Tuesday, November 24, 2009

the 411 on Smokeless Tobacco

Okay I have my notes in my lap and thoughts in my head, so let me share a couple (okay some) things about smokeless tobacco, or ST. The majority of the information that I am sharing today was learned from both a National Smokeless Tobacco Conference and an accredited Smokeless Tobacco training produced by the Mayo Clinic. I am however, explaining this in my own words and based on my comprehension of the material. I believe the following six things are the most important.

1) There are different types of Smokeless Tobacco (ST). Depending not only on where you are in a country, but which country you are in, there are differences. The following types may be the most common.
a. Chew Tobacco: This is cut leaf tobacco that comes loose, in a twist or a plug. This is usually chewed briefly and then placed between the cheek and gums. This type is used more in the USA than other countries but is not the most common ST in the USA. The most common brand is Redman. This is considered a spit tobacco. Some hard core addicts will swallow some or all of the juice. Many people who use this will say they are going to have a chew or a chaw.

b. Snuff: This is ground tobacco and it is the most common type used in the USA. The most popular brands are Copenhagen and Skoal. Snuff can come dry but most often it is moist and is either loose or in a pouch, like a tea bag, but a small rectangle. It also produces spit. It too is placed between cheek and gum, but more often towards the front of the jaw then the side of mouth. Many people refer to this as a dip. It does produce juice that is not intended to be swallowed.

c. Snus: this tobacco is even more finely ground than snuff, but it is more common in Sweden. Snus is often placed between the upper lip and gum. It produces less saliva and is not considered a spit tobacco. It is now being manufactured by Philip Morris and Reynolds American or companies that they recently purchased. Traditional Swedish snus is produced quite differently than American snuff.

d. Betel Quid: This is a tobacco blend and it is common in India. I do not know a great deal about it and do not think many people in the USA use it.

2) The health effects of ST use are not as uniform as those from cigarette smoking. For instance, the betel quid is linked to several more diseases and adverse outcomes, including cancers, than the other three products. All ST has intra oral effects and extra oral effects. There is a causal relationship between chew tobacco and snuff and oral cancer as well as gum recession, gum disease, pre cancerous lesions called leukoplakia and tooth loss. Snus is also associated with the oral diseases, but not cancer (in Sweden). The extra oral effects of chew and snuff include pancreatic cancer, an association to reproductive problems and an association of increased risk of death from existing heart disease than found in non users with heart disease. Nicotine in all the products increases heart rate, blood pressure and pulse. It is important to note that the reason scientists think that snus from Sweden is less harmful than American snuff is because of how it is made. Snuff is fire cured, fermented, packaged and shelved for sale. Snus is air cured, steamed (sterilized), packaged and refrigerated.

3) There is a variation in the nicotine content of ST and the manufacturers are responsible for some of that difference. There is some evidence to support that tobacco companies aim to have people start with lower nicotine products and gradually move up to higher ones as they build up tolerance. Using higher nicotine products can lead to addiction and addiction leads to difficulty quitting, which means the tobacco companies can continue to make money. There is generally more nicotine in the finer cuts. There are also additives. Ammonium Bicarbonate increases the amount that the user absorbs from the chew or dip and acetic acid increases salivation which also increases the amount of nicotine absorbed.

4) Quitting ST is somewhat different from quitting smoking and these methods may be helpful to current users.

a. Blending involves the use of an herbal ST substitute. You begin by taking the pouch or can and making it half and half (tobacco and herbal product), after two weeks you make it two thirds substitute and one third tobacco and use for three weeks and then you go to all substitute and quit.

b. Brand Switching refers to changing to a brand with less nicotine than you currently use, so going from Copenhagen to Skoal.

c. Fading involves the number of dips or chews that a person normally takes and fading them out. You reduce the amount by one or two per day until you get to the half way point. For example, if you do ten dip/chews a day, when you are down to five, you quit.

5) The quit smoking medications that are FDA approved for use and recommended by the PHS Clinical Practice Guidelines are not also recommended for ST cessation, but let me tell you more about that. At this time they are not recommended because they did not meet the criteria of adequately increasing quit rates. In the tobacco field this is often referred to as cessation. So ST users did not have better cessation rates on the Nicotine Replacement Therapy (NRT) than the placebo group did. However, the medications DO reduce withdrawal complications and cravings. One theory is that the ST users need much higher doses of NRT than smokers do. In research and at the Mayo Clinic they do use the non NRT medication Zyban and the also use the patch and the lozenge. They base the patch dose on cans or pouches per week. Remember, it is almost 75% or more likely to be cans or snuff than chew tobacco. Less than two cans per week users get a 14 mg patch to start, 2-3 cans per week users get a 21mg patch and greater than three cans per week users gets a 21mg patch. This is all off label use so talk to a physician or tobacco treatment specialist before dosing yourself.

6) The motivators for quitting ST often include health consequences, social pressures, rebuking the addiction and the cost. Here is some math on the cost of using and the amount that could be saved in quitting. In my area of the country, South East USA, a can or pouch of tobacco costs between 5 and 7 dollars per. The user first needs to know how many they use a week. For example 3 cans per week: 3 (cans) x 4 (weeks) x 12 (months) = 144 (cans per year) 144 x 6 (dollars) = 864 dollars spent per year. Now if that person quit tobacco for five years, they could save over 4000 dollars!

And that my friends is the end of my smokeless tobacco blog post............. whew


PBergen said...

You missed what I believe is the single most important piece of information about smokeless tobacco and that is its role in harm reduction. There is some disagreement in exactly how low the levels of risk are in the use of this product but there is little doubt that in almost every respect, the use of smokeless tobacco is much less risky than smoking (switching will reduce a smoker's risk of oral cancer as well as every other cancer dramatically).

Though domestic agencies like to downplay international results, the fact is that there are more than a few good studies showing that smokeless tobacco can be quite effective in replacing smoking.

This is all rather important since current policies are fairly ineffective at reducing the numbers of smokers (and therefore the associated effects) and the very low success rate of pharmaceutical replacements.

Thank you,

Paul Bergen
Research Associate
Public Health Sciences
University of Alberta

Deirdre Dingman, MPH, CTTS, CHES, PAPHS said...

I do believe and the research supports, that smokeless tobacco is less harmful than smoking. I will never deny that - even when my agency wishes I would. You are correct that there is controversy around "harm reduction products" and I do not necessarily believe that smokeless tobacco should be used for that, especially considersing that they too contain TSNAs. What I am interested in and have said at public forums(not well received I might add!) is that it might behoove us to regulate and sell nicotine in a nontobacco delivery system. I know that food, alcohol and caffeine can be misused, but each also has a health promoting side, and I wonder if the same could be said of nicotine, minus the tobacco.

PBergen said...


It seems as though your desire is currently being met through electronic cigarettes. Only time will tell if the powers that be allow that option to continue to be available. In my own country, the government has decided that it is preferable that people stick to using the most obviously dangerous method of obtaining nicotine.

Part of the reason for the poor success rates of pharmaceuticals can be traced to subsistence rather than pleasurable levels of nicotine, and the practice of short periods of administration. If they were approached more as a substitute and not only as a route to quitting altogether then they would no doubt end up being more effective.

Until that time, and you are probably aware, that tobacco is the only field in which safer options are being withheld on the basis of them either not being perfect or there being other options already available. Kind of like if we would have discarded airbags because we already have seatbelts, or both altogether because the only really safe option in not driving at all.

That being said, I believe that all the energy being spent trying to avoid tobacco is more political than health related. As long as it is not lit, it is fairly safe (the toxicology does show the TSNAs but the epidemiology shows that that does not exactly translate into disease...you might have seen that recent studies have found that many of the same toxins are now being found in pharmaceutical nicotine products, so it is not entirely straightforward).

As to your last comment, it is quite likely that many people do find respite through nicotine (I am not one of those but I do know people who seem to find it helpful). And if they use it in a fairly safe form....who could argue with that?

Anyway, nice to have a civil conversation on this topic...people tend to go crazy when they hear the word tobacco or nicotine..

All the best,