• Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.
• Smokeless tobacco products as a harm-reduction mechanism: a research agenda.
• A Canadian's perspective: limits of tobacco regulation.
• The basis of a comprehensive regulatory policy for reduced harm tobacco products.
• Should doctors advocate snus and other nicotine replacements? Yes.
• The place for harm reduction and product regulation in UK tobacco control policy.

Rodu B, Phillips C .  Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.  Harm Reduction Journal 5: 18, 2008.

“This study shows that switching to ST resulted in over twice the proportion of former smokers (73%) than the nicotine patch (35%), gum (34%), inhaler (28%) or nasal spray (0%).”

"Regardless of how one interprets the proportions of former and current smokers, it is particularly striking that an estimated 359,000 smokers tried to stop smoking by switching to ST – and over a quarter of a million became former smokers – especially since Americans are largely
misinformed about the health risks of ST use. For example, in 2005 a survey of 2,028 adult U.S. smokers found that only 11% correctly believed that ST products are less hazardous than cigarettes. In another survey, 82% of U.S. smokers incorrectly believed that chewing tobacco is just as likely to cause cancer as smoking cigarettes. These findings are in direct contrast to the general agreement among tobacco research and policy experts that ST use is far less hazardous than smoking. Although estimates are not precise, ST use likely confers only 0.1% to 10% of the risks of smoking."

It is safe to assume that rates of switching would increase substantially if smokers knew that switching to ST achieves almost all of the health benefits as quitting tobacco and nicotine altogether [1]. In 2000 the most
likely beneficiaries of this knowledge would have been the 1.1 million American men who were dual users of both cigarettes and ST products. These men were already comfortable consuming nicotine from both combusted and smoke-free tobacco. With the knowledge that ST products
were 100 times less hazardous than cigarettes, it is conceivable that most would have chosen exclusive use of ST, resulting in a decline of 1.2 percentage points in national adult male smoking prevalence."

"This study documents that switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. As long as American smokers are misinformed about the comparative risks of ST and cigarettes, most will not consider trying to switch, or will do so only reluctantly. A social and public health environment that honestly informs smokers about comparative risks would provide many more smokers
with the opportunity to lead longer and healthier lives."

Taylor CR, Capella ML.  Smokeless tobacco products as a harm-reduction mechanism: a research agenda.   Journal of Public Policy & Marketing, 2008.

“Compelling scientific evidence indicates that smokeless tobacco is considerably less harmful than cigarettes. Therefore, innovative approaches to nicotine replacement, such as smokeless tobacco, may provide an effective means of reducing the overall harm associated with smoking and ultimately may reduce smoking prevalence in the United
States. The underlying principle of harm reduction is that a product that has adverse health consequences is promoted as a substitute for one that has more severe adverse health consequences.”

Sweanor D.  A Canadian's perspective: limits of tobacco regulation.  William Mitchell Law Review 34: 1595-1604, 2008.

“A further limitation on regulatory strategies is that, in some cases, existing regulatory measures, such as blanket advertising bans, graphic package warnings, or industry de-normalization, have come to be seen as an end in themselves rather than as a means of achieving improved public health. As such, efforts to re-think such measures are often rejected out-of-hand by anti-tobacco forces as being “a step backwards.” Yet, this is inconsistent with the pragmatic approaches and recognition of the differences between means and ends advocated by such social reformers as Saul Alinsky, and it can stymie further progress at attaining health goals. For instance, a regulatory strategy could include advertising less toxic tobacco products to current smokers as an alternative to cigarettes, mandating smoker-friendly package messaging aimed directly at facilitating cessation, or differentiating between the culpability of different tobacco companies as a way of changing the behavior of the tobacco companies that are benefiting most from a status quo centered on cigarettes. In the absence of a willingness to re-examine previously passed regulatory strategies, however, progress in such areas is impossible.”

"This self-imposed constraint on acceptable action by some of those promoting a tobacco control agenda is perhaps most notable—and most damagingly counter-productive—when one examines the issue of harm reduction for nicotine users. There is no scientific doubt that there is a vast continuum of risk depending upon how someone obtains nicotine. If all smokers obtained their nicotine from medicinal or low-toxicity non-combustion products, the health concerns about the drug would approach those associated with the contemporary use of caffeine. Yet many tobacco control advocates generally dismiss the idea of harm reduction in favor of an abstinence-only (or “quit-or-die”) orientation. The result is that these tobacco control advocates often sound more like moralists seeking to save souls rather than health campaigners seeking to save lives. This is consistent with what has been experienced in numerous other public health campaigns throughout history and a critical question for future policy directions is just how quickly tobacco control efforts can evolve to become more pragmatic rather than dogmatic."

Sweanor D, Grunberger RC.  The basis of a comprehensive regulatory policy for reduced harm tobacco products.  Journal of Health Law and Policy 11: 83-92, 2008.

“In the case of tobacco and nicotine, there is a strong abstinence-only contingent within the anti-tobacco community that condemns any use of nicotine without apparent concern for issues of relative risk and the potential to move users to far less toxic alternative delivery systems.”

"In recent years there has also been increased interest in dispelling myths about nicotine itself (many smokers believe it to be a huge health risk) and in ending the misleading information that causes smokers to believe that some alternative products (such as medicinal nicotine and various types of smokeless tobacco) are not significantly less toxic than cigarette smoking."

"The answer is a regulated marketplace for nicotine delivering products that is based on a pragmatic risk reduction strategy. It must combine efforts focused on prevention, cessation and protection with serious efforts aimed to reduce risks for continuing nicotine product users. Such an approach has the ability to maximize health gains and minimize the risks of any unintended consequences, like less toxic tobacco products encouraging or prolonging smoking. Applying such a riskminimizing approach to nicotine delivery products also follows the examples set over many years in the regulation of a myriad of other goods and services."

"We are dealing with a category of products that can be set out along a very pronounced continuum of risk. There is a large risk differential between the use of cigarettes and alternative nicotine delivery products.66 Further, this risk differential may even be greater than some well-known reduced-harm mechanisms, like safety features in automobiles, the use of protective sports equipment in contact sports, and airline safety enhancements. The most pronounced difference in nicotine delivery products is whether a product requires lung inhalation of combustion
products to deliver nicotine or if the product is a less toxic non-combustion
product."

Britton J .  Should doctors advocate snus and other nicotine replacements? Yes. BMJ 336: 358, 2008

"Currently, 77% of UK smokers want to give up smoking, and 78% have tried and failed.6 Of the many reasons why they have not succeeded in quitting, the most important is addiction to nicotine...The tragedy is that nicotine addiction itself is not especially hazardous. Nicotine is not harmless,8 but in practice accounts for little if any of the morbidity and mortality caused by smoking. It is the hundreds of other toxins in tobacco smoke, not nicotine, that make smoking so deadly. So if smokers who are unable, unwilling, or simply unlikely to quit were to switch from cigarettes to other, less hazardous sources of nicotine, millions of lives could be saved."

"Recent data from Sweden, where snus has been available for years, indicate that habitual smokers and young people experimenting with tobacco products have substituted snus for cigarettes, resulting in low levels of smoking.13 14 This suggests that smokeless tobacco is an acceptable smoking substitute for some smokers and therefore snus may be effective in this role in other populations."

Gilmore AB, Britton J, Arnott D, Ashcroft R, Jarvis MJ  The place for harm reduction and product regulation in UK tobacco control policy.  Journal of Public Health, 2008.

“By shifting smokers from the most harmful nicotine delivery
device, the cigarette, to a less harmful alternative, the harm
caused by nicotine addiction could be significantly reduced.
In addition, by shifting smokers to smoke-free nicotine products,
involuntary exposure of others to tobacco smoke would be reduced and smoking would be further denormalized by reducing exposure of children and young people to smoking role models."

"Snus has traditionally been widely used by Swedish men and
Sweden has the highest rate of per capita snuff consumption in
the world. The high rates of snus use among Swedish men,
combined with the fact that male smoking and tobacco-related
mortality rates in Sweden are the lowest in the world has led
to a growing interest in the role that it could play in smoking
cessation and harm reduction. This ‘Swedish experience’
provides proof of concept that substitution of ST for smoked
tobacco can be effective as a harm reduction strategy."