• The nonsmoking uses of tobacco.
• Nicotine intake by snuff users.
• Less-hazardous tobacco use as a treatment for the “smoking and health” problem.
• Pharmacological approaches to smoking modification.
• Control of tobacco-related disease.
• Buccal absorption of nicotine from smokeless tobacco sachets.
• Reduction of tobacco health hazards in continuing users: individual behavioral and public health approaches.

Kirkland LR. The nonsmoking uses of tobacco. (Letter to the Editor). New England Journal of Medicine 1980; 303: 165.

“The English authors propose snuff as a healthier substitute for cigarettes; the American author unrealistically eschews all forms of tobacco. Rather than oppose the advertising of ‘smokeless tobacco,’ I urge physicians to encourage snuff and chewing tobacco as alternatives to cigarettes. No one disputes the role of snuff and similar products as the cause of oral leukoplakia, but there is a vast difference in the frequencies of oropharyngeal carcinoma and cigarette-induced lung cancer. If five new ’dippers’ are created to avert creation of one new cigarette smoker, then progress has been made.”

Russell MAH, Jarvis MJ, Devitt G, Feyerabend C. Nicotine intake by snuff users. British Medical Journal 1981; 283: 814-817.

“From our results snuff use may clearly be an efficient method of nicotine intake. This suggests that it might prove sufficiently acceptable to smokers, not only as a temporary substitute to help those who are trying to give up smoking but as a long-term alternative to continued cigarette smoking. . . .”

“Unlike tobacco smoke, snuff is free of tar and harmful gases such as carbon monoxide and nitrogen oxides. Since it cannot be inhaled into the lungs, there is no risk of lung cancer, bronchitis, and emphysema.”

“[T]he rapid absorption of nicotine from snuff confirms its potential as an acceptable substitute for smoking. Switching from cigarettes to snuff would substantially reduce the risk of lung cancer, bronchitis, emphysema, and possibly coronary heart disease as well, at the cost of a slight increase in the risk of cancer of the nasopharynx (or oral cavity in the case of wet snuff). Another advantage of snuff is that it does not contaminate the atmosphere for non-users.” (p. 816)

Kozlowski LT. Less-hazardous tobacco use as a treatment for the “smoking and health” problem. In: Smart RG, Cappell HD, Glaser FB, et al (eds.) Research Advances in Alcohol and Drug Problems. Volume 8. Plenum Press, New York; 1984: Chapter 11, pp. 309-329.

“This chapter will argue that the use of less-hazardous tobacco, if prohibitionistic impulses can be put aside, may have an important role in the treatment of the smoking and health problem. . . . The phrase ‘less-hazardous tobacco use’ is meant to be inclusive. Cigarettes, for example, are the most hazardous tobacco products overall. . . . On the other hand, some less-hazardous tobacco products are less-hazardous in certain respects no matter how they are used: chewing tobacco, for example, carries no risks of fire and essentially no risk of lung disease.” (p. 310).

“There is really no dispute about whether smokeless tobaccos present fewer hazards to the user than do smoking tobaccos. Smokeless tobaccos expose the lungs to essentially no tobacco toxins. No carbon monoxide and no tar is produced. The oral cancers associated with oral smokeless tobaccos are substantially less lethal and are more easily diagnosed than lung cancers. In addition, smokeless tobaccos pose no problems of second-hand smoke and no risks of fire.” (p. 319).

Kozlowski LT. Pharmacological approaches to smoking modification. In: Matarazzo JD, Weiss SM, Herd JA, et al (eds.) Behavioral Health. A handbook of health enhancement and disease prevention. John Wiley & Sons, New York; 1984: Chapter 45, pp. 713-728.

“Some less hazardous forms of tobacco use (smokeless tobaccos, pipes, cigars) are pharmacotherapies that can be self-applied easily by those who are poorly motivated to modify their smoking.” (p. 714).

“The use of smokeless tobaccos is not associated with lung cancer, chronic obstructive lung disease, or bronchitis. Oral smokeless tobaccos are associated with oral cancers, however, and manufactured nasal snuff may cause nasopharyngeal cancer, although direct evidence is lacking for such an effect. Smokeless tobaccos not only act to eliminate the possible problems of passive smoking, they also eliminate the definite problems of passive fire-starting.” (p. 724).

Peto R. Control of tobacco-related disease. In: The Value of Preventive Medicine. The Ciba Foundation Symposium 110. Pitman, London. 1985; pp. 126-142.

“If this [snuff dipping] or some other such habit were to become widespread and did to any substantial extent replace smoking (particularly of cigarettes), then the net effect would be likely to be a reduction in tobacco-induced mortality. For, although snuff dipping causes a vast increase in the relative risk of cancer of the gum and cheek (together with the same sort of risks of cancers of other parts of the mouth that smoking produces), the absolute excess risks of death from oral cancer associated with the habit in the South-Eastern United States appear to be at most a few per cent of the total risk of death produced by cigarette smoking. Although the absolute risks in other populations might, of course, be considerably different (especially if some diseases other than oral cancer are found to be increased by tobacco ‘dipping’) the use of smokeless tobacco is still likely to be much less hazardous than is tobacco smoking, especially of cigarettes.” (p. 128).

Russell MAH, Jarvis MJ, West RJ, Feyerabend C. Buccal absorption of nicotine from smokeless tobacco sachets. The Lancet 1985; 1: 1370.

“Unlike tobacco smoking, use of wet snuff carries no risk of lung cancer, bronchitis, or emphysema, and no risk of cardiovascular disease has been demonstrated.”

“If all smokers in Britain switched to [smokeless tobacco] sachets about 50 000 premature deaths per year might eventually be saved at an annual cost of less than 1000 deaths from mouth cancer.”

Kozlowski LT. Reduction of tobacco health hazards in continuing users: individual behavioral and public health approaches. Journal of Substance Abuse 1989; 1: 345-357.

“There is no doubt that smokeless tobacco products are gram for gram less hazardous than smoked tobacco products. Smokeless tobacco products present no fire risks. . . . No added doses of smoke toxins (e.g. carbon monoxide, tar) get into the lungs of the user of oral or nasal snuff. There are no apparent lung cancer risks of using smokeless tobacco. It may be appropriate here to emphasize again that I do not suggest that smokeless tobacco products are safe. Nonetheless, these products are unquestionably less risky than smoked tobacco products.”

“One advantage of smokeless products is that it is easier to ration the dose. . . . In other words, when one limits smokeless tobacco to a certain amount per day, one does not have the same compensatory dosing problems found with smoked tobacco products.” (pp. 352-53).