From Tobacco Info No. 5 - April 2011
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Where there's smokeless, there's fire
Snuff tobacco not a safe substitute for smoking says American Heart Association
By Joe Strizzi
If you’re thinking that smokeless tobacco may be a good alternative to lighting up, you may need to think again.
“No tobacco product is safe to consume,” said Mariann Piano, R.N., PhD, and professor in the Department of Biobehavioral Health Science, University of Illinois at Chicago, College of Nursing. “Smokeless tobacco products are harmful and addictive, that does not translate to a better alternative.”
Piano, lead author of a study published in the American Heart Association’s (AHA) journal Circulation, examined several international studies to compare smokeless tobacco use and its health risks.
“Scientists and policy makers need to assess the effect of ‘reduced risk’ messages related to smokeless tobacco use on public perception, especially among smokers who might be trying to quit,” Piano and her colleagues wrote in their study entitled Impact of Smokeless Tobacco Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment. Citing an “inadequate evidence of smoking cessation efficacy and safety,” they concluded that the promotion of smokeless tobacco as a way to reduce smoking-related diseases was inappropriate.
Ultimately, Piano and her colleagues concluded that the safest aids for lasting smoking cessation are nicotine replacement and pharmaceutical therapies, in conjunction with counselling and support.
Manuel Arango, Assistant Director of Health Policy for the Heart and Stroke Foundation of Canada stated that there has been a lot of debate over the potential for smokeless tobacco products as a viable replacement to cigarettes or as smoking-cessation aids.
“This is a landmark document and a good summary of the evidence that we’ve been waiting for,” Arango said. “I think it settles a lot of questions we’ve had in the past.”
A December 2010 Health Canada study entitled Smokeless Tobacco Products: A Chemical and Toxicity Analysis reported that there are over 3,000 chemicals in smokeless tobacco products, 28 of which are known to cause cancer. The study also stated that use of smokeless tobacco is associated with many harmful health effects, including cardiovascular disease, oral disease and certain forms of cancer, such as of the pancreas and mouth.
The federal health department analyzed the physical and chemical properties of smokeless tobacco products and assessed their toxicity. The analysis demonstrated that all the products contain nicotine, the drug found in tobacco, which has been identified as playing a key role in addiction to these products. Some of the toxic chemicals found in the analyzed products include polycyclic aromatic hydrocarbons, tobacco-specific nitrosamines, and the metals arsenic (used in poison to kill rats), chromium, nickel and lead.
Youth using chew?
According to Cynthia Callard, Executive Director of Physicians for a Smoke-Free Canada (PSC), smokeless tobacco has never been used as widely in Canada — at least in the last 100 years or so — as it has been in the United States, but there is growing concern.
The 2008-2009 Youth Smoking Survey conducted for Health Canada found that almost 8% of high school boys and 2.5% of girls reported having used smokeless tobacco products in the previous month and that almost 16% of boys and 4% of girls had tried the products at least once.
Historically associated with professional athletes, smokeless tobacco is popular among teenage boys on both sides of the border, especially members of sports teams. Soccer, hockey, rodeo and baseball are most often associated with chewing tobacco, where according to Major League Baseball’s (MLB) own numbers, some 30% of players chew.
In January, Washington Nationals’ star pitcher Stephen Strasburg announced that he was trying to quit his addiction to chewing tobacco after learning that his former coach and MLB all-star athlete, Tony Gwynn, had been diagnosed with parotid cancer (salivary glands). Strasburg began dipping smokeless tobacco during his days at West Hill High School in San Diego. Now, after hearing of Gwynn’s battle, he says that he is motivated to break the addiction that could threaten his health over the long term.
Strasburg has gone on record saying he started chewing because he was emulating his baseball heroes, aspiring to one day become an MLB star.
While baseball isn’t as popular in Canada as in the US, PSC says the use of smokeless tobacco is on the rise.
“Even though usage is small here, there is anecdotal, but reliable information that boys on hockey teams and in other peer settings are using smokeless tobacco, especially because it’s flavoured with cherry, peach or mint,” said Callard. She added that these products were not included in the 2009 Tobacco Act that banned additives and flavoured cigarettes and cigarillos.
According to PSC, sales of candy-flavoured smokeless tobacco products have steadily increased in Canada since 2005 just as tobacco companies began marketing these products more aggressively.
According to its June 2009 study entitled Smokeless Tobacco: Candy-coating Carcinogens, PSC claims that teens are three times more likely to use smokeless tobacco as those over age 25, and about 40,000 Canadian youths have tried these products in the past month. As a result, Callard believes the AHA report is important, as it is “strong and gives policy makers the direction they need.”
The 2010 Canadian Tobacco Use Monitoring Survey found that 16% of all smokeless tobacco users were teenagers.
What is smokeless tobacco?
Health Canada defines smokeless tobacco products as those made of tobacco, water and additives. They can be placed in the mouth and either chewed or sucked, or inhaled through the nose. They come in different forms, such as plug, twist or coarsely chopped tobacco, long cut, fine cut or fine powder. Smokeless tobacco products are sold loose or prepackaged in a pouch. The loose products and pouches are generally placed in the mouth between the cheek and gum to be sucked on. They are available in spit and spit less form. In 2007, the Swedish style of snuff, called snus, was introduced to the Canadian market. Unlike its competitors that undergo a fermentation process, snus is manufactured using a heat process similar to pasteurization.
The great harm reduction debate
The international tobacco control community has differing opinions on the potential of some forms of smokeless tobacco as a cessation or harm reduction tool. Tobacco harm reduction describes actions taken to lower the health risks associated with using nicotine, especially as delivered through combustible tobacco, including but not necessitating complete abstention. It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate nicotine addicts who are unable or unwilling to achieve abstinence. Harm reduction has been proposed as a potential benefit to these individuals.
Proponents of tobacco harm reduction assert that lessening the health risk for the individual user is worthwhile and manifests over the population in fewer tobacco-related illnesses and deaths. Opponents argue that some aspects of harm reduction interfere with cessation and abstinence and might increase initiation.
Studies, like that by the AHA, as well as others like Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA by Stanton Glantz et al. in 2010 and Evaluating the acute effects of oral, non-combustible potential reduced exposure products marketed to smokers by Weaver and Eissenberg in 2009, both published in Tobacco Control, suggest that promoting smokeless tobacco as a safer alternative to cigarettes is not a viable harm reduction strategy.
However, there are studies that claim that smokeless tobacco is less harmful, than smoking cigarettes, albeit still containing carcinogens and chemicals, and could be a harm reduction or cessation tool.
A report by the Tobacco Advisory Group of the Royal College of Physicians of London, in October 2007, found that in relation to cigarette smoking, the hazard profile of the lower risk smokeless products is very favourable and smokeless tobacco therefore has potential application as a lower hazard alternative to cigarette smoking.
In addition, a letter to the editor of the magazine Addiction in November 2010, signed by over a dozen experts, including Dr. Coral Gartner from the University of Queensland, cites a number of expert reports that claim, among other things, that Swedish snus is considerably less hazardous than cigarettes and there is a need for the WHO Framework Convention on Tobacco Control to re-look at the possibilities for smokeless tobacco as a self-help aid.
Dr. Gartner et al., in the journal The Lancet, published a study in 2007 entitled Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. The authors found that current smokers who switch to using snus rather than continuing to smoke can realize substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers.