• An alternative approach to smoking control.
• Smokeless fire.
• Tobacco-related mortality.
• Assessing the nicotine content of smokeless tobacco products.
• Smoking cessation: Alternative strategies. Session III: Implications of alternative treatment goals.
• For Smokers Only. How Smokeless Tobacco Can Save Your Life.
• Would a switch from cigarettes to smokeless tobacco benefit public health? -Yes.
• Modified tobacco use as a risk-reduction strategy.
• Tobacco use and cancer.
• Pharmacology of nicotine and its therapeutic use in smoking cessation and neurodegenerative disorders.
• Oral tobacco use.
• Smokeless tobacco.
• The rewards of smoking cessation.
• Oral tobacco use.
• Smokeless tobacco.
• Health hazards of moist snuff.
• Smokeless tobacco – a less harmful alternative?
• Minimizing the harm from nicotine addiction.
• Conference on tobacco dependence: innovative regulatory approaches to reduce death and disease: selected excerpts from conference proceedings.
• Can smokeless tobacco rid us of tobacco smoke?
• Nicotine replacement: A new approach to reducing tobacco-related harm.
• Social and economic aspects of reduction of tobacco smoking by use of alternative nicotine delivery systems (ANDS)
• A qualitative and quantitative risk assessment of snuff dipping.
• Social and economic aspects of reduction of tobacco smoking by use of alternative nicotine delivery systems (ANDS)
• A pilot study of smokeless tobacco in smoking cessation.
• Editorial comment: Snuff, nicotine and cardiovascular disease: Implications for tobacco control.
• Opportunities for harm minimization in tobacco control.
• More to it than smokeless.
• Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men.
• Nicotine maintenance for inveterate smokers.

Rodu B. An alternative approach to smoking control. American Journal of the Medical Sciences 1994; 308: 32-34.

“The author . . . proposes that smokeless tobacco be recommended as a cigarette substitute by persons who cannot stop smoking. This proposal is made because smokeless tobacco is associated with far fewer and considerably less serious health consequences than is smoking. . . . A public health policy that recognizes smokeless tobacco as an alternative to smoking would benefit individuals confronted with the unsatisfactory options of abstinence or continuing to smoke.” (p. 32).

“Because smokeless tobacco causes far fewer and considerably less serious health effects than does smoking, it should be promulgated as an alternative to cigarettes for smokers unable or unwilling to overcome their nicotine addiction.” (p. 32).

Whidden P. Smokeless fire. (Letter to the Editor). Nature 1994; 371: 564.

“A massive shift towards the use of oral tobacco by smokers would considerably cut the tens of thousands of deaths caused by tobacco-smoke pollution.”

Rodu B, Cole P. Tobacco-related mortality. Nature 1994; 370: 184.

“We suggest that abstinence is not the only approach to reducing tobacco-related mortality: for smokers addicted to nicotine who would not otherwise stop, a permanent switch to smokeless tobacco could be an acceptable alternative to quitting.”

Tilashalski K, Rodu B, Mayfield C.  Assessing the nicotine content of smokeless tobacco products.  Journal of the American Dental Association 1994; 125: 590-594.

“We analyzed the nicotine content of 11 brands of smokeless tobacco.  These choices represent 95% of the market share in the moist snuff category.” (p. 590)

“By the nature of its use, smokeless tobacco results in similar serum nicotine levels as smoking.” (p 594)

Benowitz NL. Medical implications. In: Davis RM (ed). Smoking cessation: Alternative strategies. Session III: Implications of alternative treatment goals. In: Tobacco Control 1995; 4: (suppl 2): S44-S48.

“A potentially useful analysis is the epidemiology of snuff use in Sweden. Snuff users have plasma or urine nicotine and cotinine levels as high or higher than cigarette smokers. A recent epidemiological study reported that snuff dippers had the same odds ratio for myocardial infarction as those who did not use tobacco. In comparison, the odds ratio for cigarette smokers was substantially higher than that of either snuff users or those who used no tobacco.” (p. S46).

Rodu B. For Smokers Only. How Smokeless Tobacco Can Save Your Life. Sulzburger & Graham Publishing, Ltd., New York; 1995.

“[S]mokeless tobacco products allow you, the hard-core and long-term smoker, to take back a measure of control over your health by indulging in a far safer form of tobacco use.” (p. 8).

“A switch to a safer delivery system, smokeless tobacco, will allow the 46 million smokers in this country (and the people they live with) to live longer, healthier lives.” (p. 18).

“If we look at ‘safe’ to mean relatively safe or ‘safer,’ something the government warnings inanely avoid here, then use of smokeless tobacco products is far safer than cigarette smoking. . . .Statistical dangers of using smokeless tobacco do exist, but they are considerablysmaller than the dangers related to smoking cigarettes.” (p. 29).

“If all smokers were instead addicted to smokeless tobacco, only 12,000 new cases of oral cancer (with a 50 percent survival rate) could be expected each year. This is only one-twentieth of all cancers that now result from smoking, and one-tenth of smoking related lung cancer cases! I haven’t even mentioned the reduction in heart disease and emphysema deaths yet. If all 46 million smokers used smokeless tobacco instead, the United States would see, at worst, 6,000 deaths from oral cancer, versus the current 419,000 deaths from smoking-related cancers, heart problems, and lung disease. Relative to cigarettes, smokeless tobacco products are a godsend.” (p. 131).

“[T]he average remaining life expectancy of a 35-year-old smokeless tobacco user is 45.92 years, which is merely four-hundredths of a year less than the nonuser of tobacco. Statistically speaking, use of full-bodied tobacco products with all the nicotine of cigarettes will cost the smokeless tobacco user only fifteen days of life! That’s about 2,780 more days than the cigarette smoker lives.” (p. 133).

Rodu B, Cole P. Would a switch from cigarettes to smokeless tobacco benefit public health? -Yes. Priorities 1995; 7: 24-30.

“[S]mokeless tobacco use is 98 percent safer than cigarette smoking. Thus, it can save the lives of smokers and of those persons who breathe second-hand smoke.” (p. 24).

“Contrary to a popular misperception, all forms of tobacco are not equally risky. Smokeless tobacco causes neither lung cancer nor other diseases of the lung, and users have no excess risk for heart attacks. In fact, the only consequential—but infrequent— adverse health effect of smokeless tobacco use is oral cancer. In 1981, writing in The New England Journal of Medicine, Dr. Deborah Winn and colleagues established that smokeless tobacco users are four times more likely to develop oral cancer than are nonusers of tobacco. However, this relative risk is only about one half the relative risk of oral cancer from smoking.” (p. 26).

Tilashalski K, Lozano K, Rodu B. Modified tobacco use as a risk-reduction strategy. Journal of Psychoactive Drugs 1995; 27: 173-175.

“A novel approach for smoking cessation has been proposed: that cigarette smokers unable or unwilling to quit change to smokeless tobacco (ST) use. In fact, surveys reveal that as many as 7% of former smokers have already modified their tobacco use to ST, which they perceive as less risky despite repeated warnings by medical authorities. Data indicate that former smokers who now use ST have indeed chosen a safer mode of tobacco use that serves as a positive risk-reduction strategy.” (p. 173).

Vigneswaran N, Tilashalski K, Rodu B, Cole P. Tobacco use and cancer. Oral Surgery 1995; 80: 178-182.

“Previous research has demonstrated that the relative risk of oral cancer with smokeless tobacco use is 4.2, about half of the risk from smoking (relative risk = 10 to 15). Mortality data from populations with sustained high-frequency smokeless tobacco use do not support the mistaken prediction of an epidemic of oral cancer with increasing smokeless tobacco use. In fact, the risks of smokeless tobacco use compare so favorably with those of smoking that smokers who switch to smokeless tobacco reduce their risks for all tobacco-related illnesses including oral cancer. Although some criticize this proposal as less than an ideal solution for the nation’s smokers, full adoption of this strategy would eventually save over 400,000 lives each year.” (p. 178).

Balfour DJK, Fagerström KO. Pharmacology of nicotine and its therapeutic use in smoking cessation and neurodegenerative disorders. Pharmacology and Therapeutics 1996; 72: 51-81.

“If nicotine preparations could be developed that were acceptable to smokers, there is the possibility of eliciting a substantial reduction in tobacco smoking, while not necessarily maintaining complete abstinence. Such use of NRT [nicotine replacement therapy], although controversial for those hoping for a total extinction of nicotine use, without doubt would do more service to mankind and public health than what NRT could contribute in smoking cessation.”

“Sweden, with a long tradition of smokeless tobacco use (16% of adult males use smokeless tobacco daily) and the highest penetration of NRT use, is the only European country that has reached (19%) the World Health Organization’s target of 20% smokers in the adult population by year 2000; about 35% of all nicotine consumed comes from nonsmoked deliver [sic] forms. The tobacco-related mortality in Sweden is by far lower than in any other European or North American country, although nicotine consumption may not be lower than in other countries.” (p. 71).

Barker BF, Barker GJ. Oral tobacco use. (Letter to the Editor). Oral Surgery 1996; 81: 132.

“It cannot be denied that serious diseases and death rates associated with the use of tobacco are far greater for those who smoke cigarettes than for those who use smokeless tobacco.” (p. 132).

Dunlap C. Smokeless tobacco. (Letter to the Editor). Oral Surgery 1996; 81: 376.

“The central theme [of Vigneswaran’s article, Tobacco use and cancer,] was that smokeless tobacco use is far safer than other forms of tobacco use. To me, the theme rings true. I have been in oral pathology for 32 years and have yet to see a single case of oral carcinoma arising precisely at the site where tobacco is held. There has been a hand full, probably fewer than a half-dozen, who used smokeless tobacco and eventually developed carcinoma, but the carcinomas were not at the spot where the tobacco was held. I have seen far more people with oral cancer who had no risk factors. Although I don’t approve of smokeless tobacco use, I think the carcinogenicity of smokeless tobacco has been overstated and the authors are essentially correct in their assessment of this issue.”

Rodu B, Cole P. The rewards of smoking cessation. Epidemiology 1996; 7: 111-112.

“Lifelong smokeless tobacco use has little impact on life expectancy, and this analysis shows that switching to smokeless tobacco has essentially the same effect on life expectancy as does quitting smoking. This finding is important because new options are needed for smoking cessation programs. The National Cancer Institute’s Community Intervention Trial for Smoking Cessation confirms that existing resourceand labor-intensive quit smoking programs are not very successful, largely because conventional approaches offer no alternative to giving up nicotine entirely, an unattainable goal for many smokers. Furthermore, these programs are unnecessarily limited, as they do not accommodate the fact that there are now several ways to satisfy a tobacco user’s desire for nicotine without the health effects of smoking. Smoking cessation programs may become more successful when their providers recognize that the benefits of quitting smoking can be achieved without quitting nicotine altogether.” (p. 112).

Vigneswaran N, Tilashalski K, Rodu B, Cole P. Oral tobacco use. (Letter to the Editor). Oral Surgery 1996; 81: 133.

“[T]he scientific and medical foundation for smokers switching to ST is solid. The average lifelong smoker loses almost 8 years of life compared with the nonuser of tobacco, whereas the ST user’s loss is 15 days.” (p. 133).

Vigneswaran N, Tilashalski K, Rodu B, Cole P. Smokeless tobacco. (Letter to the Editor). Oral Surgery 1996; 81: 377.

“Our proposal [that inveterate cigarette smokers switch to smokeless tobacco], however, has a clear and legitimate scientific basis: 1. The risk of oral cancer from smokeless tobacco use is only half that from smoking. 2. Smokeless tobacco use carries no excess risk for other cancers or for lung and heart diseases that kill over 400,000 smokers every year. 3. Smoking is the most dangerous nicotine delivery system. Lifelong cigarette smokers lose almost 8 years of life on average compared with nonusers of tobacco: in contrast, smokeless tobacco users lose only 15 days. 4. One third of current smokeless tobacco users are former smokers.”

Ahlbom A, Olsson UA, Pershagen G. Health hazards of moist snuff. The Swedish National Board of Health and Welfare-Report 1997; 11: 3-29.

“Taken together, the data suggest that long-term use of snuff does not have any marked effects on the major risk factors for cardiovascular disease.” (p. 17).

“The health hazards of snuff are in all likelihood smaller than those associated with smoking.” (p. 20).

Bolinder G. Smokeless tobacco – a less harmful alternative? In: Bolliger CT, Fagerström KO. (eds.) The Tobacco Epidemic: Progress in Respiratory Research. Volume 28; Karger Publishing, Basel. 1997: 199-212.

“[C]ompared with the extremely high risk of developing cancer due to tobacco smoking (according to the WHO, 33% of all cancers in the industrialized world are caused by smoking), it seems as if the risks associated with the use of smokeless tobacco are obviously of minor importance.” (p. 203).

“The risk of adverse health effects is evidently less serious in smokeless tobacco users than in smokers . . . .” (p. 208).

Borland R. Minimizing the harm from nicotine addiction. Health Promotion Journal of Australia 1997; 7: 138-141.

“Tobacco smoke contains more than 4000 different chemicals, many of which are known poisons, mutagens and carcinogens. It is generally accepted that most of the damage from smoking is due to components in the tar, and to a lesser extent, the carbon monoxide (CO). The contribution of the nicotine is believed to be lower, but still considerable. The strongest evidence for this is that smokeless tobacco, which has little tar, appears to be less harmful than the smoked product.” (p. 138).

Dretchen K, Slade J, Kessler D, et al. Conference on tobacco dependence: innovative regulatory approaches to reduce death and disease: selected excerpts from conference proceedings. In: Warner KE, Peck CC, Woosley RL, Henningfield JE, Slade J, Page J. Tobacco dependence: Innovative regulatory approaches to reduce death and disease. Food and Drug Law J Supplement 1998; 53: 115-137.

“I [Ken Warner] did want to mention just two interesting substances that we ought to be thinking about as we go through this discussion. One is Snus [Swedish snuff], which has been mentioned here previously. This is the smokeless tobacco that is in widespread use, for many decades now, in Sweden that is very low in cancer-causing nitrosamines, and quite high in nicotine. The evidence is that it increases health risks compared to that of nontobacco users very little. There appears to be a slight oral cancer risk. There is no evidence of an elevated cardiovascular risk. So this is a population of long-term heavily dependent nicotine users who are not observing significant health consequences over a period of decades.” (p. 130).

Fagerström KO, Ramström L. Can smokeless tobacco rid us of tobacco smoke? American Journal of Medicine 1998; 104: 501-503.

“In 1996 a commission under the National Board of Health and Welfare in Sweden concluded, with the help of a broad range of scientific evidence including two new well-controlled studies that Swedish snus did not seem to increase the incidence of upper airway cancer. Furthermore, from an international perspective, Swedish males have low rates of oral cancer despite their high level of smokeless tobacco use.”

“The Swedish National Board of Health and Welfare concluded in its report that ‘the health risks related to smokeless tobacco are with great probability lower than those related to smoking.” (p. 502).

“[The authors of this study] would like to encourage further research with smokeless tobacco because Swedish epidemiological data show that it may be used in a risk reduction approach, and United Nations Focal Point on Tobacco or Health has released a report from a meeting of experts who recommended the use of alternative and safer forms of nicotine to reduce smoking. Such studies should recognize that smokeless tobacco may work well and better than current nicotine replacement medications for highly dependent smokers who are at greatest risk for developing tobacco related diseases and that, by working with relatively minimal intervention, it may be cost effective.” (p. 503).

Jimenez-Ruiz C, Kunze M, Fagerström KO. Nicotine replacement: A new approach to reducing tobacco-related harm. European Respiratory Journal 1998; 11: 473-479.

“The most effective forms of modification are those products that do not heat or burn tobacco, i.e. smokeless tobacco. Some such preparations, e.g. moist snuff (‘snus’) used in Sweden, do not appear to cause oral or other cancers. In addition, snuff appears much less likely to cause cardiovascular disease than cigarette smoking.” (p. 473).

“[I]t appears that Swedish users of smokeless tobacco (snuff), who ingest similar amounts of nicotine to smokers, do not have a higher incidence of coronary disease than nontobacco users.” (p. 476).

“It is interesting to note that Sweden, which has the lowest incidence of tobacco-related harm among developed countries, has unintentionally been used as a reduced smoking paradigm. Sweden has relatively few smokers. . . . However, approximately 28% of adult Swedes use nicotine daily, the explanation being that approximately one third of all nicotine consumed is in the form of moist snuff . . . . The practice of using snuff has not been found to significantly increase mortality. Thus, reduced smoking and/or abstinence combined with alternative nicotine delivery devices appears to be an untapped resource in the quest to reduce tobacco-related harm.” (p. 477).

Lewin F. Smokeless tobacco. In: Ramström L, Uranga R, Hendrie A (eds.). Social and economic aspects of reduction of tobacco smoking by use of alternative nicotine delivery systems (ANDS), Adis International Limited, United Nations. 1998: 10.

“Two recent case-referent studies in Sweden that analysed overall snuff use, years since stopping, age at initiation, duration of use and total consumption showed no evidence for any increased risk of cancer of the upper aero-digestive tract. In comparison, the overall risks were 5.0 for ever-smokers and 8.0 for current smokers. In summary, the lack of health risks observed with Swedish snuff suggest that it could offer an alternative to cigarette smoking.”

Nilsson R. A qualitative and quantitative risk assessment of snuff dipping. Regulatory Toxicology and Pharmacology 1998; 28: 1-16.

“While certain physicians are engaged in a crusade to stop all uses of tobacco in a way that is reminiscent of the moods prevailing during the era of alcohol prohibition in the United States, some experts have compared the relative risks involved for active smoking with that of snuff dipping and arrived at the conclusion that turning active smokers to snuff users will drastically reduce the risk of cancer and cardiovascular disease.” (Citations omitted, p. 2).

Ramström L, Uranga R, Hendrie A (eds.). Social and economic aspects of reduction of tobacco smoking by use of alternative nicotine delivery systems (ANDS), Adis International Limited, United Nations. 1998: 1-25.

“[I]t is now evident that the risk of death and disease is related to not only the amount but also the nature of tobacco exposure; for example, daily cigarette smoking is far more dangerous than occasional use of Swedish snuff.” (p. 17).

Tilashalski K, Rodu B, Cole P. A pilot study of smokeless tobacco in smoking cessation. American Journal of Medicine 1998; 104: 456-458.

“Traditional smoking cessation programs have had limited success and only among smokers who can achieve nicotine abstinence. Inveterate smokers may benefit from strategies that focus instead on providing nicotine by a means other than cigarette smoking. Smokeless tobacco is a potential alternative for inveterate smokers because we have estimated its adverse health effects may be as low as 2% of those of smoking.” (p. 456).

Benowitz NL. Editorial comment: Snuff, nicotine and cardiovascular disease: Implications for tobacco control. Journal of the American College of Cardiology 1999; 34: 1791-1793.

“Overall, the epidemiologic and experimental data suggest that nicotine absorbed from smokeless tobacco, nicotine gum or transdermal nicotine is not a significant risk factor for accelerating coronary artery disease or causing acute cardiovascular events.” (p. 1792).

Borland R, Scollo M. Opportunities for harm minimization in tobacco control. Drug and Alcohol Review 1999; 18: 345-353.

“An alternative approach is to accept the addiction and alter the product to make it less harmful, an approach first suggested by Russell in 1974. Harm minimization at the level of delivery system could encompass: 1, modifications that would make cigarettes less harmful; 2, nicotine replacement therapies . . . that could be used not simply to assist people to quit, but also to help them reduce tobacco consumption, or even temporarily abstain from smoking; and 3, tobacco replacement products that might act as replacements for cigarettes; that is, products that would deliver nicotine in a manner that was similarly satisfying (to the user), but with less of the dangerous by-products (this could be done by chewing, or inhaling vapour rather than smoke).” (p. 348).

“It is known that long-term use of oral snuff, a form of tobacco used widely in Sweden and the United States, is less harmful than tobacco smoking.” (p. 350).

Ephros H, Blitz M. More to it than smokeless. (Letter to the Editor) Journal of the American Dental Association 1999; 130: 1558.

“ Most oral cancer in the United States is related to the use of alcohol and/or smoked tobacco products. There is anecdotal evidence to connect ST use with oral and oropharyngeal cancer, but epidemiologic data from this and other countries are not conclusive.”

Huhtasaari F, Lundberg V, Eliasson M, Janlert U, Asplund K. Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men.  Journal of the American College of Cardiology 1999; 34: 1784-1790.

“The present observations would show that, from a cardiovascular perspective, the deleterious effects of snuff dipping are much less than those of cigarette smoking. This is a complicated message. Faced with anti-smoking campaigns and restrictions on sales of cigarettes, it is tempting for the tobacco industry to turn to less controversial alternatives, i.e. various forms of smokeless tobacco.” (p. 1789).

Rodu B, Cole P. Nicotine maintenance for inveterate smokers. Technology 1999; 6: 17-21.

“[M]odern smokeless tobacco products have three major benefits to offer the inveterate smoker. First, although smokeless tobacco is perceived as hazardous, it poses only about two percent of the mortality risk of smoking. Even the risk of oral cancer—the one consequential health effect of smokeless tobacco—is only one-half that of continued smoking. Smokeless tobacco causes none of the other health effects of smoking, including lung cancer, emphysema, and cardiovascular diseases. Second, nicotine is absorbed from smokeless tobacco in a manner very similar to that from smoking, therefore the craving of inveterate smokers usually is eliminated. In fact, serum nicotine levels from smokeless tobacco use remain elevated longer than they do from smoking, and tobacco consumption is reduced. In part for this reason, the third benefit of smokeless tobacco is that it is less expensive than cigarettes. . . . A major consideration regarding smokeless tobacco relates to its image as socially unacceptable. However, newer products are packaged in small, single-dose paper pouches that are imperceptible during use. In a recent pilot study, 16 of 63 inveterate smokers used smokeless tobacco to quit, and the product was accepted by both men and women.” (p. 19).