• Clearing the smoke or muddying the water?
• Tobacco use and oral cancer: A global perspective.
• Clearing the smoke. Assessing the science base for tobacco harm reduction.
• Reducing harm to smokers: methods, their effectiveness, and the role of policy.
• The fifty-year decline of cancer in America.

Bates C. Clearing the smoke or muddying the water? (Editorial). Tobacco Control 2001; 10: 87-88.

“While I do not wish to see a rush of novel tobacco products making health claims, there are immediate real problems arising from the ‘self serving caution’ of regulators. For example, this applies to the refusal of some regulators to approve harm reduction indications for pharmaceutical NRT [nicotine replacement therapy], the regulatory barriers facing a nicotine gum manufacturer that wants to compete directly with cigarettes as a supplier of lifestyle branded nicotine, and the clumsy regulation of certain oral tobaccos that have substantially lower health risks than cigarettes.” (p. 88).

Galanti MR, Wickholm S, Gilljam H. Between harm and dangers. Oral snuff use, cigarette smoking and problem behaviours in a survey of Swedish male adolescents. European Journal of Public Health 2001; 11: 340-345.

“The prevalence of smokeless tobacco use (moist snuff) in Sweden is among the highest world-wide and snuff is gaining popularity as a less harmful alternative to cigarettes.” (p. 340).

“The use of Swedish oral tobacco (moist snuff) has not been consistently associated with relevant health hazards, and is therefore regarded as relatively safe compared to cigarette smoking.” (p. 342).

Johnson N. Tobacco use and oral cancer: A global perspective. Journal of Dental Education 2001; 65: 328–339.

“All forms of tobacco represent risk factors for oral cancer, but on present evidence, snuff habits as they exist in Scandinavia and probably in the United States carry lower risks of serious health hazards, including oral cancer.” (p. 328).

“In Scandinavia it is clear that local snuff is not a major risk factor: two recent casecontrol studies of oral cancer cases in Sweden have failed to show an association. This is because Swedish snus is not fermented and contains much lower nitrosamine levels than fermented tobaccos.  The view that smokeless tobacco use may be associated with a lower risk of oral cancer in the United States has led to a movement to advocate the practice as a less dangerous alternative to smoking and an aid to nicotine withdrawal in those addicted to smoking.”

“Nevertheless, on present evidence, snuff habits as they exist in Scandinavia and, probably in the United States, carry low risks of serious health hazards, including oral cancer.” (pp. 332-333).

Stratton K, Shetty P, Wallace R, Bondurant S (eds.). Clearing the smoke. Assessing the science base for tobacco harm reduction. Institute of Medicine. National Academy Press, Washington, D.C., 2001

“Smokeless tobacco products are associated with oral cavity cancers, and a doseresponse relationship exists. However, the overall risk is lower than for cigarette smoking, and some products such as Swedish snus may have no increased risk.” (p. 434).

Warner KE. Reducing harm to smokers: methods, their effectiveness, and the role of policy. In: Rabin RL, Sugarman SD (eds.). Regulating tobacco. Oxford University Press 2001: 111-142.

“Until recently the entire effort to help addicted smokers has rested on encouraging them to quit, to sever their ties to nicotine completely. Sweanor (1997) argues that this approach condemns millions of them to an early and avoidable grave. Among the alternatives to quitting smoking for those who cannot quit, as well as for those who do not want to quit but do wish to reduce risk, are reductions in the daily consumption of cigarettes and substitution of less harmful nicotine-delivery systems for cigarettes. Additional, more controversial possibilities include substitution of less dangerous tobacco products for cigarette smoking (e.g., smokeless tobacco or cigarettes modified to be less toxic) and the use of novel cigarette-like products developed by the cigarette manufacturers that are marketed as reducing risk. In each case, compared to the dangers posed by the unaltered smoking pattern, the alternative holds the potential of reducing the smoker’s risk.” (p. 114).

“Substitution of Less Dangerous Tobacco Products: For the nicotine addict who cannot find satisfaction in NRT products, switching from smoking cigarettes to less hazardous forms of tobacco consumption could conceivably reduce risk considerably. In recent years, Rodu (1995), an oral pathologist at the University of Alabama, and his colleagues (Tilashalski, Rodu, and Cole 1998; Rodu and Cole 1999) have argued in favor of converting ‘inveterate smokers’ to smokeless tobacco use. His argument is straightforward, though not without its detractors (Tomar 1996): many confirmed smokers, he believes, can find smokeless tobacco an acceptable substitute for cigarettes, recognizing the risk-reduction benefits it confers in contrast to continued smoking. And smokeless tobacco use, although definitely not without disease risks of its own, is unarguably less risky than smoking.” (pp. 118 – 19).

  Rodu B, Cole P.  The fifty-year decline of cancer in America.  Journal of Clinical Oncology 2001; 19: 239-241.

“When lung cancer is excluded, mortality from all other forms of cancer combined declined continuously from 1950 to 1998, dropping 25% during this period.” (p. 239)

“The focus on all-cancer mortality also led to the widespread perception of a cancer epidemic caused by environmental pollution.  A typical commentary blamed ‘increasing cancer rates’ on ‘exposure to industrial chemicals and run-away modern technologies…’  In reality, the cancer ‘epidemic’ consisted of one disease, cancer of the lung, and was due to one lifestyle factor, cigarette smoking.” (p. 241)