Category Archives: tobacco marketing

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.

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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

When quitting is an option and not a necessity

Though it seems to be so much more common and easier to divide behaviors into good and bad, the problem with drug use is that it is so much more complicated than that. Drug users are as varied as anyone, and since almost everyone is a drug user of some kind, its pretty specious to draw such presumptuous demarcations. Once you replace morality with health (health, in my opinion, actually being the more “moral” approach) more natural and pragmatically useful categories come into play.

Rather opposing abstention and use, why not envision an opposition of bad enough to worry about and not bad enough to worry about. Forgive the vernacular but to me it seems to make more sense than terms like safe or dangerous.

With the dominant mindset we have all nicotine users (whether snus-ers, smokers or vapers) lumped together and on the other side the abstainers. The inappropriateness of this grouping (in the context of public health) is also evident when nicotine users are contrasted with prescription drug users, alcohol consumers or any other drug users. Its just not helpful when someone on anti-depressants or beta blockers criticizes someone for boosting their neural process or relaxing via a dose of nicotine.

But the main point is that the practical division is along the lines of how risky a behavior is. Once health is the measure then we will find that the constructive nicotine use breakdown is smokers on one side and everyone else on the other. (This is not meant in any way as castigating individuals who choose to smoke but is simply a breakdown of what health risks the behaviors are associated with. Its no different that separating high from low risk sports activities. Higher risk activities are not morally suspect; they are just higher risk.)

Once the powers that be stop blocking basic information about the comparative risks of various nicotine deliveries and once people understand that in the long run switching to snus or e-cigarettes is roughly equivalent to quitting then we should see a dramatic increase in switching and we might also see attitudes toward quitting change.

As mentioned in the last post, even if the health risks of using nicotine are perceived as negligible some people will still want to quit -and all the power to them. The point is that people should have the information and they should have the right to do what they will with that information.

What intrigues me is what might happen to the multi-billion dollar cessation industry should the THR message be widely acknowledged. Obviously some of the current cessation products will be reconfigured or remarketed as “dual use”, that is, as either cessation or switching products. (I’m pretty sure this is already taking place to a degree.) This industry, which maintains such mutually beneficial bonds with tobacco control, just might need to disengage in the interest of developing and then promoting products for tobacco harm reduction.

If Big Pharma holds its present course, and tobacco/nicotine use policy moves to being health-based, then the whole cessation industry will become even more like the diet or exercise fad industries – useful for a very small part of the population but a waste of time, money and effort for most. Those industries serve to delay too many people from pursuing the real solutions to their problems.

Most smokers have been browbeaten into believing that they have to try and quit on a regular basis, and many do the quit and relapse dance to exhaustion. (I wonder how much smoking takes place to take the edge of having to contain that identity clash of simultaneously being a smoker and being a quitter.) They have also been misled to believe that pharmaceutical aids to quitting are pretty well mandatory. (See here for Chapman’s critique of the lack of official support for cold turkey; if you are in the market for quitting nicotine, it seems to be the way that has worked for most).

The “official” explanation of the failure rate is that it takes many attempts to successfully quit. I can just imagine the meeting on that one.

“Bob here says the figures show that almost all our customers are failing up to ten times. They do eventually quit but hey, there must be something wrong with our product. And thanks for that Bob but you are looking at it the wrong way. Its not a product problem; its a user profile. The product is perfect. Smokers are just so addicted that it takes that many time to break through their addiction.”

“Maybe they’re just quitting after trying that long and it has nothing to do with our product?”

“Don’t be an idiot.”

Regardless of the THR message being widely accepted or not, these companies will still push their products as being healthier and safer than e-cigarettes and smokeless tobacco. In the meanwhile, most everyone will come to understand that there are few real differences among all these low risk nicotine delivery methods (especially once the smoke clears on the crucial combustion/noncombustion divide). People will also realize they have the power to choose between continued use or quitting with negligible differences in health consequences.

When we reach that point, those who have been actively opposing and obscuring the truth about these products will be revealed for what they really are: not public health advocates, not beneficient guardians of the public trust, but as sadly impoverished abstinence-only advocates. And not only just abstinence-only advocates, but abstinence-only advocates of a relatively benign (and in fact very useful) drug. Here’s hoping that day comes soon.

-Paul L. Bergen

Harm reduction needs to be easy: the case of RJR’s new switching campaign

As previously mentioned, we, like many others were quite pleased to see the R.J.Reynolds Tobacco Company Christmas season campaign suggesting that smokers switch to smokeless tobacco (report here). Since many people still think the turn of the year is a time for a turn of the leaf, the time is most appropriate to put forth a suggestion that just might make more of an impact than at other times of the year.

The ads make no health claims. The idea is simply to try the switch and see if you like it. The actual text for one of the ads reads:

If you’ve decided to quit tobacco use, we support you. But if you’re looking for smoke-free, spit-free, drama-free tobacco pleasure, Camel Snus is your answer. Logon to the Pleasure Switch Challenge and see how simple switching can be. Camel Snus _ it might just change the way you enjoy tobacco.

And despite this innocuous text, an FDA spokesman is reported to have said that they were “reviewing the claims”. Nice work if you can get it is all I can say. I just reviewed the claims (none) and it took about as long as it took to read the passage. I suspect the FDA charge will require a few professionals and a board meeting and a subsequent request for recompense from RJR.

Readers of this blog know that we wholeheartedly promote switching from smoking to smokeless forms of nicotine use and thus we experience a certain degree of frustration seeing that a company trying to do the right thing, that is the thing that advances public health, has to avoid mentioning any hint of this product being 99% safer than smoking. (Because even though it is true, it could run them afoul of some fairly strong regulations).

And not to mention (and what an odd phrase that is since it signals its exact opposite) that the only health references on these ads are huge banners implying severe danger. The ads mention a website where you can learn more (https://snus.tobaccopleasure.com/modules/security/Login.aspx) and there following content devoid of any positive health claims runs a huge banner saying Warning : This product can cause mouth cancer.

If I didn’t know any better, and time was I didn’t, that would have stopped me dead in my tracks. And if that is not enough there is a rather extensive sign in system (to make sure I am not a child I suppose), the which are known to severely reduce consumer participation. (A few of us have tried to get through this hurdle with little luck so we have not been able to evaluate what lies on the other side, whether truth does survive in the Matrix or not.)

This is a pretty important point. Though we do not know what lies in the promised land, there is some implication of valuable information (and information that is qualitatively different from what we already have been given). But getting there is not unlike the security requirements to board a plane (papers and pat down) except that when you are flying you know your destination and already have decided that the difficulties of negotiating security are worth the annoyance.

Given these requirements and the uncertainty of a payoff we would bet that almost no one has crossed over.

Several of us (and we are almost certainly more motivated than the average consumer or would be switcher) answered personal information questions for minutes, including asking for U.S. social security numbers (i.e., something Americans are constantly told not to share with anyone other than employers and banks for fear of identity theft; in Canada the government actually forbids the use of our version of that number for any non-tax purposes). But after going through all of that, it asked us to make a phone call and/or fax our identity papers to them. Riiiight. It is not like they are promising a coupon for anyone who gets in, or even a transaction — this is just to be able to read information. Those phone lines must be flooded with the, let’s guess, 1/1000th of interested consumers who are actually willing to go to all that trouble.

(Carl plans to post more on these ad later, so we will let you know what excitement lies beyond the barrier if one of us ever gets through.)

It would be easy to blame RJR for being too soft when they should be actively pushing the safer alternative but the fact is they have little choice. For simply revealing the same benefits known to anyone doing the research, they could be subject to substantial fines.

Kind of like trying to sell driving with seat belts not because it is safer but because it looks cooler or feels nice to have something around you while you drive.

The usual suspects have been quite vocal in criticizing the campaign, painting it as a competition for would be quitters. While it is true that some quitters might appreciate learning about this alternative, the tone of the ad clearly emphasizes those who have considered quitting but are not doing so. Moreover, since the health benefits of switching are effectively the same as those from quitting, the would-be-quitters lose little (and more than make up for it by getting to continue using a product they like) and their health costs (if there are any) are overwhelmed by the benefits seen by switchers who would not have quit.

That “more than make up for it” reflects the fact that if they freely chose switching when quitting was still an option, it must be because it makes their lives better, a point that Carl has analyzed at length. It brings to mind the sportsman’s assertion that “winners never quit”. I guess the paraphrase would be that those who choose not to quit must be winners. In any case, like winners, most smokers who want to quit do not do so either, at least not for a long while, though perhaps they would switch with these alternatives available.

– Paul L. Bergen

Signs should really be telling you something you don’t already know

Imagine this.

There is a place I like to drive to. The road leads to a spot where the view is so beautiful and so calming that just to sit there for a while makes everything right. I don’t have to go there but I like to. The road itself is not that safe but I think the risk is worth it. After years of driving to my spot, a warning sign goes up.

Do I stop going to my spot? I don’t think so.

I already know the road is bad and this does not make it worse. Maybe the sign is good for people who don’t know the area but for me it doesn’t change much.

There is a sign that might cause me to change my ways and that is a detour sign. Offer me a safer way to get to my spot and I will probably take it.

Currently comments are being taken at the FDA regarding the new proposed warning labels for cigarettes and in Canada there is an uproar in certain circles that the existing warnings are not being traded in for stronger ones. (I’m sad to say that my country seems less concerned about health than about losing their place as a leader in this area. It seems only in tobacco control do people openly brag about these sorts of things; even repressive Singapore realizes that it is rather Neanderthal to brag about being a leader in curbing behaviors).

The thing is that everyone knows smoking is bad for you and even those people who think it will not personally hurt them still think that in general it is dangerous. The fact that it is a cigarette pack broadcasts the message of harm. You don’t need any more signs.

(Around 1915, some of my ancestors in Russia were well aware that smoking was bad for your health. That was before television and the net, and before warning labels. They were not health professionals; they were educated but not much more than most. Of course, the science had not yet been done on smoking so this was anecdotal. But it is hard to think of anything which is not harmful that will after some time cause your breath to falter, your heart to skip, your voice to thicken, and your throat to hurt and hack. As they say, you didn’t have to be a rocket scientist to have figured this one out.)

What you need is the tobacco version of the detour sign. Get the message out that many people still are not aware of -that there are safer ways of using nicotine.

-Paul L. Bergen

Single cigarette sales; harm reduction or not?

I have always found the bans against selling loose cigarettes or cigarettes in packs of less than 20 counter to my sense of harm reduction.

Though restricting cigarette purchases to pack only might set a bar too high for some curious not-yet smoker or for a kid with only two dollars in his or her pocket (less common these days) I suspect that on average it does not stop too many from ponying up the larger outlay.

However, among the ever smokers I know, almost every one of them smokes less than they used to (even if they are daily smokers), many have quit but still have the occasional cigarette and many others have gone to social or weekend smoking. For the last two categories, those who still sometimes smoke but generally don’t, being able to buy a few cigarettes would be perfect.

Since they are grown up and have enough money to pay rent or mortgages, cigarettes are not that expensive even if it is a whole pack and especially if it is an entertainment expense. So they are going to buy the cigarettes for the weekend.

If cigarettes were purchasable in quantities of 2 or 5 (or even 1), they would be pleased and perfectly satisfied. However they end up buying a pack, and though some might save the pack for the next weekend, I think it is just as likely that they will over the next while smoke them all (after all, they will go stale might be the excuse). And now you have a seldom smoker moving into constant smoking. This is not good. And those 20 cigarettes were smoked by someone who might have stopped at 2.

This points out one of the constant problems with tobacco regulations in that you have at least two very distinct groups being served with actions that may help one group but to the detriment of the other.

-Paul L. Bergen

Thinking about the tobacco black market

The Canadian Convenience Stores Association have asked “the Federal and Provincial governments to adopt a freeze on new regulation or taxation of legal tobacco products until the authorities have significantly reduced the contraband tobacco rate to under 10 per cent for a sustained period”. (Story here.)

Reports of increased black market activity in tobacco have become quite regular and not surprisingly most often from those countries that regularly increase the price of cigarettes (see here for a good five part series in the illegal trade in Canada, or in Ireland ).

Though people will remain loyal to the usual outlets with reasonable price increases, there is a point at which going elsewhere becomes a better choice, and if the market is as tightly controlled as with tobacco, the only real reduction in spending can be got by going to black market sources.

The odd thing about tobacco is that though the original rationale behind the added tax was to address the increased health costs to society though still a popular discussion point, the argument loses strength when you realize that society as a whole pays somewhat for almost all forms of consumption or activities. However, as common a justification these days is that higher cigarette prices will stop some from starting to smoke and give those already smoking a greater motivation to stop.

That probably works on some people but not quite as well as the sin taxers would like. The problem is that this supply side policy does nothing to change the demand. The person still wants to smoke just as much but now the only difference between before and after is that to satisfy their desire they have to pay more. With every other good, they can sacrifice some quality, they can shop around, find a cheaper brand but with a controlled market they have to leave the market itself, step outside of the norm, to restore their previous quality of life.

Among other factors that could drive one to the market is the increased stigmatization of tobacco use (wouldn’t it be less stressful to purchase from someone who appreciates the business?). But buying contraband instead of licit cigarettes could also function as a political act.

First and foremost, everything should have the same sales tax. Picking and choosing who gets taxed more is simple discrimination and that’s wrong. However, if you are going to discriminate, you must allow another source, so that a product can be bought there as a protest. That’s why the native cigarettes, or “reserve rockets”, are so important. Buying them for a lot of people isn’t simply a matter of saving money, it’s a protest against a government that taxes the product 500% (compared, of course, to the 13% most things are taxed). (posted on LiveJournal)

People have been known to withhold taxes because they do not approve of it supporting a war effort. I can think of quite a few reasons why a smoker would not want to pay the tax that have nothing to do with the amount of money involved.

Some of the money collected on cigarettes goes toward social budgets but only some. That money supports organizations that stigmatize smokers, that actively campaign against safer alternative products for smokers, that on one hand work hard for ever more graphic warning labels and on the other for plain packaging, that campaign for ever more encompassing non smoking regulations, and ultimately use these funds to promote efforts to raise the taxes even higher.

Ultimately the most bizarre thing about tobacco taxes is that the user is giving money to the very people who are doing everything they can to remove any pleasure from their consumption. Instead of a sin tax it should perhaps be called a misery tax because that its purpose, to fund the people who make the lives of smokers ever more miserable.

There is much more to be said on this topic and though it might not appear to relate strongly to harm reduction it actually does.

Harm reduction works best as freely chosen within an atmosphere of acceptance and trust and good information. Any stigma works against effective harm reduction and certainly any actions that drive consumers to black markets do the same. Harm reduction also encompasses the concept of someone not participating. Its all about having all the information, having a range of options (some safer than others) and then having the power to choose.

-Paul L. Bergen

FCTC: Constructing a new assault on smokeless tobacco and electronic cigarettes: Part 2: more misinformation

This the second of a series on this latest development at the FCTC. See Part1: Background.

In a thoughtful overview of smokeless tobacco and its application to harm reduction, Snus Use in the U.S.: Reducing Harm or Creating It? (from the most recent edition of the Journal of the National Cancer Institute) Renee Twombly writes:

“But a 2008 literature review commissioned by the European Union study found that use of smokeless tobacco almost eliminated respiratory disease and substantially cuts the hazard of other health effects, such as cardiovascular disease and oral and gastrointestinal cancers. The exception, they and other experts say, is highly carcinogenic smokeless tobacco produced and consumed in India, Southeast Asia, and northern Africa, which increases oral cancer risk.”

This passage from this relatively modest though learned journal manages to convey that smokeless tobacco is a category shared by products that have very different health risks. However, for some reason, the Convention Secretariat report, supposedly representing an analysis of the most current and in depth information on the subject, (as we would hope since it is intended to influence global policy and millions of lives) is a grade school level essay in comparison in which all manifestations of smokeless tobacco around the world are characterized as one basic undifferentiated product. The different ones are listed off but there is no attempt to distinguish among the wildly varying risk levels of these very different substances. Its as if, and I suppose we may one day have that unhappy day as well, alcohol was the target and all beer (including light beer), wine, spirits, moonshine and every exotic unusual liquor, were treated as one substance.

Another inappropriate generalization is made in the following on page 1:

“Until recently it was erroneously believed that smokeless tobacco was a less harmful alternative to smoking tobacco as it did not contain PAH. This assumption was proved to be wrong by recent research that has established that moist snuff becomes contaminated with PAH during the curing of tobacco leaves required for its preparation.”

Though PAH levels are worth studying, they are not the reason smokeless tobacco is a less harmful alternative; it is less harmful because, when compared with smokers, people who use it live longer and have lower levels of disease. (And while there are many stated disease associations and other health statements in this report that are quibble-worthy, this ground has been covered enough times already that these insufficiencies will be ignored in the interests of a not too long post).

But now that it has been established that all smokeless tobacco is pernicious, it needs to be emphasized that there is no possibility of a rational increase in demand for smokeless tobacco (whether motivated by health concerns or simply by preferring it to smoking) but only an increase in response to untoward machinations on the part of Big Tobacco. On page 3:

“The tobacco industry, however, is expanding its operations in developing countries and increasingly places an emphasis on smokeless tobacco products. The tobacco industry regards smokeless tobacco as a low-cost and highly profitable vehicle for creating dual users (those who use smokeless products along with cigarettes), whose addiction to more than one product makes cessation very difficult. The tobacco industry is also promoting the use of smokeless tobacco as an alternative in countries that have made good progress in ensuring smokefree environments.”

It turns out that smokeless tobacco and its marketing is actually evil in intent. Persistently nudged by tobacco companies, users will add this to their current smoking, and thus make cessation even less likely (see this previous post for a discussion of this nonsense or Brad Rodu’s take on it) . Not only that, and that last sentence has a wondrous lack of any logic, this will also happen in countries with good smoke-free environments. If one were to attempt any logical construction with the elements of that sentence it would be something along the lines of smokeless tobacco helping to maintain smoke-free environments.

And because electronic cigarettes are the great new epidemic (how they love that word) they have to act before even more people use them to quit smoking (at least stop them before too many people use them to quit smoking before they are proven in randomized controlled trials that they can help people quit smoking). On page 5:

“[Electronic cigarettes] should be regulated as nicotine delivery devices, and where this regulation is not possible under tobacco control laws, should be subject to regulation of contents and labelling, prohibitions against use in public places, and restrictions on advertising, promotion, and sponsorship.”

If I read this correctly, they are suggesting that if local tobacco laws do not cover these new devices, go ahead and prohibit them anyway like any tobacco product. Oddly enough, and though there are reasonable arguments to treat them as tobacco products, they do not produce tobacco smoke which is the basis for many of those existing regulations. But of course, as they love to repeat, and I will repeat it here as well: “Nicotine is a highly toxic and addictive substance that poses a serious risk to health. Nicotine and nicotine products for human use should be regulated.” (Page 6). This leads off the arguments against electronic cigarettes and given the prominence you wonder how they could ever use this demon substance in Nicorette or other pharmaceutical cessation aids.

In regards to smokeless tobacco, the Secretariat writes of control and prevention but there is no hesitation in considering banning when discussing e-cigarettes –banning and the protection of public health (on page 5). And this relates to what we’ve written about before here and there about anti-tobacco activism in general in that one of the key problems is that this product is not being placed in the context of a population that for better or worse likes to and continues to smoke but rather in some fantasy of a nicotine free world. Protecting public health is as much about providing safer alternatives for desired yet risky practices as it is about making sure products are safe. It is all about that balance, and the FCTC is sitting firmly and heavily on one end of the nicotine teeter totter watching as users are flying into the air and risking possible injury.

The next and perhaps last post in this series will discuss the confusing arguments around the pricing of smokeless tobacco products (for instance why they should never be cheap but why it is criminal that they strain subsistence household budgets, and more).

-Paul L. Bergen

GlaxoSmithKline and the FDA entreaty

GlaxosmithKline, the maker of Nicorette and Nicoderm, have petitioned the FDA to remove dissolvable tobacco products on the grounds that a better action would be to enhance their own product and make it more widely accessible. They argue as well that there is a lack of efficacy of smokeless products in regards to smoking cessation and that they are marketed in such a way as to initiate and perpetuate smoking. (Article link here.)

(Let’s just remove that last phrase first since it has been discussed here before: tobacco companies are not allowed to market these products as cessation aids or to accurately describe them as safer; such claims might encourage switching. They are restricted to marketing their much safer than smoking products only as “for when you cannot smoke”. So it is disingenuous to criticize a company for using the only marketing hook left if they are not allowed to promote the rational use of these products.)

This message from this successful company (45 billion in revenue in 2009) has been widely criticized as trying to obtain competitive advantage at a time when smokeless products are at their most vulnerable. Not only is the FDA focusing on these products but the advisory panel is stacked with members who have financial interests in pharmaceutical products. As a business strategy, this makes sense.

What is less obvious is how amoral and possibly evil this action is. Though I hesitate to apply “evil” to these machinations, what else can you call an action that could result in many dying as a result not of their principles but of your own, and principles solely in the interest of profit?

We know that people smoke or do not smoke for many reasons. We know that they vary quite a bit in how difficult it is for those who wish to quit to do so, and that for different people, different methods are successful. It is all about individual differences. This means that some people will not be able to quit using pharmaceutical products which in itself means that if those are the only option, the people that could have succeeded by other means are needlessly doomed by removing those alternatives.

I understand the concerns of makers of these pharmaceutical nicotine products. With the new smokeless tobacco products, the distinctions between the two categories are becoming quite subtle. And if anybody has long term evidence of relative safety on their side, it is the tobacco products. We have decades of good data on populations using these products day in and day out for years and we do not have that for pharmaceutical products. They are likely to be as safe as smokeless tobacco if so used but we don’t have the proof of that because people have not been using them that way.

What we do have is evidence in support of is that smokeless tobacco products outperform pharmaceutical nicotine in helping people quit smoking (see Rodu and Phillips).

And this same press release has the temerity to use the old “Tobacco use, including smokeless tobacco, is the largest cause of preventable death and disease in the world. More than 400,000 Americans die every year from tobacco-related disease.” For one thing, the stale move of collapsing “including smokeless tobacco” into this figure is misleading (one could have included “eating apples and oranges” and the statement does not become false). But the key word as always is preventable. Is not this impeding one of the more successful means of avoiding disease while using nicotine not preventable?

Finally, our modern anti-tobacco culture has allowed this story to be construed only as a slightly sleazy business move but imagine if RJ Reynolds or some tobacco company had issued the same release regarding pharmaceutical products. They would actually have had the stronger case (not that any alternative should be removed) but imagine the op eds on that, the outcry from the American Heart Association and so many others.

-Paul L. Bergen

Dual use is not an obstacle to tobacco harm reduction

In a recent article in Nicotine and Tobacco Research, Does Dual Use Jeopardize the Potential Role of Smokeless Tobacco in Harm Reduction?
Kimberly Frost-Pineda et al investigate and discuss the ramifications of dual use (link to abstract).

(First of all to get the terminology clear, dual use refers to the same individual sometimes smoking and sometimes using smokeless tobacco. At exactly the same time is quite unusual unless you are Babe Ruth who was reputed to not only chew tobacco and smoke at the same time but to do so while eating and downing liquor.)

Though dual use itself has never been a great concern to THR advocates, it has been seen as a strong argument by opposing factions for a number of reasons. They have argued that promoting smokeless tobacco as means to quit smoking would not only make quitting less likely but would increase the risk by increasing the overall exposure to tobacco.

(I will not discuss the first in any detail except to say that this particular point hinges partly on the idea that smoking restriction regulations lead to quitting because smokers have few places and times in which to comfortably smoke. At some point, the annoyance outweighs the pleasure and the person quits. Of course, the original impetus for non smoking spaces was to reduce the health risk to non smokers but now using bystander-friendly e-cigarettes or smokeless tobacco in these spaces is considered a “loophole”. In other words, people can and will use these products to get nicotine even when they cannot smoke which lessens the impact (or annoyance) of no smoking spaces. Oddly enough, in the case of smokeless tobacco, companies cannot actually encourage switching by saying it is a safer product but are restricted to promoting it as a temporary substitution, so smokers are actually getting the message that the most proper use of these products is to maintain the original more harmful habit.)

But to the meat of the matter.

Does dual use which might be more tobacco use overall result in greater risk? Frost-Pineda et al looked at many studies which calculated and reported on the disease risks associated with types of tobacco use (current and former smoking only, smokeless only, dual and no use) and compared the risk estimates associated with current dual use with current smoking only. To make a long story short, dual use was found to result in lower disease risk than smoking only.

There are good basic reasons for why this is the case. Smokeless tobacco use is very low risk and smoking is very high risk and whenever you use smokeless instead of smoking, overall risk decreases. If the user is aware of the risk differences and they are somewhat risk averse, they may start using smokeless even at times when smoking was possible. In some cases that will result in switching over entirely.

The point here is that even if total switching does not occur, dual use is a step in the right direction. As well, the data appear to indicate that a dual user is more likely to quit smoking than a cigarettes only user. It is not as harm reducing as supplanting smoking entirely but it reduces harm in the short and long term and therefore should not form the basis of any argument against promoting smokeless tobacco as part of harm reduction policy.

-Paul L. Bergen