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Autumn 2008 | Vol 12 No 1

Q & A

Smoke and mirrors? Smokeless tobacco and the harm reduction debate

By Nate Hendley

Harm reduction approaches to tobacco are relatively recent. They are also highly controversial. While proponents argue that harm reduction strategies are a more realistic approach to tackling the health risks of this highly addictive product, critics argue that harm reduction strategies distract from the only safe option – quitting tobacco entirely. Entering the scene are smokeless tobacco products (STPs) such as snuff and chewing tobacco, which are promoted as products to use when you can’t smoke.

Dr. Roberta Ferrence, executive director of the Ontario Tobacco Research Unit at the Centre for Addiction and Mental Health in Toronto, and Michael Chaiton, a graduate student in the University of Toronto epidemiology program, weigh in on the STP debate.

What issues are at the core of the smokeless tobacco products debate?

Ferrence: The current debate centres on whether users of smoked products should be encouraged to switch to STPs, which are supposedly less risky, and whether promoting STPs discourages quitting and encourages non-smokers to start using STPs, because they are touted as being safe. Proponents argue that because STPs produce no carbon monoxide and fewer carcinogens than smoked products, they can reduce health risks for those who can’t or don’t want to quit tobacco use. Critics argue that determining the harm reduction value of STPs is difficult to determine because STPs are developed by tobacco companies, whose main goal it is to keep their brand alive and some of the research on these is done by people funded by the tobacco industry.

Proponents of smokeless tobacco products argue that they are safer than smoked products. What do the critics say?

Ferrence: Switching to STPs eliminates the risks of inhaling smoke, but there remain other concerns about the effect on individual smokers. Perhaps more important, there is evidence that the availability of less harmful substitutes may keep many people using tobacco products who might otherwise have quit.

Chaiton: Traditionally, in North America, people who use snuff or chewing tobacco are also more likely to smoke cigarettes or to be heavier smokers. Smokeless tobacco certainly could be a harm reduction product under some circumstances. It’s not as harmful as smoking. But if tobacco companies are marketing STPs as a means of maintaining addiction during times when you can’t smoke, that isn’t harm reduction. I’ve noticed washroom ads for STPs in restaurants and bars, which are smoke-free places. This seems to be an attempt to build a market for smokeless products in smoke-free places.

Ferrence: The tobacco industry is beleaguered to some extent. What would you do if smoking rates were falling? You would try to bring in new products that appear to be less harmful and allow you to keep your brand name in the public eye. There is a whole strategy by tobacco companies to develop starter products with low nicotine that target youth, such as STPs, and then building up to stronger products. This has been documented in the literature. Indeed, tobacco compa­nies are targeting youth with flavoured products that appeal to them.

But if STPs are less dangerous than cigarettes, shouldn’t their use be encouraged to get smokers to quit?

Ferrence: If the government were willing to ban cigarettes and just allow STPs, there would be a huge reduction in tobacco-related disease. But that’s not going to happen soon. If you want to encourage people to use STPs you would have to have the government recommending them. The problem is that STPs still increase the risk of developing certain diseases. It’s just that tobacco is so out of the ballpark – the level of risk of lung cancer, for example, is 20 times that of non-smokers. The government can’t recommend something that causes cancer.

Where does pharmaceutical nicotine fit into the harm reduction continuum?

Ferrence: The present debate focuses on pharmaceutical nicotine – nicotine replacement therapy (NRT) in the form of nicotine gum, the patch and other such products – versus STPs. The patch and gum release nicotine very slowly, which means the potential for addiction is lower. The big difference is that nicotine replacement products are pure nicotine and are made under controlled conditions by pharma­ceutical companies, whereas smokeless products contain tobacco and tobacco carcinogens, can have very high levels of nicotine and are made by tobacco companies, which are not subject to the same regulations for manufacture.

Do you see any role for smokeless tobacco as part of a harm reduction strategy?

Ferrence: We know that certain strategies reduce harm such as increasing taxes, smoking bans in public and private places. I feel it would not be inappropriate for a doctor, on an individual basis, to say, “If you can’t quit right now, try pharmaceutical nicotine, such as nicotine gum, and if that doesn’t help, try a smokeless tobacco product,” but we do not promote that. We aren’t opposed to people using STPs to quit or to reduce their risk. What we are calling for is some skepticism – the tobacco industry can’t be allowed to run the show, because their interests are not health related. There may be a small role for STPs for some people, but I don’t think it’s the answer. There is the potential for increased risk of harm if it’s not handled properly.

Chaiton: Nothing about STPs is intrinsically about harm reduction, unless it can substitute for cigarette smoking. It can be a harm-reducing product, but STPs are still a dangerous product, so when we talk about harm reduction, we’re really talking about strategies around promotion of use of STPs, or taxation policies, or restructuring the tobacco markets. Those are the more promising harm reduction strategies.