Wednesday, August 11, 2010

What If We Told the Truth About Snus?

In a recently published study in the British Medical Journal Tobacco Control, Adrienne B Mejia, Pamela M Ling, and Stanton A Glantz state, “Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.” http://tobaccocontrol.bmj.com/content/19/4/297.abstract

The researchers used a Monte Carlo simulation to estimate the health effects of five different patterns of increased use of smokeless tobacco. Here we see the age-old principle of GIGO at work: Garbage In, Garbage Out.

Dr. Joel L Nitzkin, Chair, Tobacco Control Task Force of the American Association of Public Health Physicians questioned both the underlying assumptions applied in creating the computer models and the scoring arbitrarily assigned for various health effects. http://tobaccocontrol.bmj.com/content/19/4/297.abstract/reply#tobaccocontrol_el_3470

One of the critical assumptions applied in the calculations was the rate at which smokers would be willing to substitute snus for Smoking. Dr. Nitzkin commented, “All of their data on switching rates in the United States is conditioned on the warning on smokeless tobacco products, in place in the USA since 1984, that this product is not a safe alternative to cigarettes. This purposely misleading warning has left over 80% of American smokers with the incorrect impression that smokeless tobacco products present the same risk of tobacco-related illness and death as cigarettes.”

How might those estimates change if we all told smokers (and their doctors) the truth?

What if the government changed the warning labels to read "THIS PRODUCT IS NOT A 100% SAFE ALTERNATIVE TO SMOKING"? See what a difference one tiny change can make? This would lead folks to ask, "Well if it's not 100% safe, how much safer is it?"

The way the message is worded now, 85% of the people who read it conclude it means that smokeless tobacco products cause just as much disease and premature deaths as smoking. [1] We know it isn't true. But smokers don't know that, now do they?

And then what if the American Cancer Society, American Heart Association, American Lung Association, American Medical Society, and the Centers for Disease Control and Prevention informed smokers that their excess risk of lung disease would be totally eliminated if they switched from smoking to smokeless? What if they provided comparisons between smoking and smokeless of the odds of developing various types cancers, having a heart attack or a stroke?

We know that users of smokeless tobacco products have a lower mortality rate from all these diseases than continuing smokers. [2,3] We know that for most diseases, the Swedish snus user's mortality risks are reduced to the level of those who gave up all use of tobacco. [4] We know all that. But the smokers do not know that.

Most smokers do not read medical journals. They rely on the popular press and information provided by respected organizations that claim to have public health as a mission.

Curiously, most physicians are just as misinformed as their smoking patients. What if the doctors were to learn that their patients could reduce their risk of developing a smoking-related disease by 90 to 99% if they switch completely to a smokeless form of tobacco? Might not more smokers give snus a try if their own doctor told them it was safer than smoking?

What if the FDA required the tobacco companies to develop and conduct advertising campaigns aimed at convincing smokers to switch to smokeless products?

What if we did all these things? What effect would that have on the number of U.S. smokers who switch and consequently on the smoking-related morbidity and mortality rates? Factor in truth-telling and run those Monte Carlo simulations again.

References:

[1] Phillips, C.V. et al. You might as well smoke; the misleading and harmful public message about smokeless tobacco. BMC Public Health 2005, 5:31doi:10.1186/1471-2458-5-31.

[2] Accortt, N.A., et al. Chronic Disease Mortality in a Cohort of Smokeless Tobacco Users. American Journal of Epidemiology 2002; 156:730-737

[3] Roth, H.D. et al. Health Risks of Smoking Compared to Swedish Snus. Inhalation Toxicology, 17:741-748, 2005.

[4] Gartner C.E, et al., Assessment of Swedish snus for tobacco harm reduction: an epidemiological modeling study. Lancet. 2007 Jun 16;369(9578):2010-4

7 comments:

  1. I submitted the following to Dr Glantz-

    After 25 Years of Misinformation, What Would You Expect

    Joel L Nitzkin and Elaine Keller did an excellent job of identifying problems with this study so I shall not endeavor to duplicate their suggestions. Instead I wish to speak as a 43 year, at the end 2 to 3 pack, smoker who used Swedish snus 6 months ago to completely stop smoking.

    I attempted smoking cessation for over 30 years using just about every NRT product except Chantix. I tried hypnosis twice, group and individual, and herbal remedies. Nothing worked. I was persuaded by my girlfriend to purchase an electronic cigarette over a year ago. That immediately got me down to a half dozen cigarettes a day plus the ecig. However, I was unable to stop smoking completely.

    If it had not been for an electronic cigarette forum, I would never have tried any smokeless tobacco product. I was told decades ago that these were no better than smoking. In addition, the only vision I had of smokeless tobacco was the type that you had to spit the juices which I still would not do. That being said, I'm sure that there are many that would even consider that form of smokeless if they didn't feel it was just as dangerous as smoking.

    Even after being directed to Swedish snus, I had serious doubts ingrained from bad science and worse publicity. It wasn't until I started investigating on my own that I realized what most of the 44 million smokers in the US don't know. Smokeless is anywhere between 90 and 99% safer than smoking. I was shocked and angry that I might have quit a quarter century ago if this information was provided by those that were supposedly trying to get people to stop smoking.

    In her response, Elaine Keller wrote, "What if the government changed the warning labels to read "THIS PRODUCT IS NOT A 100% SAFE ALTERNATIVE TO SMOKING"? See what a difference one tiny change can make? This would lead folks to ask, "Well if it's not 100% safe, how much safer is it?" "

    I shall take her thought one step further. How about a warning 25 years ago that read "THIS PRODUCT IS ONLY 95% SAFER THAN SMOKING", or whatever the right percentage is. Six months ago I had my first portion of Swedish snus. Six months ago I had my last cigarette with absolutely no desire to smoke since. For me, the electronic cigarette is still useful in certain circumstances, but it currently sits mostly unused as about four portions of Swedish snus have replaced cigarette smoking entirely.

    Now you produce a modeling study using parameters that draw a conclusion that selling the idea of smokeless won't make a difference in the smoking rate. Had the industry been honest 25 years ago, your study wouldn't have needed to be done. We'd have the answer. My guess is that the number of smokers would have seriously been reduced. Of course that would not have aligned well with the goal of Big Pharma in providing the answer and that makes me angry.

    How the industry and the "health" associations could continue to push products that have a success rate only a couple percent better than cold turkey after a year is beyond my comprehension. I know that 25 years less smoking would have improved my odds health wise in the future and that does not make me happy.

    My last point is that the only snus mentioned was the American versions that have come out over the last year or so. These are not Swedish snus. I have difficulty even accepting that they can be considered snus. Whether it's nicotine content or the other tobacco alkaloids that are missing, I'm not sure. The product has to be adequate to fulfill the needs of the smoker.

    Conflict of Interest:

    I hold quite a few shares of Pharmaceutical shares, many with companies that sell NRT products.

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  2. I have been a 1 pack a day smoker for the last 8+ years. I've tried cold turkey, and patches to quit w/ minimal success(was able to stop for a couple weeks).

    I started seeing the Camel Snus signs when I would stop to get smokes at the store. I finally decided to try Camel Snus and it was not very good and didn't seem to help w/ any cravings for smokes.

    One day I decided to search Snus online and was surprised to find out that Camel didn't invent Snus. So, I started learning about the "real" snus which comes from Sweden. I was also seeing multiple reports of people being able to quit smoking w/ Swedish Snus.

    So I got some Swedish snus and once you get past the adjustment period this stuff is a cigarette killer! I haven't had a cigarette for almost 3 months and the biggest difference between using snus and other attempts(w/ or w/ out nicotine) is I have completly no cravings for cigs!!! I don't even think about them anymore. The reason is that the Swedish Snus actually gives you the nicotine you need to replace the loss of nicotine when you stop smoking or use a quit smoking aid that limits the amount of nicotine.

    I understand there are still risks associated w/ tobacco use but the government doesn't want you to know how "less harmful" any smokeless tobacco product is compaired to smoking.

    The term "harm reduction" is not accepted here in the U.S. This is sad because what it says to me is that you will either smoke and die or quit using any nicotine what so ever. A lot of lives are being lost because of the history of all tobacco products being treated the same.

    So, I've had a very positive experience so far w/ Swedish Snus and don't see going back to cigarettes as they almost make me sick to my stomach just to smell someone smoking one!

    If you can quit using nicotine completly, that is the best thing for your health. If you can't, it is far safer to switch to a less harmful alternative like Swedish Snus. Do your own research and see if it is something you want to try.

    Finally, there is a significant diffrence betweek the tobacco processing in American(camel, marlboro) snus and Snus from Sweden. These changes dramatically reduce the harmful cancer causing agents. Like I said before do some research on your own and educate yourself to the risks and benefits of all alternatives to smoking cigarettes.

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  3. You are all fools...Substitute SMOKING related cancers and diseases for NON-SMOKING related cancers and diseases. Tobacco is to blame, not smoke.

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  4. Dear Anonymous: Switching from smoking to a non-smoked form of tobacco immediately removes tar, carbon monoxide, particulates, and thousands of chemicals created solely by the process of combustion from the equation. Those are the elements that cause all of the lung disease and the vast majority of smoking-related cardiovascular disease and cancers. You may be confused by the fact that older forms of smokeless tobacco were much higher in carcinogens than modern smokeless products. Swedish snus has been systematically developed to lower the number of carcinogens. Switching from smoking to Swedish snus reduces risks to that of the smokers who stopped using all forms of tobacco. http://www.ncbi.nlm.nih.gov/pubmed/17498798

    Your favorite Fool, Vocal EK

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  5. Just thought I'd post my experiences with Swedish Snus here, as well...I have been a 1.5 pack a day smoker for 13 years, and my father smoked for almost 40 years. I stumbled upon Swedish Snus online about a year ago, and finally decided to try some in January 2011. My father also joined me in the experiment.

    The results? We've both been smoke-free for over a month. Not only are we smoke-free, I have ZERO thoughts about a cigarette. Anybody who's ever quit smoking knows how special that thought is. SWEDISH Snus, in both mine and my father's experience, provides the easiest method of complete smoking cessation I've ever seen!

    Swedish Snus is the cleanest, most unobtrusive, least noticeable way to use tobacco. The little pouches sit in your upper lip where NOBODY can see them, and they don't discolor your teeth the way smoking does. I don't reek of smoke anymore, either.

    My dad uses Jacobssen's Mint Strong Portions snus, about 4-5 portions a day. I use Nick & Johnny Strong Portions, about 6 portions a day. We can also recommend General Mini Mints and General Long Sterk for those who've just quit smoking. If you don't care for the taste of tobacco in your mouth...try the mints.

    A word of warning: several studies have suggested that the U.S. brands marketing Snus (Camel, Marlboro) have intentionally kept Nicotine levels low through a variety of means to discourage users to quit smoking. Some have even suggested that Phillip Morris is intentionally marketing a failing Snus brand to convince smokers that snus cannot help them. PLEASE don't try this crap! The U.S. producers won't say how they make it, won't tell you whats in it, and don't want you to use it to quit smoking!

    So my take? If you've never used tobacco, I wouldn't use Swedish Snus. The stuff is just as addictive as smoking...why form an addiction you don't need? However, if you are a smoker, why not lower your risks of cancer/stroke/heart disease very nearly to that of a non-tobacco user?

    Cost Breakdown: Cigarettes (1 pack a day @ $4) - ~$120 month. Swedish Snus (1 can every 3 days @ $4) - ~$40 month.

    Want to try REAL snus? Go to a reputable site and buy some real Swedish Snus. I would recommend the blog Snubie.com as additional reading...they have a great list of sellers there, as well...

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  6. The handwriting is on the wall. Now that the FDA can regulate tobacco products, I think it is inevitable that they will try to make cigarettes as unsatisfying as possible. Tobacco companies are not foolish and they realize that the future of their profits is in their smoke-free products. They will be working to make those products as safe and as palatable as possible.

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