A Smokeless Alternative to Quitting

NY Times ^ | April 6, 2004 | SALLY SATEL, M.D.

[neverdem]

COMMENTARY

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.

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. 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," said Dr. Brad Rodu, a pathologist at the University of Alabama at Birmingham.

Eliminate the smoke, and you significantly reduce the risk.

Snus, a Swedish version of snuff, is especially attractive to smokers because it produces nicotine levels comparable to smoking. Gum and the patch administer too little nicotine to reliably prevent craving and withdrawal symptoms.

The health benefits are impressive. Forty percent of Swedish men use tobacco products. 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 women.

Smoking opponents should herald snus. But instead, the very notion of harm reduction inflames them.

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

Over 20 epidemiological studies show that smokeless tobacco is far safer for mouth cancer than cigarettes. Even traditional smokeless products bring one-third to one-half the risk. Users of snus, which contains low levels of tobacco-specific nitrosamines, a carcinogen, incur a risk of developing oral cancer no greater than nonsmokers, the journal Tobacco Control reported last year.

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. But Sweden has the best record of smoking reduction in Europe. Moreover, the proportion of current smokers who are former snus users is far less than the proportion of snus users who once smoked.

In short, snus has largely been a pathway away from smoking, not vice versa. 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 brands of compressed 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, Dr. Richard H. Carmona, told Congress, "There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes." This is simply wrong in the case of smokeless tobacco in general, and snus in particular.

"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. Experts have for years endorsed harm reduction as a pragmatic last resort for addicts, because they are convinced of the relative safety that accrues to the user and society.

No one disputes that quitting is optimal. But 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.

Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.

[Ragtime Cowgirl]

All credit (and my undying gratitude) to our awesome troops and their ultimate "Commander in Chief" (upstairs). (^:

[cinFLA]

A jar of picked buggars and a jar of bit-off toenail clippings... yuck! Maybe if the toe nail clippings also include the jam, it wouldn't be too bad. LOL

Jelly Belly is marketing flavors such as vomit, ear wax, buggers, etc. Not sure if the wholesale buyers will "bite" on them.

[rikkir]

My understanding is that they bear no resemblance to the little snuff packets. Even those increase saliva production.
I am going to try them. I tried to quit several times over the years. Patch only worked for a couple of weeks, and only the first time I used it. Hypnosis was a $100 joke, sitting in a room with a 100 other people while a guy talks soothingly to you, and then sells you another $100 of worthless vitamins, "to stop the craving for cigarettes" which is what the hypnosis was supposed to do.
I have to quit now. I was just diagnosed with kidney cancer, and while every doctor I've seen has said this cancer has no relationship to smoking, I'm not taking any chances. After Friday I'll only have one kidney and I figure I had better not roll the dice.
If this product lets me break the habit of lighting up when triggered maybe that will make it easier to kick the nicotine out of my system.

[Dog Gone]

Good luck with that operation. That doesn't sound like much fun at all.

And if you ever find these products, let us know what you think.

[EEDUDE]

"I wonder how these products differ from Skoal Bandits. It sounds like the same thing."

They are.

Brad Rodus' book came out about 7 years ago. He is an epidemioligist at UAB.

His book states that the risk of oral cancer is LESS than that of smokers, and that lung cancer, emphysema, and heart disease are not a factor with smokeless tobacco.

I believe the guy is sincere, and has the credentials to back up his assertions.

His book was trashed by the extreme anti tobacco lobby, but what they don't understand is that SOME folks simply cannot break this powerful addiction.

For those in this category, smokeless tobacco may indeed be a lifesaver.

BTW, in his book, he was strongly against the use of smokeless tobacco EXCEPT in those cases.

Again, I believe the man sincerely wants to help those smokers who are unable to give up nicotine.

Another question: If the gov't is so worried about the healthcare costs that smokers presumably cost the "system", then why not subsidize treatment and nicotine supplements instead of allowing smokers to have to pay $75.00/wk for these things?

[rikkir]

Thank you. I went to my pre-op screening yesterday and was surprised to find out that this is outpatient surgery. My jaw hit the floor. They are going to remove a major organ from my body, and send me home the same day. Medical science has sure come a long way.
I think those products are being sold here in NC. I've seen ads for Revel in the Charlotte Disturber. I'll keep everyone posted to let you know how they work.
I don't know if it's appropriate to do so, but I would ask if any are inclined to do so, I would appreciate being remembered in prayers on Friday. I hope to feel the strength and warmth of God's love when going into the operating room. For the first time in my adult life I find my courage faltering.

[Dog Gone]

OUTPATIENT??? I figured you'd be lying on your side in the hospital for a week! That's incredible.

As for the prayers, you got 'em.

[neverdem]

Your biggest risk is probably general anesthesia. I've said prayers for you already. Don't worry. You'll do fine.

[neverdem]

Daylate, thanks for letting me know about the smoker's paradox. You'll probably need a medical dictionary if you read the links.

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Items 1-8 of 8

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1:	Angeja BG, Kermgard S, Chen MS, McKay M, Murphy SA, Antman EM, Cannon CP, Braunwald E, Gibson CM.	Related Articles,
	The smoker's paradox: insights from the angiographic substudies of the TIMI trials. J Thromb Thrombolysis. 2002 Jun;13(3):133-9. PMID: 12355029 [PubMed - indexed for MEDLINE]

2:	Gourlay SG, Rundle AC, Barron HV.	Related Articles,
	Smoking and mortality following acute myocardial infarction: results from the National Registry of Myocardial Infarction 2 (NRMI 2). Nicotine Tob Res. 2002 Feb;4(1):101-7. PMID: 11906686 [PubMed - indexed for MEDLINE]

3:	Andrikopoulos GK, Chimonas ET, Toutouzas PK.	Related Articles,
	Paradoxical clinical value of another smoker's paradox. Circulation. 2002 Feb 26;105(8):e55. No abstract available. PMID: 11864939 [PubMed - indexed for MEDLINE]

4:	Cohen DJ, Doucet M, Cutlip DE, Ho KK, Popma JJ, Kuntz RE.	Related Articles,
	Impact of smoking on clinical and angiographic restenosis after percutaneous coronary intervention: another smoker's paradox? Circulation. 2001 Aug 14;104(7):773-8. PMID: 11502701 [PubMed - indexed for MEDLINE]

5:	Shander D.	Related Articles,
	A real smoker's paradox. J Am Coll Cardiol. 2001 Jun 1;37(7):2009-10. No abstract available. PMID: 11401150 [PubMed - indexed for MEDLINE]

6:	Himbert D, Juliard JM, Golmard JL, Feldman LJ, Aubry P, Benamer H, Karila-Cohen D, Gauci L, Steg PG.	Related Articles,
	[Revision of the "Smoker's Paradox": smoking is not a good prognostic factor immediately after myocardial infarction] Arch Mal Coeur Vaiss. 2001 Apr;94(4):262-8. French. PMID: 11387931 [PubMed - indexed for MEDLINE]

7:	Andrikopoulos GK, Richter DJ, Dilaveris PE, Pipilis A, Zaharoulis A, Gialafos JE, Toutouzas PK, Chimonas ET.	Related Articles,
	In-hospital mortality of habitual cigarette smokers after acute myocardial infarction; the "smoker's paradox" in a countrywide study. Eur Heart J. 2001 May;22(9):776-84. PMID: 11350110 [PubMed - indexed for MEDLINE]

8:	Barbash GI, Reiner J, White HD, Wilcox RG, Armstrong PW, Sadowski Z, Morris D, Aylward P, Woodlief LH, Topol EJ.	Related Articles,
	Evaluation of paradoxic beneficial effects of smoking in patients receiving thrombolytic therapy for acute myocardial infarction: mechanism of the "smoker's paradox" from the GUSTO-I trial, with angiographic insights. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol. 1995 Nov 1;26(5):1222-9. PMID: 7594035 [PubMed - indexed for MEDLINE]

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Apr 6 2004 10:25:18

[rikkir]

Thank you, all are appreciated.

[neverdem]

The links of the eight articles to the abstracts by left clicking the authors' names all failed. That's the first time I that I've seen this happen, but if you click on "related articles", you'll find links that work and have access to articles with links to abstracts.

I didn't read everything, but I came across one explanation for the paradox was that smokers tend to be younger patients who are less likely to have diabetes, hypertension or obesity.