Smokeless Tobacco Products as a Harm-Reduction ... - AMA Journals

Smokeless Tobacco Products as a HarmReduction Mechanism: A Research Agenda Charles R. Taylor and Michael L. Capella Increased awareness of the dangers of cigarettes has failed to prevent millions of Americans from continuing to smoke. Thus, policy makers should consider viable options to reduce the harmful effects of smoking. Among the proposed options is increasing public awareness of the relative health risk of smokeless tobacco in comparison with cigarettes. 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. As a result, the authors review the relevant literature and put forth a research agenda to advance this notion of tobacco harm reduction. The policy debate would be enhanced by evidence of the constructs and relationships outlined in the proposed model. Specifically, the authors discuss five particular areas of needed research. Keywords: smokeless tobacco, harm reduction, cigarettes, tobacco

s a result of the well-documented harmful effects of cigarette smoking, a coalition of public and private agencies in the United States has been working for decades to raise awareness of the dangers of smoking and to encourage a reduction in the prevalence of cigarette smoking. These efforts appear to be having an impact because consumption of cigarettes has declined, as evidenced recently by the 19% decline in per capita adult cigarette consumption from 2001 to 2006 (Capehart 2006). However, these efforts, combined with higher taxes and other measures, including indoor (and outdoor) smoking bans in some locales, advertising restrictions, and higher prices, have failed to eliminate smoking, and 45 million Americans continue to smoke, many of whom die prematurely from smoking-related diseases (Centers for Disease Control and Prevention 2005). Consequently, it has been proposed that policy makers should consider viable options to reduce the harmful effects of smoking. Among the options that have been put forward is increasing public awareness of the relative health risk of smokeless tobacco in comparison with cigarettes (e.g., Ault and Ekelund 2002; Kozlowski 2002, 2007). Although “safer” cigarettes may be one possible mechanism for reducing the harmful effects of smoking, to date no such product has been successfully marketed; therefore, we focus on a product that already has substantial sales—

namely, smokeless tobacco. Scientific evidence indicates that smokeless tobacco is considerably less harmful than cigarettes (e.g., Britton and Edwards 2008), and therefore this information should be disseminated to the public. However, this may prove to be difficult because the information regarding the effects of smokeless tobacco available through online and printed material from public and private health groups often directly conflicts with scientific research (Waterbor et al. 2004). For example, researchers have cited many examples of erroneous information suggesting that smokeless tobacco is just as dangerous as or even more dangerous than cigarettes (e.g., Kozlowski 2007; Ramstrom and Foulds 2006). One change currently under review by Congress that could have a positive impact on the communication of information about the risks of smokeless tobacco is the proposed regulation of tobacco by the Food and Drug Administration (FDA). Specifically, congressional bills backed by the longtime tobacco industry critics Rep. Henry Waxman of California and Sen. Edward Kennedy of Massachusetts cleared a key Senate committee in August 2007, and companion legislation passed a key House committee in April 2008. Both bills would give the FDA broad control over tobacco products, including the power to set product standards. Furthermore, the bills offer the possibility for tobacco companies to promote products that can be scientifically proved to “significantly reduce harm” to smokers if their availability would also benefit the health of “the population as a whole.” Although the pending legislation has garnered wide support from public health advocates, many remain skeptical about the FDA allowing any health-related marketing claims. Concerns have also been raised that the bar for reduced-risk products as set forth in the pending leg-

A

Charles R. Taylor is John A. Murphy Professor of Marketing (e-mail: [email protected]), and Michael L. Capella is Assistant Professor of Marketing (e-mail: [email protected]), Department of Marketing, Villanova School of Business, Villanova University.

© 2008, American Marketing Association ISSN: 0743-9156 (print), 1547-7207 (electronic)

187

Vol. 27 (2)

Fall 2008, 187–196

188 Smokeless Tobacco Products as a Harm-Reduction Mechanism

islation is set so high that it would be difficult for the industry to introduce and market a reduced-risk product to the U.S. public (Royal College of Physicians 2007). It is believed that addictive features of nicotine contribute to the continuing use of cigarettes among many smokers; fewer than 5% of smokers successfully quit each year, according to the National Institutes of Health (2006). Thus, innovative approaches to nicotine replacement, such as smokeless tobacco, may provide an effective means of reducing the overall harm associated with smoking and ultimately 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 (Hatsukami, Lemmonds, and Tomar 2004). In 2001, a study sponsored by the National Academy of Science and the Institute of Medicine (see Institute of Medicine 2001) laid the foundation for tobacco-related harmreduction research. The report defined a product as “harm reducing if it lowers total tobacco-related mortality and morbidity even though use of that product may involve continued exposure to tobacco-related toxicants” (p. 1). The report goes on to conclude that smokeless tobacco “may be a viable substitute for cigarette smoking” because among all the alternatives to cigarette smoking, smokeless tobacco is not only the most cost effective but also the fastest-acting and longest-lasting vehicle in the delivery of nicotine—far more effective than the use of nicotine gum, inhaler, patch, or spray (pp. 4–16).

Prior Literature on Harm Reduction Smokeless tobacco products offer a potential harmreduction strategy for which the magnitude of health risk to an individual user would be expected to fall somewhere between pharmaceutical-grade nicotine and smoking, which includes any of the toxic constituents of smokeless tobacco as well as many others resulting from incineration (Savitz et al. 2006). In recent years, many studies have examined the risk level of smokeless tobacco in comparison with cigarettes. A review of the literature proposes that the vast majority of scientific evidence suggests that smokeless tobacco is substantially safer than smoking (e.g., Accortt et al. 2005; Critchley and Unal 2004; Foulds et al. 2003; Furberg et al. 2005; Gartner et al. 2007; Lee 2007; Lewin 1998). For example, after comprehensively reviewing the literature, the U.K. researchers Critchley and Unal (2004) state that most smokeless tobacco products are considerably lower risk than cigarette smoking (taking all the potential health effects, particularly cancers, into account). In studying cancer rates among U.S. smokeless tobacco users, Accortt and colleagues (2005) find that in contrast to the well-known harmful effects of cigarette smoking, smokeless tobacco use did not substantially increase the risk for cancer incidence beyond that of tobacco abstainers, particularly among males. More recently, in an Australian research context, Gartner and colleagues (2007) conclude that the impact of substituting smokeless tobacco products for cigarettes will be long-term health benefits for the overall population. A list of key studies, their characteristics, and their

conclusions regarding smokeless tobacco use as consumed in Western societies appears in the Appendix. The rationale for this focus is that smokeless tobacco products differ substantially in their risk profile. For example, in some parts of the world, particularly South Asia, smokeless tobacco is commonly mixed with other harmful products (Royal College of Physicians 2007). Because the list of included studies is not meant to be comprehensive, the goal is to highlight quantitative research and reviews that pertain specifically to smokeless tobacco as a harm-reduction mechanism and the resultant population effects. Research has indicated that a substantial portion of the risk associated with smoking might be eliminated with the smokeless tobacco products (including spit-free options) currently available on the market. Research conducted in Sweden, where smokeless tobacco prevalence is the highest in the world, is particularly encouraging. For example, Rodu and Cole (2004) indicate that smokeless tobacco products are primarily responsible for a decline in smoking rates among males from 19% in 1986 to 11% in 1999, which coincided with a significant decrease in cancers typically associated with smoking. They conclude that the low smoking-related mortality among Swedish men is probably due to their use of snus (Swedish smokeless tobacco), which produces a low risk for cardiovascular diseases and no risk for pulmonary diseases; furthermore, for oral or other cancers, there is no demonstrable incremental burden of mortality among Swedish men who use snus. The available epidemiologic research also indicates a minimal risk for oral cancers, far lower than that found with cigarette consumption (e.g., Rodu and Cole 2002; Rodu and Jansson 2004). Indeed, Sweden has one of the lowest incidences of cancers of the lip and oral cavity among developed countries (Nilsson 2006) and is significantly lower than countries in which oral tobacco use is prevalent, such as the United States and India (Chapman 2007). This could be due in part to the content of the smokeless tobacco in Sweden compared with that of other countries. For example, research has suggested that certain countries exhibit higher incidences of cancer risk as a result of higher levels of toxic ingredients in smokeless tobacco products (Lee 2007; Weitkunat, Sanders, and Lee 2007). Other recent Swedish research has shown that the use of snus reduces the likelihood of smoking initiation and enhances the odds of quitting (Foulds and Ramstrom 2006). Furthermore, longitudinal data from Sweden confirm no increased risk for oral or lung cancer with snus; however, the data suggest that snus could be a tentative risk factor for pancreatic cancer (Luo et al. 2007). Another longitudinal study conducted in Norway and the United States supports this possibility, concluding that smokeless tobacco may be responsible for an increase in the risk for pancreatic cancer in long-term smokeless tobacco users (Boffetta et al. 2005). Although the exact magnitude of reduction in risk gained from substituting the use of smokeless tobacco (particularly one low in nitrosamine, the primary carcinogen in smokeless tobacco) for cigarette smoking is not easily quantified and can lead to disagreement, there appears to be a consensus among experts that smokeless tobacco is considerably safer than cigarettes. In support of this view, a statement issued by Britain’s Royal College of Physicians in 2002

Journal of Public Policy & Marketing

described smokeless tobacco as between 10 and 1000 times less hazardous than smoking, depending on the product. Convincing support for this assertion is provided by Levy and colleagues’ (2004) study, in which a panel of experts estimated reductions in total mortality in the range between 90% and 95%. For total mortality, the estimated median relative risks for individual users of low-nitrosamine smokeless tobacco were 9% and 5% of the risk associated with smoking for those ages 35 to 49 and greater than 50 years, respectively. Therefore, Levy and colleagues conclude that these results clearly indicate that experts perceive these products as far less dangerous than conventional cigarettes. As a result, they also conclude that the risks associated with smokeless tobacco should not be characterized as comparable to those of cigarettes, as has been the practice of some public and private health agencies. Conversely, Americans are not well informed about the differential risks of smokeless tobacco use, especially compared with smoking. For example, a 2001 survey found that 82% of U.S. smokers incorrectly believed that smokeless tobacco is just as likely to cause cancer as smoking cigarettes (Cummings 2001). Another survey of 36,012 young adults in 1999–2000 found that more than 75% incorrectly believed that switching from cigarettes to smokeless tobacco would not result in any risk reduction. Fewer than 2% correctly understood that a large risk reduction would occur by switching from cigarettes to smokeless tobacco (Haddock et al. 2004). Finally, a survey of 2028 adult U.S. smokers found that only 10.7% correctly believed that smokeless tobacco products are less hazardous than cigarettes (O’Connor et al. 2005). Although the reasons for this lack of differential risk information are not well known, some critics have suggested that government agencies and tobacco control advocates are partially to blame. For example, Phillips, Guenzel, and Bergen (2006, p. 4) have made some of the most pointed comments about this occurrence: Certain health advocates believe it is acceptable to mislead people into making choices they would not otherwise make…. Through the use of various tactics, advocates who oppose the use of smokeless tobacco as a harm reduction tool have managed to convince most people that the health risk from smokeless tobacco is several orders of magnitude greater than it really is. The primary tactic they use is making false or misleading scientific claims that suggest that all tobacco use is the same.… Apparently motivated by their hatred of all things tobacco, they are trying to convince people to not switch from an extremely unhealthy behavior to an alternative behavior that eliminates almost all of their risk.

Thus, the debate is no longer about whether the scientific community considers smokeless tobacco a significantly reduced-risk alternative compared with cigarette smoking. The question now is whether that information should be communicated to the public and what the potential ramifications are for doing so. As we discuss subsequently, research from marketing academicians can provide needed insight into this question. Many public health and tobacco policy experts have argued that smokers have a fundamental right to accurate information about less hazardous tobacco products (see, e.g., Kozlowski 2002) and that smokeless tobacco should

189

be encouraged as an option for adult smoking cessation (Kozlowski 2007). As these researchers point out, only then can smokers make informed choices if they are unable or unwilling to quit tobacco altogether. Therefore, tobacco policy experts suggest that an emphasis should be placed on informing the public about the facts regarding the risks involved with smokeless tobacco and that this information should not be suppressed from consumers. A growing number of experts have weighed in on the case for providing smokers with relevant risk information and safer tobacco options. For example, Cummings (2002, p. 957) argues for a market approach involving risk information, stating “until smokers are given enough information to allow them to choose products because of lower health risks, then the status quo will remain. Capitalism, and not government regulation, has the greatest potential to alter the world-wide epidemic of tobacco-related disease.” In addition, Kozlowski and Edwards (2005, p. ii5) suggest that smokers deserve more information: The “not safe” or “not harmless” messages don’t address the reality that some tobacco products are substantially safer than others…. Saying tobacco “isn’t safe” isn’t incorrect, but it isn’t saying enough. Going beyond the no safe tobacco message to provide better information on the nature of risks from tobacco products and nicotine delivery systems is necessary to respect individual rights to health relevant information.

On the contrary, some researchers have questioned the validity of smokers actually switching to smokeless tobacco, suggesting that “few young smokers in the United States switch completely to smokeless,… whereas a substantial portion of smokeless tobacco users switched to cigarettes” (Tomar 2003, p. 567). The most effective way to reduce the harm associated with cigarette smoking would be to quit altogether. However, many current cigarette smokers who have been unsuccessful using nicotine replacement therapy (i.e., gum, inhaler, patch, or spray) may require assistance to reach goals, which can range from reducing the number of cigarettes smoked daily to quitting cigarette smoking. In the only clinical trial of its kind, Tilashalski, Rodu, and Cole (1998) determined that smokeless tobacco was an effective and more healthful alternative to smoking after discovering that many participants significantly reduced, if not ceased, cigarette smoking altogether one year after the trial. Another U.S. study indicated that the use of smokeless tobacco decreased the probability of smoking cigarettes (Ault et al. 2004). Although some dissenting viewpoints exist (e.g., Gilljam and Galanti 2003; Haddock et al. 2001; Henley et al. 2005, 2007), as Meister (2006) demonstrates in a thorough review of research regarding smokeless tobacco use in the United States and Sweden, the majority of evidence suggests that smokeless tobacco not only aids in cigarette smoking cessation but also is less harmful to users than cigarette smoking. If the goal is to reduce the harmful effects of smoking and increase smoking cessation, educating the public and health professionals about the true risk of nicotine and about tobacco harm reduction may be effective (Capella 2007). Therefore, the compelling scientific evidence that smokeless tobacco is a safe and viable alternative to smok-


ing could be disseminated to the public by allowing harmreduction information to appear in marketing materials. Furthermore, if the actual risks involved with smokeless tobacco use were effectively communicated to consumers, it might have a significant impact on attitudes, which could lead to a reduction in smoking behavior. Implementation of tobacco harm reduction will require reanalyzing conventional tobacco control policies and their underlying assumptions. The recently released report of the Royal College of Physicians (2007) concludes that though tobacco harm reduction may challenge many of the current and entrenched views of medicine and public health, the principles behind them have the potential to save millions of lives and thus deserve consideration. For example, one often-cited concern regarding tobacco harm reduction is the unintended consequence that the dissemination of information about less hazardous tobacco products might adversely affect public health if it creates new users. For example, Haddock and colleagues (2001) assert that smokeless tobacco may be a gateway product for subsequent smoking among young adult males. In addition, many tobacco control advocates fear that the peddling of a “safer” alternative could discourage smokers from quitting. However, other research has suggested that these fears are unfounded because of the impractical numbers of new users necessary to offset the substantial decrease in mortality from switching (Kozlowski 2007; Kozlowski et al. 2001). Swedish researchers also support this view, stating that snus is notably less harmful to health than cigarettes and that, in Sweden, snus has served as a pathway from smoking rather than a gateway to smoking among Swedish men (e.g., Foulds et al. 2003; Furberg et al. 2005; Ramstrom and Foulds 2006). Similar conclusions are reached in a comprehensive review of the existing evidence by Broadstock (2007), who finds that smokeless tobacco has a positive effect on smoking cessation and a negative impact on smoking initiation.

Needed Research in Marketing-Related Areas Given that prior research from the medical field provides evidence that (1) the use of smokeless tobacco is safer than the use of cigarettes and (2) smokeless tobacco is a potentially effective mechanism for harm reduction and/or smoking cessation, it is important to examine several issues related both to consumer attitudes toward harm-reduction information and to information provision in marketing materials. Figure 1 shows a model of the impact of tobacco harm-reduction information on the health of adult smokers and nonsmokers. The left-hand side of the model examines whether harm-reduction communication would change perceptions of the risk of using smokeless tobacco. The righthand side then examines whether changes in behavior would result from changed risk perceptions and whether changed behaviors would result in different health outcomes. Panel A examines the impact on smokers. Of interest here is whether a substantial number of smokers would switch to smokeless tobacco and whether any of those would eventually quit. With respect to nonsmokers, the model leaves open the possibility of smokeless tobacco ini-

tiation and eventual tobacco use. Here, the “gateway argument” is incorporated into the model because such evidence needs to be considered in the policy debate. Note that Figure 1 refers to smokers and nonsmokers and does not make an explicit distinction between those ages 18 and over and those under the age of 18. However, researchers are cautioned to account for this distinction because both cigarette and smokeless tobacco companies are subject to policies, including the Master Settlement Agreement and the Smokeless Tobacco Master Settlement, that prohibit marketing the product to adolescents. Thus, the research model in Figure 1 is designed to propose research on adult smokers and nonsmokers. The policy debate would be informed by evidence of the constructs and relationships outlined in this model. Notably, research by marketing experts would be important to several aspects of the model. Subsequently, we discuss marketing-related issues regarding harm reduction in the context of the model. Specifically, we outline five particular areas in which research is needed. First, to what degree is the public aware of the relative level of health risk associated with smokeless tobacco? As we indicated previously, there is compelling evidence that, in general, the public is not very aware of the differences in the level of health risk associated with smokeless tobacco versus cigarettes. Still, additional research on the current level of awareness would be timely to provide updated information. To this end, a survey examining the proportion of the public that is aware of the relative risks of smokeless tobacco versus cigarettes would be worthwhile. In addition, examining the degree to which those who are aware of harm reduction believe that smokeless tobacco is safer is also a question of interest. Regarding awareness of harm reduction, a comparative study of the perception of relative risk of smokeless tobacco as perceived by the public versus medical experts would be worthwhile. To this end, primary research using survey instruments directed at oral pathologists, or similarly qualified experts, would provide for comparative data. Moreover, this research would be useful in its own right in terms of providing a hard estimate of the level of risk from qualified practitioners. Preliminary hypotheses would suggest that a far greater number of oral cancers would be evident for smokers and former smokers than for smokeless tobacco users. If true, this would further validate the existing evidence that smokeless tobacco is a much less risky and, therefore, viable alternative to smoking. Second, if the public were aware of the relative level of health risk associated with smokeless tobacco versus cigarettes, would it make a difference in consumption intentions and behaviors? Although studying public awareness of the harm-reduction potential of smokeless tobacco is worthwhile, a more fundamental question is whether public awareness of potential harm reduction associated with smokeless tobacco would influence consumer intentions and behaviors. Intuitively, it seems highly likely that providing information about a product that research shows to be associated with a lower medical risk could lead to some smokers switching to smokeless tobacco. As Figure 1 shows, there is a need to test the relationship between com-


Figure 1.

191

Impact on Health of Tobacco Harm-Reduction Information on Smokers and Nonsmokers A: Smoker Population Effects

B: Nonsmoker/ Non–Tobacco User Population Effects

munication of harm-reduction information and changes in perceptions of the risk of smokeless tobacco. With respect to specific research on whether awareness would make a difference to smokers, both quantitative and qualitative research is needed. Survey research examining the intention of smokers (or the general public) to use smokeless tobacco if the actual risks are communicated to them, along with measures of “intention to use” or “intention to continue to use” cigarettes, would provide useful information. Qualitative research using focus groups of smokers to gauge their reactions when they are presented with the best evidence on harm reduction would also be worthwhile to understand their thought processes. Third, does the public believe that it has a right to know the best available information on the relative risk of products? In the context of the public policy debate over harm reduction, it is important to examine whether the public believes it has the right to know the best available information on the relative risks of tobacco products. In the context of deciding whether data on the actual risks of smokeless tobacco should be disseminated to smokers and nonsmokers

(see Figure 1), it is important to assess the degree to which consumers believe that such information should be available to them. In a special issue of Journal of Public Policy & Marketing titled “Helping Consumers Help Themselves,” Lynch and Wood (2006) focus on three key public policy interventions that can be beneficial to consumers: (1) offering more choices, (2) providing better information to consumers about options they might consider, and (3) providing incentives for consumers or sellers to change their behavior. Some observers have taken the position that the provision of harm-reduction information falls into the second category. As Kozlowski and Edwards (2005), Calfee (2002), and others assert, some people believe that the ability to exercise the right of information with regard to health information is an important part of health literacy. As Kozlowski (2002, p. 55) states, “Avoiding or objecting to, the fair presentation of information on effective harm reduction products to smokers to allow them to make an informed choice can represent a violation of a human right—the right to information.” This view is consis-


tent with the United Nations Declaration of Human Rights, which includes principles of autonomy and selfdetermination. Additional conceptual and theoretical work on the macro issue of whether the public should have access to the best available health information could inform the public policy debate over harm reduction. Moreover, to assess the public’s opinion of whether information on harm reduction should be distributed, a survey examining whether the public believes that information on harm reduction should be freely disseminated would be helpful. If surveys indicate that public opinion favors dissemination of harm-reduction information, a strong case could be made in favor of consideration of policies that effectively publicize the best available information in a socially responsible manner. Fourth, how can harm reduction information be effectively disseminated? Assuming that a decision were made to allow for harm-reduction information to be communicated to the public by marketers of smokeless tobacco, research on how to communicate this information effectively would be needed. In conjunction with this, it would be important to examine the most effective mechanism for communicating information to consumers in a way that leads to accurate perceptions of risk. Experimental research aimed at identifying the types of information on packaging (or in advertising and promotional materials) that would (1) increase awareness of the actual level of risk associated with smokeless tobacco and (2) most effectively leave the consumer with an accurate impression of the level of risk would be worthwhile. Prior literature on disclosures in prescription drug advertising, warning labels on various types of products, and nutritional labeling could be used to help develop research hypotheses for such studies (e.g., Drichoutis, Lazaridis, and Nayga 2006; Stewart and Martin 1994; Taylor, Capella, and Kozup 2007). Some of the types of independent variables that have been experimentally manipulated previously in these areas include the amount of risk information, specificity of the information, and presentation format. These same variables would also be of interest in the area of harmreduction information presentation in an effort to determine which types of information affect consumer perception. It is particularly important for research on the dissemination of harm-reduction information associated with smokeless tobacco to focus on providing the consumer with information regarding both the overall level of risk of smokeless tobacco and its relative level of risk in comparison with cigarettes. Thus, it makes sense to conduct research on how health information might change public perception, presumably toward a better appreciation of the possible trade-offs. As Stewart and Martin (2004, p. 188) note, “Consumers are not well served if the presence of disclaimers, warnings, and other disclosures causes them to generally ignore or become indifferent to such information.” In the context of advertising disclaimers, Stewart and Martin also note that unintended consequences can result if disclosures are not carefully constructed, such as when excessive information obscures attention from the most important piece of information or when “overwarning” consumers leads to less concern about a necessary warning. Whether it would be stated on packaging or in advertising/promotional materi-

als, it is clear that responsible policy in the area of harmreduction information by marketers would involve a focus on ensuring that the consumer is left with an accurate impression. Academic research on this topic could be useful toward this goal. Fifth, would better dissemination of information on the risk level of smokeless tobacco contribute positively to public health? Determining whether substituting smokeless tobacco for smoking would reduce overall population harm depends on the answer to multiple questions, including the following: (1) Does tobacco harm-reduction marketing benefit smokers by informing them of their options regarding substituting smokeless tobacco for cigarettes? (2) Does tobacco harm-reduction marketing increase smokeless tobacco use by former abstainers? and (3) Does tobacco harm reduction discourage current tobacco users from quitting tobacco altogether? With respect to considering public policy that would allow smokeless tobacco companies to communicate information on the relative risks of the product, it is important to examine the ultimate impact of such policy on public health. From a research perspective, recent scientific evidence implies that it is possible to generate data to assess whether there are differences in risks of adverse health effects between cigarettes and smokeless tobacco products (St. Hilaire 2007). In conjunction with research regarding the degree to which communicating information on the actual risks of smokeless tobacco would change perceptions of the product, it is also important to examine whether it would lead to changes in behavioral intentions. For example, research on the overall health impact of smokeless tobacco promotion and tobacco harm-reduction information dissemination would need to combine medical findings with consumer research. Therefore, at this point, better consumer research could contribute significantly to the ongoing task of assessing the current and potential role of smokeless tobacco products in reducing risk. To this end, we provide an overall model of the impact of dissemination of information on smokeless tobacco risks on public health. Figure 1 shows a proposed model of harm reduction that incorporates (1) the degree to which information dissemination through marketing or by other means changes perceptions of the risk of smokeless tobacco, (2) the behavioral responses associated with these changes in perception, and (3) the ultimate impact of changes in behavioral pattern on the public health. As Figure 1 shows, the possible responses to changes in perceptions of the risk of smokeless tobacco are different for smokers and nonsmokers or, more specifically, non– tobacco users. Yet it is clear that both groups need to be considered because it is important to examine whether current smokers would switch to smokeless tobacco and whether nonsmokers who would not otherwise use any tobacco would choose to use smokeless tobacco. Although Furberg and colleagues (2005), Kozlowski (2007), and Ramstrom and Foulds (2006) all conclude that extant research suggests a minimal impact in terms of new users that is more than offset by smokers switching to smokeless tobacco and perhaps even quitting altogether, further research on this topic in the context of an overall model is warranted.


As the National Institutes of Health (2006) states, no previous systematic reviews have been conducted that directly address the net population effects of better communication of smokeless tobacco risks. As a result, data about the effectiveness of smokeless tobacco in facilitating smoking cessation and associated population harm reduction are currently limited. A lone exception is the recently released conclusion of an expert panel, which states that smokeless tobacco products marketed with a warning label consistent with the evidence of relative health risks would accelerate a

193

decrease in smoking prevalence from a rate of 1.3% to a rate of 3.1% over five years (Levy et al. 2006). Thus, the expert panel’s estimate is that 4 million smokers would switch to smokeless tobacco, and though there would be a modest increase in additional smokeless use, there would be “substantial health benefits” overall. In conclusion, more effort to develop the types of estimates of the specific level of harm reduction that would occur if information were disseminated adequately in the context of a model, such as that shown in Figure 1, is needed.

Appendix. Key Tobacco Harm-Reduction Articles

Study

Type of Location of Sample Sample Research Study Size Age

Duration of Study

Findings/Conclusions

Population Effect/Health Outcome

Ault and Ekelund (2002)

Cost– benefit analysis

United States

N.A.

Adult

N.A.

Ault et al. (2004)

Survey

United States

4842

17+

Longitudinal

SLT may decrease probability of smoking.

Smoking cessation from SLT use leads to significantly longer and healthier life and reduced health care premiums.

Boffetta et al. (2005)

Survey Norway and 10,136 United States

Adult

Longitudinal

SLT may lead to increased risk for carcinogenic effect on pancreas.

Possible risk of pancreatic cancer in long-term SLT users.

18

Adult

N.A.

SLT is less harmful to health than cigarettes.

Depends on smoking cessation (positive effect) versus initiation (negative effect).

N.A.

35+

Cross-sectional

No significant difference in life expectancy between smokers who quit all tobacco and smokers who switch to snus.

Quitting smoking or switching to SLT will lead to health benefits.

Broadstock (2007)

Review (of previous research)

Sweden

Gartner et al. (2007)

Statistical Australia data

Smokeless tobacco (SLT) Health care costs and cost to is one of the least expensive society from smoking are and successful ways to quit significantly reduced with smoking. SLT use.

Gilljam and Galanti (2003)

Survey

Sweden

1985

25–55

Cross-sectional

SLT use by Swedish smokers may have increased chance of abstinence by 70%–80%.

SLT is not a necessary component of smoking cessation.

Haddock et al. (2004)

Survey

United States

36,012

Adult

Cross-sectional

Perception that SLT has no health benefits over cigarettes.

Perceived lack of harm reduction may discourage quitting smoking.

Henley et al. (2005)

Survey

United States

More than 2.2 million

30+

Longitudinal

Current SLT use may increase risk for coronary heart disease, stroke, and digestive and respiratory disease.

SLT is less harmful than cigarette smoking but not necessarily less harmful or more effective than other replacements.

Henley et al. (2007)

Survey

United States

116,395

30+

Longitudinal

SLT switchers may have increased risk for lung cancer, heart disease, and stroke than those who abstain from tobacco

Current cigarette smokers may significantly reduce tobacco-related diseases by quitting rather than switching to SLT.

194 Smokeless Tobacco Products as a Harm-Reduction Mechanism Appendix. Continued

Study

Type of Location of Sample Sample Research Study Size Age

Lee (2007)

Review

Levy et al. (2004)

United States and Sweden

Duration of Study

Findings/Conclusions

Population Effect/Health Outcome

N.A.

N.A.

Various

U.S. SLT use may increase SLT use in United States is risk for heart disease, stroke, still less harmful than and blood pressure, but smoking, and there are no there are no risks with risks with Swedish snus use; Swedish SLT use. overall reduced risk compared with smoking.

Expert International panel

9

35+

N.A.

SLT is safer than cigarette smoking, except for younger users.

Cannot be predicted.

Levy et al. (2006)

Expert International panel

7

16–20 36–40

N.A.

SLT reduces smoking.

Switching to SLT lowers health risks and reduces mortality rates.

Luo et al. (2007)

Survey and registry review

Sweden

279,897

Adult

Longitudinal

SLT may increase risk of pancreatic but not oral or lung cancers.

SLT may be a possible general risk factor for pancreatic cancer.

Meister (2006)

Review

United States and Sweden

N.A.

Adult

N.A.

SLT aids in cigarette smoking cessation; SLT has fewer health risks than smoking.

Reduced mortality rates and health risks with SLT use.

Ramstrom and Survey Foulds (2006)

Sweden

6752

22–79

Cross-sectional

SLT is an effective alternative for cigarette smoking cessation.

Reduced risk of daily cigarette smoking with SLT; increased likelihood of quitting cigarette smoking.

Rodu and Cole (2004)

Survey

Europe

N.A.

25+

Cross-sectional

Swedish SLT use results in lower smoking-related mortality.

200,000 annual smokingattributable male deaths in the European Union would be avoided at Swedish smoking rates.

Tilashalski, Rodu, and Cole (1998)

Clinical trial

United States

63

18+

Longitudinal

25% successfully quit cigarette smoking using SLT.

SLT is a more healthful and effective alternative to cigarette smoking.

Weitkunat, Sanders, and Lee (2007)

Review

United States and Europe

N.A.

N.A.

Various

SLT use may create a very minor increased risk for oral cancer.

SLT composition varies from country to country, causing more harm in specific populations.

Notes: N.A. = not applicable.

References

———, ———, John D. Jackson, and Richard P. Saba (2004), “Smokeless Tobacco, Smoking Cessation and Harm Reduction: An Economic Analysis,” Applied Economics, 36 (1), 17–29.

Accortt Neil A., John W. Waterbor, Colleen Beall, and George Howard (2005), “Cancer Incidence Among a Cohort of Smokeless Tobacco Users (United States),” Cancer Causes and Control, 16 (9), 1107–1115.

Boffetta, Paul, Bjarte Aagnes, Elisabete Weiderpass, and Aage Anderson (2005), “Smokeless Tobacco Use and Risk of Cancer of the Pancreas and Other Organs,” International Journal of Cancer, 114 (6), 992–95.

Ault, Richard W. and Robert B. Ekelund Jr. (2002), “The Personal Economics of Smoking Cessation,” Journal of Family and Consumer Sciences, 94 (4), 41–49.

Britton, John and Richard Edwards (2008), “Tobacco Smoking, Harm Reduction, and Nicotine Product Regulation,” Lancet, 371, 441–45.


Broadstock, Marita (2007), “Systematic Review of the Health Effects of Modified Smokeless Tobacco Products,” NZHTA Report, 10 (1), i–110. Calfee, John E. (2002), “Public Policy Issues in Direct-toConsumer Advertising,” Journal of Public Policy & Marketing, 21 (Fall), 174–93. Capehart, Thomas C. (2006), “Tobacco Situation and Outlook Yearbook,” Market and Trade Economics Division, Economic Research Service, U.S. Department of Agriculture, (December), (accessed December 17, 2007), [available at http://www.scribd. com/doc/552690/CDC-Release-TBS04242007]. Capella, Michael L. (2007), “The De-Marketing of Smokeless Tobacco for Harm Reduction,” Journal of Consumer Marketing, 24 (2), 68–70. Centers for Disease Control and Prevention (2005), “Cigarette Smoking Among Adults-United States, 2004,” Morbidity and Mortality Weekly Report, 44 (11), 1121–24. Chapman, Simon (2007), Public Health Advocacy and Tobacco Control: Making Smoking History. Oxford: Blackwell. Critchley Julia A. and Belgin Unal (2004), “Is Smokeless Tobacco a Risk Factor for Coronary Heart Disease? A Systematic Review of Epidemiological Studies,” European Journal of Cardiovascular Prevention Rehabilitation, 11 (2), 101–112. Cummings, K. Michael (2001), “Informing Consumers About the Relative Health Risks of Different Nicotine Delivery Products,” paper presented at the National Conference on Tobacco and Health, New Orleans, (November 27–29). ——— (2002), “Can Capitalism Advance the Goals of Tobacco Control?” Addiction, 97 (8), 957–58. Drichoutis, Andreas C., Panagiotos Lazaridis, and Rodolfo M. Nayga Jr. (2006), “Consumers’ Use of Nutritional Labels: A Review of Research Studies and Issues,” Academy of Marketing Science Review, 9, (accessed November 27, 2007), [available at http://www.amsreview.org/articles/drichoutous09-2006.pdf].

195

ation in Young Adult Males,” Preventive Medicine, 32 (3), 262–67. Hatsukami, Dorothy K., Charlotte Lemmonds, and Scott L. Tomar (2004), “Smokeless Tobacco Use: Harm Reduction or Induction Approach?” Preventive Medicine, 38 (1), 309–317. Henley, S. Jane, Cari J. Connell, Patricia Richter, Corinne Husten, Terry Pechacek, Eugenia E. Calle, and Michael J. Thun (2007), “Tobacco-Related Disease Mortality Among Men Who Switched from Cigarettes to Spit Tobacco,” Tobacco Control, 16 (1), 22–28. ———, Michael J. Thun, Cari Connell, and Eugenia E. Calle (2005), “Two Large Prospective Studies of Mortality Among Men Who Use Snuff or Chewing Tobacco (United States),” Cancer Causes and Control, 16 (4), 347–58. Institute of Medicine (2001), Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction, (accessed October 3, 2007), [available at http://www.nap.edu/openbook.php?isbn= 0309072824]. Kozlowski, Lynn T. (2002), “Harm Reduction, Public Health, and Human Rights: Smokers Have a Right to Be Informed of Significant Reduction Options,” Nicotine and Tobacco Research, 4 (4, Supplement 2), 55–60. ——— (2007), “Effect of Smokeless Tobacco Product Marketing and Use of Population Harm from Tobacco Use: Policy Perspective for Tobacco-Risk Reduction,” American Journal of Preventive Medicine, 33 (6S), 379–86. ——— and Beth Q. Edwards (2005), “‘Not Safe’ Is Not Enough: Smokers Have a Right to Know More Than There Is No Safe Tobacco Product,” Tobacco Control, 14 (Supplement II), ii3–ii7. ———, Andrew A. Strasser, Gary A. Giovino, Jennifer A. Erickson, and Joseph V. Terza (2001), “Applying the Risk/Use Equilibrium: Use Medicinal Nicotine Now for Harm Reduction,” Tobacco Control, 10 (3), 201–203.

Foulds Jonathan and Lars Ramstrom (2006), “Causal Effects of Smokeless Tobacco on Mortality in CPS-I and CPS-II?” Cancer Causes and Control, 17 (2), 227–28.

Lee, Peter N. (2007), “Circulatory Disease and Smokeless Tobacco in Western Populations: A Review of the Evidence,” International Journal of Epidemiology, 36 (4), 789–804.

———, ———, Michael Burke, and Karl Fagerström (2003), “Effect of Smokeless Tobacco (Snus) on Smoking and Public Health in Sweden,” Tobacco Control, 12 (4), 349–59.

Levy, David T., Elizabeth A. Mumford, K. Michael Cummings, Elizabeth A. Gilpin, Gary Giovino, Andrew Hyland, David Sweanor, and Kenneth E. Warner (2004), “The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimates of a Panel of Experts,” Cancer Epidemiology Biomarkers Prevention, 13 (12), 2035–2042.

Furberg, Helena, Cynthia M. Bulik, Caryn Lerman, Paul Lichtenstein, Nancy L. Pedersen, and Patrick F. Sullivan (2005), “Is Swedish Snus Associated with Smoking Initiation or Smoking Cessation?” Tobacco Control, 14 (6), 422–24. Gartner, Coral E., Wayne D. Hall, Theo Vos, Melanie Y. Bertram, Angelo L. Wallace, and Stephen S. Lim (2007), “Assessment of Swedish Snus for Tobacco Harm Reduction: An Epidemiological Modeling Study,” The Lancet, 369, 2010–2014. Gilljam, Hans and M. Rosaria Galanti (2003), “Role of Snus (Oral Moist Snuff) in Smoking Cessation and Smoking Reduction in Sweden,” Addiction, 98 (9), 1183–89. Haddock, C. Keith, Harry Lando, Robert C. Klesges, Alan L. Peterson, and Isabel C. Scarinci (2004), “Modified Tobacco Use and Lifestyle Change in Risk-Reducing Beliefs About Smoking,” American Journal of Preventive Medicine, 27 (1), 35–41. ———, Mark W.V. Weg, Margaret DeBon, Robert C. Klesges, G. Wayne Talcott, Harry Lando, and Alan Peterson (2001), “Evidence That Smokeless Tobacco Is a Gateway for Smoking Initi-

———, ———, ———, ———, ———, ———, ———, and ——— (2006), “The Potential Impact of a Low-Nitrosamine Smokeless Tobacco Product on Cigarette Smoking in the United States: Estimates of a Panel of Experts,” Addictive Behaviors, 31 (7), 1190–1200. Lewin, Freddi (1998), “Smokeless Tobacco,” in Social and Economic Aspects of Reduction of Tobacco Smoking by Use of Alternative Nicotine Delivery Systems (ANDS), Lars Ramström, Rachel Uranga, and Anne Hendrie, eds. Auckland, New Zealand: Adis International Limited: United Nations. Luo, Juhua, Weimin Ye, Kazem Zendehdel, Johanna Adami, Hans-Olov Adami, Paolo Boffetta, and Olof Nyren (2007), “Oral Use of Swedish Moist Snuff (Snus) and Risk for Cancer of the Mouth, Lung, and Pancreas in Male Construction Workers: A Retrospective Cohort Study,” The Lancet, 369 (9578), 2015–2020.

196 Smokeless Tobacco Products as a Harm-Reduction Mechanism Lynch, John G., Jr., and Wendy Wood (2006), “Special Issue Editors’ Statement: Helping Consumers Help Themselves,” Journal of Public Policy & Marketing, 25 (Spring), 1–7.

——— (2007), “Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit,” a report by the Tobacco Advisory Group of the Royal College of Physicians, London.

Meister, Kathleen (2006), Helping Smokers Quit: A Role for Smokeless Tobacco. New York: American Council on Science and Health, (October), [available at http://www.acsh.org/ docLib/20061004_smokeless.pdf].

Savitz, David A., Roger E. Meyer, Jason M. Tanzer, Sidney S. Mirvish, and Freddi Lewin (2006), “Public Health Implications of Smokeless Tobacco Use as a Harm Reduction Strategy,” American Journal of Public Health, 96 (11), 25–30.

National Institutes of Health (2006), “Tobacco Use: Prevention, Cessation, and Control,” (September 5), (accessed October 29, 2007), [available at http://consensus.nih.gov].

St. Hilaire, Catherine L., ed. (2007), “Scientific Methods to Evaluate Potential Reduced-Risk Tobacco Products,” report of the Life Sciences Research Office, (April), (accessed August 7, 2008), [available at http://www.lsro.org/articles/rrrvw_report_ 042407_execsum.pdf].

Nilsson, Robert (2006), “Possible Carcinogenicity of Smokeless Tobacco,” International Journal of Cancer, 118 (6), 1582–83. O’Connor, Richard J., Andrew Hyland, Gary Giovino, Geoffrey T. Fong, and K. Michael Cummings (2005), “Smoker Awareness of and Beliefs About Supposedly Less-Harmful Tobacco Products,” American Journal of Preventive Medicine, 29 (2), 85–90. Phillips, Carl V., Brian Guenzel, and Paul Bergen (2006), “Deconstructing Anti-Harm-Reduction Metaphors: Mortality Risk from Falls and Other Traumatic Injuries Compared to Smokeless Tobacco Use,” Harm Reduction Journal, 3 (15), 1–5. Ramstrom, Lars M. and Jonathan Foulds (2006), “Role of Snus in Initiation and Cessation of Tobacco Smoking in Sweden,” Tobacco Control, 15 (3), 210–14. Rodu, Brad and Philip Cole (2002), “Smokeless Tobacco Use and Cancer of the Upper Respiratory Tract,” Oral Surgery Oral Medicine Oral Pathology, 93 (5), 511–15. ——— and ——— (2004), “The Burden of Mortality from Smoking: Comparing Sweden with Other Countries in the European Union,” European Journal of Epidemiology, 19 (2), 129–31. ——— and Christer Jansson (2004), “Smokeless Tobacco and Oral Cancer: A Review of the Risks and Determinants,” Critical Review of Oral Biological Medicine, 15 (5), 252–63. Royal College of Physicians (2002), “Protecting Smokers, Saving Lives,” a report by the Tobacco Advisory Group of the Royal College of Physicians, London.

Stewart, David W. and Ingrid M. Martin (1994), “Intended and Unintended Consequences of Warning Labels,” Journal of Public Policy & Marketing, 13 (Spring), 1–19. ——— and ——— (2004), “Advertising Disclosures: Clear and Conspicuous or Understood and Used?” Journal of Public Policy & Marketing, 23 (Fall), 183–92. Taylor, Charles R., Michael L. Capella, and John C. Kozup (2007), “Does DTC Advertising Provide Information or Create Market Power?” Advances in International Marketing, 18 (1), 9–30. Tilashalski, Ken, Brad Rodu, and Philip Cole (1998), “A Pilot Study of Smokeless Tobacco in Smoking Cessation,” American Journal of Medicine, 104 (5), 456–58. Tomar, Scott L. (2003), “Is Use of Smokeless Tobacco a Risk Factor for Cigarette Smoking? The U.S. Experience,” Nicotine & Tobacco Research, 5 (4), 561–69. Waterbor, John W., Rex M. Adams, Joshua M. Robinson, Forrest G. Crabtree, Neil A. Accortt, and M. Janice Gilliland (2004), “Disparities Between Public Health Educational Materials and the Scientific Evidence That Smokeless Tobacco Use Causes Cancer,” Journal of Cancer Education, 19 (1), 17–28. Weitkunat, Rolf, Edward Sanders, and Peter N. Lee (2007), “Meta-Analysis of the Relation Between European and American Smokeless Tobacco and Oral Cancer,” BMC Public Health, 7 (147), 334.