Nicotine without the smoke

Anti-smoking groups worry that smokeless tobacco products will exacerbate a public health problem.

While standbys like chewing tobacco and snuff have long been around, newer alternatives, such as dissolvable pellets and tobacco-coated sticks, offer less messy, more socially acceptable ways for nicotine-addicted users to get what they need.

For tobacco companies pinched by declining smoking rates and increasingly strict indoor air laws, these smoke-free options may be a growing source of revenue. Cigarette consumption has been declining about 3 percent each year, while sales of smokeless tobacco have been growing by about twice that amount annually. Last month, after New York City implemented laws banning smoking in parks, public beaches and other crowded areas, Reynolds American Inc. launched an advertising campaign encouraging smokers to switch to Camel Snus, a pouch-type smokeless tobacco product.

Anti-smoking advocates worry that the growing popularity of smokeless products could reignite interest in tobacco consumption and keep people addicted who might have otherwise quit. In the past, anti-smoking laws like Delaware’s 2002 Clean Indoor Air Act offered the incentive needed for many smokers to finally kick the habit, helping drop the number of adult smokers in the state to 18.3 percent, according to 2009 statistics from the state’s behavioral risk factor survey. Among high school students, 19 percent smoke cigarettes.

As tobacco manufacturers look for ways to keep customers while enticing new ones, smokeless tobacco is being positioned as a bridge that allows consumers to manage their nicotine needs without stepping outside for a smoke break, said Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids. That’s particularly worrisome since teen boys are one of the faster-growing segments of the smokeless tobacco market, he added.

Dissolvable products, such as pellets, sticks and strips, that contain nicotine haven’t yet made it to Delaware, where 2 percent of the adult population uses smokeless tobacco, according to the 2009 survey data. But the state Division of Public Health is already trying to put out the message that these “other tobacco” options — which also include cigars and cigarillos — come with their own health risks.

Both adults and teens are the target audience; almost 7 percent of high school students said they use smokeless tobacco.

“In some cases, we’re seeing individuals become dual users,” said Deborah Brown, president and chief executive officer of the American Lung Association of the Mid-Atlantic. “We’ve seen people with the snus, sliding them in front of their cigarette pack. If they’re indoors, they’re using the snus, if they’re outside they’re smoking, so it may be harder for them to quit smoking.”

Transition product?

The health risks associated with smoking and secondhand exposure are well-known — lung cancer, heart disease and stroke. There are 40 or so carcinogens that go into making a cigarette.

Smoking costs the state of Delaware more than $1 billion a year, according to a Penn State study released last year by the American Lung Association. That includes $430 million in direct medical expenses and $417 million in premature death costs. In Delaware, one in five deaths is still caused by tobacco use.

Because cigarettes can be hard to quit, a few public health advocates have suggested smokeless tobacco products may help some smokers make the transition to being nonsmokers. A University of South Carolina researcher is conducting a yearlong study looking at whether the use of smokeless products like snus leads to attempts at quitting, smoking reduction or cessation among smokers. In Sweden, where snus is most popular, studies suggest that users of the moist snuff product face fewer health problems than those who smoke. Sweden has one of the lowest smoking rates in the world.

But Brown said that doesn’t mean smokeless tobacco is safe, especially since it keeps people addicted to nicotine while putting them at risk for other health problems later on, including oral cancer, tooth loss and gum disease. The amount of nicotine in smokeless products typically is about the same or slightly less than the level found in cigarettes, although one brand of tobacco sticks has about three times as much nicotine.

In addition to the oral health risks, smokeless tobacco can be dangerous if accidentally ingested by children, according to a study published last year in the medical journal Pediatrics.

Newer varieties like dissolvable lozenges have a higher amount of the nicotine that is most rapidly absorbed in the mouth, which could make them more toxic if accidentally swallowed by children.

Smokeless tobacco is different than nicotine-replacement medication products, which include gum, nasal spray, inhalers, lozenges and patches. Those are designed to wean the body off cigarettes by providing nicotine in controlled amounts without the chemicals found in other tobacco products. They require FDA approval as smoking cessation aids.

In 2009, Congress passed legislation to give the U.S. Food and Drug Administration authority to regulate tobacco products. Anti-tobacco advocates want the FDA to regulate dissolvable tobacco products, too, but in March the FDA ruled that one company’s brand of dissolvable tobacco didn’t fall under the jurisdiction of the new law. The company, Star Scientific, had hoped to market its dissolvable tobacco lozenges as a reduced-risk product (compared to cigarettes), which would have required FDA approval.

Some analysts suggest it may be difficult for tobacco companies to prove smokeless tobacco products pose different health risks than cigarettes.

“We have the position that there is no safe tobacco,” Brown said.

Marketing criticized

McGoldrick said the colorful marketing, portable packaging and candy-like appearance of smokeless tobacco products may give people, kids in particular, the idea that smokeless tobacco is a healthier alternative. He and other anti-tobacco advocates are concerned about statistics that found 15 percent of high school boys nationwide used smokeless tobacco in 2009, a 36 percent increase from 2003.

“These are efforts to make it easier to use, with the pouches and things, and also somewhat more amenable,” McGoldrick said. “They’ve just done a masterful job going after where the replacement users are.”

Tobacco companies contend that their products are marketed for adults and must be purchased with identification. Still, Brown and McGoldrick said these products represent something of a graduation strategy, with young people starting with mild, flavored tobacco products before moving on to other products once they’ve gotten addicted to the nicotine.

Vanessa Adams, a nurse practitioner and director of the Indian River High School wellness center, said some kids, mostly boys, tend to use chewing tobacco to get them through situations when they can’t smoke.

“I don’t think they’re saying, ‘Let’s do smokeless tobacco.’ Most of the time they hide it,” said Adams, who tries to talk with chew users about oral health and the effect it has on their teeth.

Mount Pleasant High School student Matt Coyle serves as the statewide chair for the Kick Butts Generation, a youth movement focused on decreasing tobacco use in Delaware. He said most of the questions he gets from young people are about smoking, but some kids want to know if the newer products are better for them.

“A lot of people think the toxins are only in the cigarette, when tobacco and nicotine are still bad for you,” said Coyle, who drives a car wrapped with anti-tobacco messages. “We’re still in an area where it’s still cool to smoke. But the smokeless tobacco is making an appearance with their color ads. I’ve heard from downstate people who say it’s common down there. It’s easy to consume and conceal.”

Role models

Nationally, there’s a growing effort by anti-tobacco advocates to educate people about smokeless tobacco. McGoldrick said Major League Baseball, whose players have long been seen spitting tobacco juice on the field and in the dugout, is trying to ban chewing tobacco from the clubhouse as part of its upcoming collective bargaining agreement. At the same time, several prominent players have announced they are trying to stop the habit, most notably Josh Hamilton and Stephen Strasburg.

“We know baseball players are a huge role model for our kids. We can have all these messages, but when their heroes are doing this, it’s hard to ignore,” McGoldrick said.

Delaware is starting its “Other Tobacco” campaign, which hopes to educate parents and kids about smokeless tobacco products, cigars and cigarillos, said Lisa Moore, tobacco prevention and control program manager with the Division of Public Health. The campaign is being funded with a grant of more than $1 million from the U.S. Centers for Disease Control and Prevention. It will include television and radio ads, social marketing messages and billboards aimed at exposing the risks of these tobacco alternatives.

Moore said pricing is one area of concern, because smokeless tobacco products, cigars and cigarillos cost less than a pack of cigarettes, which may add to their appeal. Such products aren’t taxed at the same levels as cigarettes. Almost 12 percent of high school students in Delaware smoke cigars, according to the 2009 risk survey.

Beth Mattey, school nurse at Mount Pleasant High School, said cigarettes remain the focus of prevention efforts among young people, but as more products appear on the market, anti-tobacco organizations are expanding their efforts. She said members of Kick Butts Generation recently approached a vendor at a mall who was selling electronic cigarettes, a battery-operated device that uses liquid nicotine to produce a vapor.

They had more information about the product, including its risks, than the vendor did, which was an empowering moment for the students, she said.

“We’re being proactive is what we’re doing,” she said.

By Kelly Bothum, 324-2962
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