More Chicken Little from Alberta Action on Smoking and Health

Today in the Edmonton Journal (Flavoured products a blatant ploy to target youth, Alberta anti-tobacco group declares) Keith Gerein wrote

New survey results indicating large numbers of Alberta teenagers are hooked on flavoured tobacco products is evidence enough that the province should immediately ban the items, medical professionals and advocates said Tuesday.

The supposed source for this statement was Health Canada’s 2010-2011 Youth Smoking Survey. To wit

Among youth who had ever tried smoking a cigarette, 30% (about 218,000) had used at least one flavoured tobacco product in the last 30 days, compared to only 1% (about 29,000 ) of youth who had never tried smoking a cigarette.

In my lexicon hooked is not quite the same as having tried something once in the last 30 days. Nor does this seem to be much of a problem if only 1% of non smokers try them (again maybe no more than once in the last 30 days).

Since smokeless tobacco, which as most who read this blog know, is about 99% safer than smoking, you can argue that 1. anytime those people who would have smoked used smokeless instead it was a good thing and 2. there is a chance that someone who might otherwise have become a smoker gravitated towards smokeless instead and ended up with the much less harmful habit. Of course no one wants the kids do be doing any of this – these are toys for adults.

One real problem with this survey is that the flavoured tobacco category conflated smokeless tobacco with menthol cigarettes and flavoured cigars. Considering the vast harm differences between inhaling and not inhaling smoke it would be no different than having a category consisting of e-cigarettes and menthol cigarettes together.

I suspect that Gerein did not read the survey which would have lead to quite a different sort of headline since the findings are that smoking (and marijuana and other drug use, and alcohol use) declined for all the groups. Isn’t that headline worthy? We can’t tell about smokeless tobacco since this was the first time that use was polled.

The language throughout the article suggests it was cobbled together from a press release from Les Hagen given the antiquated but incendiary cliches the anti-nicotine groups like to use. “Fruity spit tobacco” leads off the old argument that tobacco companies are targetting youth through the use of flavours. I have always found the implication that adults don’t like flavours odd. Humans like flavoured products. In fact, one of the things a lot of adult smokers found quite attractive about e-cigarettes, and sealed the switch, was the variety of flavours.

According to the article the most commonly used flavoured tobacco product by Alberta youth were cigarrillos. This seems to occasion a ban on flavoured tobacco products in general (again lumping them with the vastly different smokeless products). The real worry then from a harm reduction perspective is that flavoured smokeless tobacco has been gaining popularity as an alternative for smokers, and as a cessation aid. As the case is with e-cigarettes, once you introduce an effective and satisfying alternative to smoking, if you then remove it, you are then encouraging people back into a riskier lifestyle choice.

If we are going to ban something, why not ban groups from using public money (money from you and me) to agitate for removing healthier alternatives from the market?

Finally, the Health Canada report found that almost all youth obtained their products through social sources. In other words these products are not being sold to minors. I worry that if kids start liking Pernod even if they all get it from their parents that high minders will argue that it should be removed from liquor stores.

On a lighter note, the SAIT student paper had a nice little article by Sarah Pynoo – Health Canada’s E-Cig restrictions deserve to go up in smoke.

As for the criticism that cigarettes could lead towards children and young adults getting hooked on actual cigarettes, it seems a bit silly. For one thing, while both regular cigarettes and e-cigarettes have a variety of flavours, both are only available with ID to those over 18. Also, it’s pretty hard to imagine a kid getting hooked on candy-flavoured, nicotine-free vapour, and switching over to the harsh, lung-burning alternative of an actual cigarette.

Even professional harm reduction workers have issues with tobacco harm reduction

Ask any doctor what they would recommend if a patient of theirs who felt compelled to use a drug with proven health risks asked whether it would be better to take another drug which made them feel exactly the same but was a lot safer. Odds are the doctor would suggest switching.

Now ask them about smoking and e-cigarettes and the answer might change.

Though many doctors are coming around the health community as a whole is still experiencing a bizarre disconnect when it comes to nicotine. You can’t even call it cognitive dissonance because they don’t seem to experience any anxiety from endorsing harm reduction in general while rejecting it when it applies to smokers.

A few years ago at a small meeting held at one of the conferences of what used to be called the International Harm Reduction Association I witnessed a similar occurrence which given the context was even more disturbing. The meeting had arisen due to certain influential elements within the organization who wanted to eliminate tobacco harm reduction from their community.

It was very strange to see individuals who had supported safer sex, safer drug injection practices, and safe injection sites, practically foaming at the mouth at the thought of promoting tobacco harm reduction. One of the central objections was that one avenue of harm reduction, smokeless tobacco, was produced by tobacco companies, and these same people who would, if it improved the likelihood of safer practices, collaborate with drug producers and dealers, with difficult anti-democratic bureaucracies, and with pimps, would rather cut off their own hands than join with tobacco companies to find a solution.

When the people who are on the front lines of the battle reject what should be contiguous with their own goals (reducing the harm in risky practices) you have to be concerned about the average public health official.

I don’t want to be entirely negative here. I believe the tide is turning and to a great degree because e-cigarettes arose independently of the tobacco companies. However the companies are buying into the e-cigarette market and you can expect the objections to increase in number.

Most of these objections will be of the “just a way of maintaining nicotine addiction” nature. But guess what – along with the independent e-cigarette companies these “evil” folks are taking pretty well all the harm out of using nicotine. The addiction was never really the issue.

The anti-nicotine forces like to promote the idea that there is something special about smoking, nicotine and tobacco companies.

Not so.

Smoking is just another popular behavior with some safer satisfying alternatives available. Nicotine is just another drug like caffeine that feels good enough to make a difference but not so good that it disrupts the rest of your life. And tobacco companies are no different from any other large corporations that will do anything to keep customers.

Bad apple studies – pt 2 (and Josey Wales too)

Following from Part 1

There is something else that is special about the Winn and FDA studies.

Typically when one study becomes a standard citation it is an examplar of some sort. It either represents best some aspect of the ideas being expressed or it summarizes much of the knowledge acquired to date in the field. While these need not be perfect studies they should be of a fairly high caliber. They do not need to be universally accepted but disagreements will tend to centre on the interpretation of the results.

Just about anyone looking at the Winn and FDA studies conclude that they are methodologically unsound. And if you don’t trust the method how can you trust the results.

And yet they are presented as pillars of evidence.

Perhaps it is better to think of them as mantras.

They function quite well as articles of faith. Words repeated by believers.

Because these are so central to the ANTZ messages it feels as though we have to critically respond to them time and time again when in fact they are so poor that they should be ignored. Were it not for the timing, or their usefulness to anti-nicotine forces these studies would never have caused the slightest ripple.

And this is where we can easily claim the superior moral ground. We take these bad studies seriously enough to think about them, to accept them as possible evidence.

Both sides are guilty of assembling lists of references to support a particular position but one main difference is that pro-tobacco harm reduction researchers accept that studies not supporting their position exist. You won’t hear a pro-THR researcher denying that any study does not exist. On the other hand rather than doing the work and critically engaging opposing studies ANTZ will simply say they don’t exist.

One lesson we can all learn from this though is that as much as we like a particular conclusion or result we should remain critical.

I like both coffee and alcohol and will have an immediate reaction of “of course” to any popular report of either of them being beneficial and an “as if” to any report of them being harmful to health. I would like to think however that if I was professionally studying either that I would be critical of both pro and con studies.

And this is another reason these studies were taken up so quickly and became so persistent. They supported existing views.

While the health effects of chewing tobacco were not certain, the practice was seen as reprehensible as most people now see smoking. In films the dastardly villain might be a spitter, rarely the hero (though see anti-hero Josey Wales below).

If it is gross it must be bad for you. Winn played to popular sentiment. And the FDA study played to the folks who thought that anything that looked like smoking had to be bad for you (also the reason the exploding battery made such a news splash).

On some level we are all looking for substantial arguments against things we dislike but can’t really make a good case against. Its an understandable impulse but it is a luxury no one with any influence over public health should be allowed.

Bad apple studies – pt 1

I was thinking about the persistence of that FDA assay despite the rounds of criticism from all the right quarters. Just about every article or health web site arguing against vaping will cite this one study and often no others. This became quite evident to me when I was writing about a possible ban on e-cigarettes in the Gulf states (curiously enough two years ago to the day).

Not only did I think it odd that it was that one study that kept getting referenced (as though none other existed) but that an American study would be used half way across the world as authoritative in a culture that not only has its own resources but that often as not decries American influence. And reversing the situation, can you imagine the American Lung Association using an e-cigarette study out of Qatar as the sole citation on a post?

However, as odd as this situation is, it is tobacco harm reduction history repeating itself.

In 1981 the New England Journal of Medicine published Deborah Winn et al’s Snuff dipping and oral cancer among women in the southern United States. I won’t retread old ground about the shortcomings of this article – see Brad Rodu’s excellent summary – however let’s just say that the paper makes better reading as anthropology than health risks. The authors managed to run down a group of white women who had used an antiquated version of powdered dry snuff for most of the hours of the day for over fifty years. In comparison to non-users, this group was determined to have about 50 times the risk of developing oral cancer. The figure mentioned in this deeply flawed study ended up being used to represent the typical risk to the average user using products that had little in common with the product in that study.

It used to be that every site warning off smokers who were thinking of switching to smokeless tobacco would cite this figure. Looking again for the first time in a couple of years I see that little has changed (see Web MD or Illinois Department of Public Health). Their overall message much like the one that attends bad vaping articles is that smokeless tobacco is as or possibly even more harmful than smoking.

Just as with the FDA case, there were plenty of other studies out there. In fact the situation was much more pronounced. As well as other American studies there existed a body of strong research from Sweden where more people were using snus than smoking and where the shift resulted in a decline in smoking related disease rates. You think that would have clinched the deal but rather than this one bizarre outlier being consigned to ignominy there seemed to be no effect at all on the messages that public health resources were giving out.

(In addition to other studies, it is this same Swedish data that allows us to be pretty sure that e-cigarettes are so very much safer than smoking).

Paralleling the situation with e-cigarettes you would typically also read that the authors felt there were no studies demonstrating that these alternatives were any safer than smoking.

So what you have are the bad apples, the early studies that don’t seem to be replicated or supported by any other studies, which go against everything that follows, and yet remain the official sources. Even more upsetting (and detrimental to public health), these official messages ended up becoming common knowledge – basic truths everyone “knows”.

The other thing to note is that both the Winn and FDA reports were obviously flawed in themselves. You did not require other information to know that these lacked credibility. And yet these bad apples stuck.

Part 2 will explore possible reasons why these zombie studies would not die.

More on this tomorrow….

We should really be doing this more often…

Over at ep-ology is a posting of some new research re the candy-tobacco issue. It’s called Demonstrating that children believe that deadly tobacco products are harmless candy, an experimental study.

Excerpt:

There has recently been an explosion of organized concern about the risk of accidental poisoning of children who mistake dissolvable smokeless tobacco products for candy. It is already known that that young children may be at risk of ingesting small objects that come within their grasp. However, since tobacco is completely unlike any other consumer product, previous research on other products cannot be considered informative. The nicotine lozenge variants of dissolvable tobacco products have already been implicated in a significant number of toxicant exposure events, which suggests that there is risk that one of the tobacco company products might someday poison someone also.

Several previous studies demonstrate that there is a view that the public health community should encourage worry about the poisoning risk:

An anti-tobacco QUANGO of the Virginia state government calling itself “Virginia Foundation for Healthy Youth” issued a press release [1] reporting that when teens were presented with dissolvable tobacco products without any context, they often thought they were mints or candies. While it might be considered a minor limitation of the study that the methods and actual results of the study were never reported or that the research was designed and conducted by high school students without any apparent supervision by scientists, the subsequent wide coverage in the popular press confirms that it was credible, important, high-quality research.

We’ve been writing off and on about this for years (see Like candy to children and Iowa more worried about candy than cigarettes but take the time and check this latest one out. At least a couple of laughs guaranteed.

Canada’s health experts don’t mind lying to the public

Two items this week once again make me think twice about self-identifying as Canadian. I suppose I can take solace in the fact that one’s country and one’s identity is something quite different from what occurs in the corridors of power, or whenever prohibitionism rears its mishapen head.

The first item, brought to my attention via Velvet Glove, and reported in the Huffington Post, is about a spate of tainted ecstacy related deaths in Western Canada. What is crucial in the report is that the coroner, Lisa Lapointe, had pinpointed the unique look of the bad batch but did not make this information available to potential victims because “We don’t want to give the impression that these are the tablets that are risky, and other tablets are safe”.

While we might not be certain that the other ones are safe, we do know that the ones she found were poisonous, and in the interests of a political and not a health-related aim, she left the public at the same level of risk as before. Her job, as I understand it, is to find out what is causing harm and then taking the steps to reduce the likelihood of it recurring.

What is also remarkable about this is that the most prominent Canadian reports on this ceased to mention that the unique design had been uncovered and that that information was being deliberately withheld from the public.

How provincial are we getting when we need another country’s news agency to report on the most information in a domestic story, and the locally relevant life and death ramifications.

As far as I know, this dereliction of duty has not imperiled Lapointe’s appointment; how do you suppose we would treat a transport commissioner who did not label dangerous roads because that might give the false impression that all the other roads were safe?

The second story did get good local coverage but reported verbatim misinformation (lies to be perfectly accurate about it) from physicians who claimed to be concerned about public health. The story was a bit of a press release/ activism trying to raise support for the banning of shisha (flavoured tobacco used in hookahs).

The “good” doctors don’t seem to have much of a problem with unflavoured tobaccos but just tart up the product a bit and suddenly it is more dangerous.

They start with the old loophole complaint in that tobacco companies responded to the banning of flavoured small cigars by making them bigger and thus not subject to the regulation. What they seem to ignore is the ban was motivated by the belief that kids liked small cigars (which is why they did not target regular cigars in the first place). So if the company, which is well aware that there were plenty of adults who liked small flavoured cigars, sought to deliver a second-best choice to their stranded adult customers, how is that a loophole?
But I digress.

The passage I found such exception to was

Physicians for a Smoke-Free Canada wants all flavoured tobacco products banned, including shisha, because of their appeal to young people. Shisha, flavoured chewing tobacco and other flavoured products are sold with no warning labels, or with small ones, leading the public to believe they are not as dangerous as cigarettes, the group said.

“If Health Canada required these products to carry large health warnings like those on cigarettes, kids would be more likely to understand how harmful these products are,” Kapur said.

I find it quite strange when most of us regular folks are quite concerned about tossing around anything that could be construed as lies or ignorance, that this Dr. Atul Kapur, the leader of a national organization, has no problem parading, in full view, what is certainly one or the other. Insanity or arrogance, take your pick.

As in the case with the ecstacy, health officials are deliberately withholding information from the public which could affect their future prospects. Here they wish the authoritative line to be that cigarettes are no more dangerous than smokeless tobacco.

Of course what we really should all be clamouring for are large product descriptions saying just how much safer these products are than smoking.

Elementary my dear Watson

Though the show has been on for some time, I just saw this a couple of days ago and it fit neatly in with what had been tumbling about in my head in regards to nicotine and the times we live in.

Nicotine has been seen as a good fit for the industrial age in that it was one of the few drugs that not only provided a respite from stress, but did not interfere with productivity. If anything, it enhanced it.

Though many of our everyday chores have been either eliminated or become much less onerous, life is not experienced as being any less stressful. It could well be that some of these chores, even if not exactly pleasurable, functioned also as islands of calm – stabilizers of everyday existence. With the emphasis on information, speed, and connectivity, it is not surprising to see reports on rising attention deficit disorders, and in general the drop of the average person’s ability to read to the end of a sentence or even complete the simplest

Nicotine focuses attention and relaxes. If ever there was a drug for our age, nicotine is it.

And with the rise of safe enough sources such as smokeless tobacco and electronic cigarettes, for many it might just be the answer to dealing with the modern, fast-paced, and cluttered cognitive environment.

Just to be clear, this is not a nicotine-for-all argument but a recognition that for some it is a pragmatic solution to the fragmentation of modern life. Even though I never get headaches, and thus don’t need aspirin, doesn’t mean that I don’t recognize that it might be essential for others.

There’s more elephants in the room or on contemplating the new user red herring.

Forgive the proliferation of other life forms in this title (and post) but it seems that whenever nicotine or tobacco are discussed, we end up wading knee deep through a bog of misinformation and ANTZ (thank you again Kristin Noll-Marsh for this most appropriate acronym for anti-nicotine and tobacco zealots). So we end up talking of caffeine and automobiles and unlike most other health related topics having to dress the discussion in children’s clothing so as not to enrage or offend.

Some time ago, Elaine Keller wrote in these pages about the nicotine as self medication elephant. But it is just one out of this herd thundering about and for the most part ignored by diligent and blinkered prohibitionists. One of the other pachyderms is that nicotine use is just another human behavior and a particularly popular one if history is a guide (and shouldn’t history constitute better evidence than utopian (or is it dystopian) fantasies?). But the tusker today is one that even many pro-THR activists and vaping communities are not talking about.

This elephant is the likely increase in the numbers of never before nicotine users trying snus or vaping.

From the ANTZ side this seems worse than smoking. After all, the promise of low risk nicotine use can only result in more people trying it and more people staying with it. Once health risks are no longer a sticking point, it won’t matter if the nicotine using proportion of the population goes up or down (as Carl Phillips has pointed out time and again, the economics of the case are that when you lower the cost of something, in this case the health risks, consumption will increase).

From their point of view nicotine use is intrinsically bad and any associated health risks are a side issue. We know this because if they did care about health risks they would be agitating for THR on every street corner.

But to the point at hand.

The central hope of THR is that low risk nicotine use supplants smoking. Currently more smokers than ever are switching and this is good. Every survey of vapers seems to come back with a result that implies that almost every vaper is an ex-smoker or a smoker trying to quit. Snus users (outside of Sweden) seem to be more of a mixed bag but the proportion of switchers seems to be getting larger there as well.

And if there is one thing both camps agree on, nicotine is not for kids.

But here’s the thing. The presaging of victory will be when we see more would be nicotine users starting with these products. ANTZ will be up in arms but if we accept that nicotine use is with us for the foreseeable future then only once initiation is typically with low risk products will that future be a better one.

Right now, vaping is almost considered as a post-smoking activity. While it is great that smokers have switched, isn’t it a little odd that smoking be thought of as a precondition for vaping? Should you be allowed only to vape or snus if you have first exposed yourself to a high risk nicotine delivery system? Should we only let you use seatbelts after driving for a while without?

No.

When you think that very little smoking will expose you to the same total risk as a lifetime of low risk nicotine use, you should be glad to see an uptick in new users. It is the only way that the transition to low risk nicotine use being dominant will occur.

And that is why, and we have already discussed this point often enough, low risk alternatives need to be at least as accessible as cigarettes. If someone (old or young) is about to try nicotine for the first time, that choice should not be weighted, as it now is, toward the one choice that might have serious consequences. As we have already seen in Sweden, once safer alternatives are both accessible and socially acceptable, cigarettes can become the less favoured option. The would be smoker turning instead to snus or e-cigarettes is not only virtually eliminating any health risks but is also making it more likely others will do the same.

We need to reach that tipping point.

(Just a note for the ANTZ: you can only ignore elephants for so long. Once you factor in the size difference, safety in numbers no longer applies.)

It’s Official: No More DuMaurier Snus in Alberta

There have been more than a few moments in the last little while where I’ve been nearly inconsolable in my disappointment in the actions of my Canadian government.  One of those moments was when Health Canada peremptorily banned the e-cigarette.  Another was when my friend told me that he had tried to buy duMaurier snus (the only Canadian brand of pouched moist snuff available in my hometown of Edmonton, Alberta) at a major convenience store and was told they were no longer stocking it (Carl wrote about this here).  And yesterday, I learned from two different major convenience store chains in Alberta that not only were they not stocking it anymore, but duMaurier snus had been discontinued.  I could find no official announcement by the manufacturer, and I frankly found it surprising that they decided to discontinue it altogether; could the product really be losing that much money on an ongoing basis (beyond the initial costs, which I realize were great, but they are sunk now) that it was worth completely abandoning?  Especially in light of how Camel snus is taking off in the States, it was a surprise to me.

But then again, maybe it shouldn’t be that surprising.  As Carl has already written about in the above linked posting, a big part of the reason for why duMaurier snus was doomed inAlbertais because of the local anti-THR forces who ramped up their anti-smokeless campaign (which occurred after Carl set up shop at the University of Alberta where he and Paul started TobaccoHarmReduction.org).  Carl has described how the local government and NGO anti-tobacco people basically redirected all of their efforts from being anti-smoking to being anti-smokeless-tobacco after he started educating people there about THR.  The first of two fatal blows to duMaurier snus was the ban on all point-of-sale information (so smokers had no way of learning there was something else they might buy).  The second was an increase in taxes on smokeless tobacco that made duMaurier snus – formerly a relative bargain that might encourage smokers to switch – basically as unaffordable as cigarettes (at about $11 per pack). Restrictions on marketing (which were essentially anti-free speech laws) came into play, and it became impossible for Imperial TobaccoCanada (who introduced the snus) to communicate with their customers anything about the relative risks of their new tobacco product.

It is worth reiterating here Carl’s point about why the anti-tobacco activists were motivated to do these things: because if people found out about the low-risk THR products, they would quite logically start to use them more, and this would undermine the activists’ goal of universal abstinence from all nicotine (regardless of how low its health costs might be). Low-risk nicotine use would undermine the justification for their enormous salaries. In other words, the existence of duMaurier snus (and our group) in Edmonton threatened the existence of the anti-tobacco activists.

Unfortunately, those activists had about 100 times the resources we did, and with Imperial Tobacco basically muzzled, there was very little we could do to counteract the mass media campaign they waged against our group and duMaurier snus.  So it is not very surprising to find that it has, now, officially been killed in Alberta.  I guess congratulations are in order to the Alberta government and anti-tobacco activists, in their victory over public health, and in protecting the cigarette market from competition.

My disappointment yesterday was pretty great.  I generally buy snus online (since the taxes on the local snus successfully drove me away from that product – again, congratulations Alberta government), but occasionally I do use the local product when I run out of my shipped-in snus.  I have convinced many of my friends and family who smoke to use that snus, and I suddenly felt like because some rich activists in an ivory tower somewhere, with goals of purifying people’s behavior rather than improving their lives or health, decided to thwart our desire for better public health, we now have to accommodate them.  Our real life choices have changed for the worst because of them.

Now, there was briefly an unchecked thought that popped up from my subconscious that considered buying a pack of cigarettes instead, but it was vetoed before it took much form, because – as I’ve previously written – I simply don’t enjoy smoking.  However, the story is quite different for at least one of my friends – a former smoker – who has already switched back to smoking whenever he can’t find snus.  I wonder how many others this will have affected in that way as well.

[A note to readers: There are still many smokeless tobacco products available behind the counter at convenience stores, but these products tend to not have the mass appeal that Swedish-style snus seems to have.  They have not been marketed as THR products in Canada, nor do they seem to have made any inroads in that area.  It is important to note, however, that – being smokeless – it is still almost as good as quitting smoking entirely to switch to these products.]

-Catherine M. Nissen

Its a harm reduction epidemic!! Somebody do something!

Thanks to J Anzalone for twittering re this study that I somehow missed when it came out.

This Norwegian article published in Nicotine and Tobacco Research (Feb 2011) is much more interesting than it sounds (Expectancies and Intentions to Use Snus Among Norwegian First-Year Students). Its not so much the findings, which are as straightforward and undumbfounding as they possibly could be. Its more about the thinking around the findings which in less creative individuals would have manifested themselves simply as misinterpretations but here have emerged as wonderfully rendered examples of oracular thinking. (This is where a story (or tradition) is maintained despite any facts to the contrary; the logic of a predetermined narrative override any logic which would naturally emerge from the data).

In this case the story is that nicotine or tobacco use is bad, period.

The prevalence of use of snus (low-nitrosamine smokeless tobacco, Swedish type) has reached epidemic proportions in parts of Northern Europe, and the trend is escalating.

If this had been a North American paper, that statement would have been followed up by citing old and now discredited sources such as Winn to dwell on the potential harms of using smokeless tobacco. But in the inscrutable ways of Norwegian tobacco control thinking, the case is made that using snus is much less harmful than smoking and respectable sources of evidence are cited.

The study itself was run in order to see what expectancies led to using snus, and lo and behold, one of the main determinants was knowing that its use was low risk and safer than smoking. So, these on average 20 year old Norwegians are using snus because they think it is low risk, and though this particular study did not find using snus to quit smoking to be a significant factor, I suspect that if the group had been a little older, quitting smoking would have been of greater interest to more of the participants. The authors do write that quitting smoking is one of the drivers of increasing snus use in Scandinavia. Or in their words:

It can thus be argued that snus is a better alternative for those who otherwise would have started to smoke cigarettes (a possible immunization effect) and that snus could be a quitting alternative for cigarette users who are not able or willing to quit.

So this epidemic is one of people using a product because it has little risk and/or because it helps them replace a high risk behavior (smoking). Sure sounds like it is time to call in the health police.

But come the discussion and:

Given that health authorities want to encourage adolescents quit using snus, the results suggest that it might be useful to target expectancies related to health risks in persuasive communications.

So what are they exactly saying here? That they wish to misrepresent the risk (because these users are aware that the risk is low)? They have already made the case that using snus is protective for smoking, that it helps people quit and that it is low risk.

Now you would think that if the authors were paying attention to all the parts they had laid before us that the obvious conclusion would be to question the motives of the health authorities rather than actually suggesting lying to the public which could very well help reverse the trend away from smoking in Norway. Or alternatively to rejoice in the fact that people attracted to nicotine know which product is safer, and they are acting on that knowledge.

We should have more epidemics like this!