Smokeless Doesn't Mean Harmless

This report stated that "a product [such as smokeless tobacco] is harm-reducing if it lowers total tobacco-related mortality and morbidity, even though use of that product may involve continued exposure to tobacco-related toxicants."

Translation: If there is less illness or death from using smokeless tobacco, than its use can be justified as a means to quit smoking.

The second factor that influenced the recent push to use smokeless tobacco as a means to quit smoking was the tobacco experience in Sweden. Tobacco-related death rates have declined dramatically in this country, even though many smokers switched from cigarette smoking to snus, a form of Swedish smokeless tobacco.

Unfortunately, it is unclear whether the Swedish experience applies to the United States. The concentrations of nitrosamines, such as NNK, are about 20 times higher in the most popular American brands of smokeless tobacco (Skoal and Coppenhagen) compared with snus.

In addition, nitrosamine levels increase over time in Skoal and Coppenhagen when stored at room temperature. These same carcinogen levels do not change in stored snus.

Using their research, Henley and colleagues rebut the notion of harm reduction.

"Our study suggests that switching from smoking to using spit tobacco compares unfavorably with both complete tobacco cessation and complete abstinence from all tobacco products, and supports the stand that smokers who want to quit should be offered safe, clinically proved treatments for [complete tobacco] cessation," they write.

Medications a Safer Alternative

Further undermining the concept of harm reduction: There are a variety of effective medications that can help any tobacco user quit -- smokers or spit tobacco users. These agents include nicotine products such as nicotine gum or the patch, as well as bupropion (Zyban) and the recently approved smoking cessation medication, varenicline (Chantix).

Self-help groups as well as psychological support also work. All these quit methods double or even quadruple the chance of successfully quitting tobacco use.

But because the amount of nicotine that a smokeless tobacco user receives is up to 10 times greater than the amount received by a smoker, smokeless tobacco users often become even more addicted to their habit than smokers do. For these users, a combination of medications, including nicotine, is often essential to help them quit.

Because of the oral delivery of nicotine by smokeless tobacco, many experts recommend using at least the nicotine gum to help patients quit.

Dr. John Spangler is director of tobacco control intervention programs and professor of family medicine at Wake Forest University School of Medicine.

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