Why Anti-Smoking Groups Should Endorse Snus And E-Cigarettes December 08 2014

Sally Satel, Forbes, 12/01/2013

The good news is that the smoking rate has hit a new low. It is now just under 18% of all adults – but the goal of a totally smokeless society is elusive. Epidemiologists estimate that if the smoking rate continues to decline at the current pace, it will take 40 years to halve again, and cigarettes will claim millions more lives.

Now if only anti-smoking groups would endorse them. Unfortunately, organizations like the America Cancer Society and the American Lung Association are getting the facts wrong or distorting them.

Swedish snus, as I discussed in my last column, is tobacco that comes in a tiny tea bag. The user puts it between upper lip and gum. There is no spitting. Nicotine is absorbed into the bloodstream while rates of oral cancer are very low: comparable to individuals who never smoked at all.

Electronic cigarettes are battery powered devices that produce inhalable nicotine vapor. I wrote about them here. Both Swedish snus and e-cigs represent a very effective harm reduction strategy for those who want to continue nicotine.

This brings us to the Great American Smoke Out, which took place last month. First instituted in 1977, when the smoking rate was a little over one-third of adults, the event was initiated by American Cancer Society (ACS), to challenge smokers to stop for 24 hours. The idea was that the resolve to last without a cigarette for one would become a lifetime habit.

What advice did the ACS give would-be quitters on the anniversary of this much-lauded public health campaign?

Its smoke-out page starts off with misguided advice for anyone who smokes. It says “stay away from tobacco.” Wrong. The proper advice is to stay away from combusted tobacco. Smokeless snus is a fine way to reduce harm for people who do not want to give up nicotine.

But the ACS is tepid about snus and tendentious in its description:

Swedish snus has been touted by some people as a safer way to use tobacco, and even as a way to quit smoking cigarettes. Snus made in Sweden is a type of moist snuff that is reported to have lower levels of tobacco-associated nitrosamines (TSNAs), a potent cancer-causing agent in tobacco products. Lower TSNA levels may mean less risk of cancer, but there are still TSNAs and other carcinogens in Swedish snus.


To be precise, “some” don’t “tout” that Swedish snus “may mean less risk of cancer”. Any data-loving person can assert that fact with confidence, supported by the extensive epidemiological record of the negligible relationship between Swedish snus, a low TSNA product, and cancers of all kinds.

Nor is the impact of snus on quitting a matter of speculation, as critics allege. Indeed, the striking inverse relationship between snus’ growing popularity over 20 years and the decline of smoking in proportion, suggests that Swedish men have been using snus to quit smoking.

For some reason, the American Lung Association did not have a Smoke Out page this year but it did have some ominous words about e-cigs: “The American Lung Association is very concerned about the potential health consequences of electronic cigarettes.” It went on to discuss second-hand vapor while failing to emphasize a key point: that whatever indirect effects there are from vaping – and data suggest they are negligible in the short-term — they are not nearly as great as those due to smoking.

The Centers for Disease Control had some good basic suggestions for smokers on the Great American Smoke Out day. Among them: distract yourself during cravings by, for example, “calling or texting a friend.” Reduce smoking cues by throwing away lighters and ashtrays, and purging the smell of smoke from your car. And, of course, try “nicotine patches, gum, or other approved quit medicines.”

But the agency’s recommendations were silent on snus and e-cigarettes. This reflects its outsize worry that e-cigs are guiding teens to a smoking career. Earlier in November, the agency released information on teens, smoking, and e-cigarettes and played up a purported “gateway” effect from e-cigs to smoking. As a Reuters headline reported it: “U.S. Youth Smoking, Increased Use of E-cigarettes a Worry: CDC.”

Here is the full picture. The percentages of high school students who used e-cigs at least once within 30 days, rose from 1.5% to 4.5% between 2011 and 2013. But high school smoking declined from 15.8% to 12.7%, the lowest it has ever been, in parallel.

This pattern is less a “cause for concern” than for encouragement. It suggests that kids who smoke may be turning to e-cigarettes to stop. There may be other interpretations of this pattern but, at the very least, it shows, to date, that e-cigs do not prevent declines in smoking.

All three of these agencies fail the first rule of tobacco harm reduction: if alternative’s (here, snus and e-cigs) advantages are portrayed as uncertain, they will not seem appealing to smokers who are looking for an alternative. This forecloses any opportunity to divert a smoker away from cigarettes.

At a Wells Fargo WFC -0.47% Securities conference on e-cigs two weeks ago, Clive Bates, who runs a science watchdog website called The counterfactual, noted how public optimism surrounding e-cigs has deteriorated. Eighty percent of the public believed that e-cigarettes were safer than regular cigarettes in 2010 but three years later, that percentage had dropped to 60% Bates’ view, as New York Times columnist Joe Nocera reported, “was that this was largely because of the anti-e-cigarettes bias displayed by far too many people in the public health community.”

That’s a very plausible interpretation, though superficial media coverage is part of the problem too. Indeed, strategic omissions, half-truths and misinformation are among the biggest hurdles facing tobacco harm reduction. Patient groups, such as the ACS and the ALA, and the CDC play an enormous role in public education. When it comes to smoking, they are derelict in their duty to the people they purport to help.