive Ariva or Stonewall dissolvable smokeless products, or to continue smoking cigarettes.  Smokers were given “minimal instructions on how to use” these products and were “told that there is no safe tobacco product and that the best thing they can do for their health is to quit entirely.”   

Carpenter and Gray wrote that their findings suggest “that Ariva and Stonewall are effective products to curb withdrawal and craving,” and that there is “no evidence that ST (Ariva or Stonewall) undermines quitting. To the contrary, readiness to quit (in the next 1 month and within the next 6 months) significantly increased among smokers who used a ST product relative to those who continued to smoke conventional cigarettes.”  This addressed the concern that telling smokers about vastly safer smokeless substitutes will “undermine quitting.”

In 2011 Kotlyar et al. published the results of a clinical trial from 2006-7 showing that RJ Reynolds’ Camel Snus and Philip Morris’ Taboka (a precursor of Marlboro Snus) were viable substitutes for cigarettes (6).  They recruited smokers who were interested in quitting, assigning them to use one of three products: 4 milligram nicotine gum or lozenge, Camel Snus or Taboka (participants had a choice of various flavors for each product).  Participants were instructed to use at least one or two doses of the assigned product per day during a one-week sampling period; for the next four weeks, they were told to use the product at least 6 to 8 times daily (and additional doses if needed).  During week 5, participants were required to reduce consumption of the substitute; by the end of that week they had to be completely tobacco- and nicotine-free. 

There were several interesting results.  First, all participants in all groups had a reduction in exhaled carbon monoxide, clearly demonstrating that they smoked less than before the study.  Participants in all groups had a reduction in the urine concentration of N’-nitrosonornicotine (NNN) and NNAL.  The reductions were statistically significant except for NNN in Camel Snus users (p = 0.07).

Overall craving and withdrawal scores decreased over the 4 weeks in all groups, with no differences between the groups.  Continuous abstinence rates over the 4 treatment weeks varied from 33% (Taboka) to 43% (Camel Snus).  Two weeks after the treatment ended, 39% of the Taboka group, 47% of the Camel Snus group and 56% of the nicotine group were not smoking, but these percentages dropped to 23%, 31% and 33% respectively after ten weeks of complete abstinence.  One possible reason for the precipitous drop in the smoke-free percentages was the insistence on abstinence after 4 weeks. 

3. Survey Evidence from Test Markets in Indiana

In 2006 Philip Morris launched a test market for Taboka snus in Indianapolis (in 2008 it was discontinued when Marlboro snus was launched), and in 2007 the city was one of several expansion markets for RJ Reynolds’ Camel Snus; that product went on to national distribution in 2009. 

Lois Biener and Karen Bogen, from the University of Massachusetts Center for Survey Research, analyzed data from the 2006-7 Indiana Adult Tobacco Survey, and their recently published study provides some valuable information about the consumer interest in snus (7).

Biener and Bogen reported that almost 20% of survey respondents throughout Indiana were aware of snus.  Awareness among smokers statewide was 44%, which was 4.5 times higher than awareness among non-smokers.  Awareness among respondents in central Indiana (i.e. around Indianapolis) was 29%.  More importantly, about 64% of male smokers in central Indiana had heard about snus, and 20% had tried it.  This is evidence that Philip Morris and Reynolds were targeting adult male smokers in their test-market campaigns, and that the manufacturers were fairly successful.

Biener and Bogen also reported that risk perception played an important role in getting people to try snus.  Respondents who correctly believed that ST is less harmful than cigarettes were almost 4 times as likely to try snus as those who had been misinformed about the differential risks.  Unfortunately, this study revealed that 88% of all respondents had been misinformed, so they incorrectly believed that ST was just as dangerous as cigarettes. 

Biener and Bogen offered some perceptive comments on the state of smoker misinformation:

“Both marketing and health education messages should include the information that all tobacco products are harmful and that abstinence from all tobacco products is the most healthful choice. At the same time, simply saying that ST is ‘not safe’ is not a sufficient stance for public health communications.  There is a recognized continuum of risk along which various tobacco products can be placed, with low-nitrosamine ST products much lower on the risk continuum than combustible tobacco, although it is not harmless. Devising an effective way to inform the public about the continuum should be an important research priority, as currently consumers are woefully incorrect in their assessments of relative risk of various tobacco products. This state of affairs could result in people deciding not to give up smoking in favor of a product lower on the risk continuum because they assume that all tobacco products are equally harmful.”

Evidence from Sweden

1.  Smokeless Tobacco Use Has Had a Profound Effect on Smoking in Sweden

For the past 100 years, cigarette smoking has been the dominant form of tobacco consumption in almost all developed countries.  One notable exception is Sweden, where smoking rates, especially among men, have been considerably lower than those of comparable countries for decades.

Per capita consumption of nicotine from tobacco in Sweden is quite high and on par with other countries such as Denmark, the U.S. and Austria (8).  The difference between Sweden and the other countries is how nicotine is consumed.  In Denmark, the U.S., Austria and many other developed countries, almost all nicotine consumption is derived from tobacco combustion.  In Sweden, ST use (in the form of snus) accounts for almost 50% of all contemporary nicotine consumption in Sweden.  Snus use in Sweden is much more common among men than among women; over 60% of nicotine consumption among Swedish men is from snus.  This is not a new phenomenon; for over a century, Swedish men have had among the world’s highest per capita consumption of ST (9).    
   
Beginning in 2002, an American-Swedish research group used a World Health Organization database to describe in detail the impact of snus use on smoking among the population in northern Sweden during the period 1986-2004 (10,11,12). 

Among men, the prevalence of all tobacco use was stable during the study period, at about 40%.  However, there were striking, and opposite, changes in prevalence of smoking and snus use.  Smoking prevalence was 19% in 1986, and it was lower in all subsequent surveys, reaching 9% in 2004.  The prevalence of exclusive snus use increased from 18% in 1986 to 27% by 2004.  Snus use was the dominant factor in the higher prevalence of ex-smoking among men compared to women (prevalence ratio 6.18, 95% CI 4.96 – 7.70).   
 
Among women the prevalence of all tobacco use also was steady at 27 to 28%, and women smoked at higher rates than men in all surveys.  But these studies showed that snus use was associated with lower smoking rates among women in 1999 and 2004.  Smoking prevalence was about 25 to 27% in 1986, 1990 and 1994, but declined to 21% in 1999, and 16% in 2004. The prevalence of snus use was 0.5% in 1986 and increased to 1.9% in 1990, 2.0% in 1994, 5.1% in 1999 and 8.9% in 2004. 

In these reports snus use was not associated with smoking initiation, as the prevalence of smoking among former snus users was low in all survey years (3-4%).  The evidence showed that among adult men in northern Sweden the dominant transition is from smoking to snus, not vice versa.

In 2003, Gilljam and Galanti reported the results of a telephone survey of current and former smokers in Sweden (13).  They reported that using snus increased the probability that male smokers would be smoke-free by 50% (OR 1.54, 95% CI = 1.3-2.5). 

In 2003 Foulds et al. reviewed the evidence relating to the effects of snus use on smoking and concluded, “Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.” (14)  The investigators noted that “in Sweden we have a concrete example in which availability of a less harmful tobacco product has probably worked to produce a net improvement in health in that country”.

In 2005 Furberg et al examined tobacco use data from the Swedish Twin Registry, finding that regular snus use was associated with smoking cessation, not initiation, among almost 15,000 male participants (15).  Both regular and occasional snus use were protective against having ever smoked.

In 2006 Ramström and Foulds examined data from a 2001-02 nationally representative Swedish social survey (16).  They found that snus use among men was significantly protective against smoking initiation (OR = 0.3, CI 0.2-0.4).  They also found that snus was the most commonly used cessation aid among men (used by 24% of men on their most recent quit attempt).  Men who used snus as a quit-smoking aid were more likely to quit successfully than those using nicotine gum (OR=2.2, CI=1.3-3.7) or the patch (OR=4.2, CI=2.1-8.6), which was also true for women.

2.  Smokeless tobacco Use Has Had a Profound Effect on Smoking-Related Deaths in Sweden

Over the past 50 years Swedish men have had the lowest rates of smoking-related cancers of the lung, larynx, mouth and bladder in Europe (17), and the lowest percentage of male deaths related to smoking of all developed countries (18,19).    

In 2004 Rodu and Cole documented that if men in the (15-country) European Union had the smoking prevalence of Sweden, almost 200,000 deaths attributable to smoking would be avoided each year (20).  In contrast, women in Sweden smoke at rates much more similar to women in other European countries, and this is reflected in similar rates of smoking-related illnesses.   They found that only 1,100 deaths would be avoided in the EU at Swedish women’s smoking rates.

In 2009 Rodu and Cole contrasted Swedish lung cancer mortality rates and smoking-related deaths with those in 24 other European Union countries (21).  They concluded that snus use has had a profound effect on smoking prevalence and smoking-associated deaths among Swedish men for the past 50 years.  In 2002, 274,000 smoking-attributable deaths would have been avoided in the European Union if men in all countries had the smoking rate of Swedish men.

References

1.  Rodu B., Phillips C.V.  Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.  Harm Reduction Journal 5: 18, 2008 (Open Access, available here )

2.  Tilashalski K, Rodu B, Cole P.  A pilot study of smokeless tobacco in smoking cessation.  American Journal of Medicine 104: 456-458, 1998.

3.  Tilashalski K, Rodu B, Cole P.  Seven year follow-up of smoking cessation with smokeless tobacco.  Journal of Pscyhoactive Drugs 37: 105-108, 2005.

4. Mendoza-Baumgart MI, Tulunay OE, Hecht SS, Zhang Y, Murphy S, Le C, Jensen J, Hatsukami DK.  Pilot study on lower nitrosamine smokeless tobacco products compared with medicinal nicotine.  Nicotine &Tobacco Research 12: 1309-1323, 2007.

5. Carpenter MJ, Gray KM.  A pilot randomized study of smokeless tobacco use among smokers not interested in quitting: changes in smoking behavior and readiness to quit.  Nicotine &Tobacco Research 12: 136-143, 2010.

6. Kotlyar M, Hertsgaard LA, Lindgren BR, Jensen JA, Carmella SG, Stepanov I, Murphy SE, Hecht SS, Hatsukami DK.  Effect of oral snus and medicinal nicotine in smokers on toxicant exposure and withdrawal symptoms: a feasibility study.  Cancer Epidemiology Biomarkers and Prevention 20: 91-100, 2011.

7. Biener L, Bogen K.  Receptivity to Taboka and Camel snus in a U.S. test market.  Nicotine & Tobacco Research 11: 1154-1159, 2009.

8.  Fagerström K.  The nicotine market: an attempt to estimate the nicotine intake from various sources and the total nicotine consumption in some countries.  Nicotine & Tobacco Research 7: 343-350, 2005.

9.  Nordgren P, Ramström L.  Moist snuff in Sweden: tradition and evolution.  British Journal of Addiction 85: 1107-1112, 1990.

10.  Rodu, B, Stegmayr, B, Nasic, S, Asplund, K.  Impact of smokeless tobacco use on smoking in northern Sweden.  Journal of Internal Medicine 252: 398-404, 2002.

11.  Rodu, B, Stegmayr, B, Nasic, S, Cole, P, and Asplund, K.   Evolving patterns of tobacco use in northern Sweden.  Journal of Internal Medicine 253: 660-665, 2003.

12.  Stegmayr B, Eliasson M, Rodu B.  The decline of smoking in northern Sweden.  Scandinavian Journal of Public Health 33: 321-324, 2005.

13.  Gilljam H, Galanti MR.  Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden.  Addiction 98: 1183-1189, 2003.

14.  Foulds J, Ramström L, Burke M, Fagerström K.  Effect of smokeless tobacco (snus) on smoking and public health in Sweden.  Tobacco Control 12: 349-359, 2003.

15.  Furberg H, Bulik CM, Lerman C, Lichtenstein P, Pedersen NL, Sullivan PF.  Is Swedish snus associated with smoking initiation or smoking cessation?  Tobacco Control 14: 422-424, 2005.

16.  Ramström L, Foulds J.  Role of snus in initiation and cessation of tobacco smoking in Sweden.  Tobacco Control 15: 210-214, 2006.

17.  LaVecchia C, Lucchini F, Negri E, Boyle P, Maisoneuve P, Levi F, 1992.  Trends of cancer mortality in Europe, 1955-1989:  II and IV.  European Journal of Cancer 28, 514-599; 28A, 1210-1281.

18.  Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr., 1992.  Mortality from tobacco in developed countries: indirect estimation from national vital statistics.  Lancet 339, 1268-1278.

19.  Peto R, Lopez AD, Boreham J, Thun M, 2006.  Mortality from Smoking in Developed Countries 1950-2000, (2nd edition, revised June 2006). CTSU, Oxford University 2006, available here .

20.  Rodu B, Cole P.  The burden of mortality from smoking: comparing Sweden with other countries in the European Union.  European Journal of Epidemiology 19: 129-131, 2004.

21.  Rodu B, Cole P.  Lung cancer mortality: comparing Sweden with other countries in the European Union.  Scandinavian Journal of Public Health 37: 481-486, 2009.