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Mountain Vapor Blog

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Drinking, Bingeing and Toking More Popular Than Smoking Among Teens in 2014

Teen smoking deservedly gets a great deal of attention from the media and public policymakers, but one government survey shows that teens consume alcohol and marijuana at far higher rates than cigarettes.The National Surveys on Drug Use and Health (NSDUH), which I discussed last week (here), provide intriguing insights into use of licit and illicit products.At left are 2014 NSDUH estimates of the numbers – and percentages by age – of Americans using cigarettes, smokeless tobacco, alcohol and marijuana in the past month. (Binge drinking is defined as consuming five or more drinks within two hours)  There were nearly 56 million smokers, 8.6 million smokeless tobacco users, 22.5 million marijuana users and a whopping 140 million drinkers.  There were actually more binge drinkers (61 million) than smokers.  The following table shows the number of teens (12-17 years) and young adults (18-20 years) who used these substances in 2014..nobr br { display: none } td { text-align: center} Numbers (millions) of Teens and Young Adults Who Were Past-Month Smokers, Smokeless Users, Drinkers, Binge Drinkers and Marijuana Users in 2014Teens (12-17 yrs)Young Adults (18-20 yrsTotalSmokers1.233.244.47Smokeless Users0.500.661.16Drinkers2.805.888.68Binge Drinkers1.533.745.27Marijuana Users1.852.774.62There were some 1.2 million past-month smokers under 18, and about half a million underage smokeless users.  These numbers pale in comparison to those for alcohol.  There were 2.8 million drinkers under 18, and another 5.9 million between 18 and 20.  There were more underage binge drinkers (1.5 million) and marijuana users (1.85 million) than smokers.  The totals for marijuana, drinking and binge drinking are all greater than smoking.Teenage smoking must be prevented, but teen abuse of alcohol and marijuana also requires attention.Original author: Brad Rodu
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U.S. Can’t Decide How Many Adults Use Smokeless – 8.1 Million or 5.1 Million?

Federal officials routinely obfuscate on the subject of smokeless tobacco, and particularly on the number of smokeless users in the U.S. The newest numbers are reported by Dr. Rachel Lipari and Mr. Struther Van Horn of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). They say, “In 2014, an estimated 8.7 million people aged 12 or older used smokeless tobacco in the past month.” (available here)  Their finding is based on data from the National Survey on Drug Use and Health (NSDUH). That number included teens (Age 12-17 years).  When including only adults (18 and older), the NSDUH estimate is 8.1 million in 2014, which contrasts with a 2015 CDC-supported National Health Interview Survey (NHIS) adults-only estimate of 5.1 million. The 59% higher NSDUH number probably results from the use of different definitions.  NSDUH collects information on past-30 day use, whereas current users in NHIS is every day or some days. The primary conclusion in the Lipari/Van Horn report is that “Smokeless tobacco is not a healthy alternative to cigarette smoking.”  This is a non sequitur, as the NSDUH survey includes no information on health.  The government inconsistency also extends to smoking numbers, as I discussed previously (here, hereand here).  The NSDUH estimate of adult U.S. smokers for 2014 was 55.8 million, about 40% higher than the NHIS estimate of 40 million for that year. It is time for federal officials to acknowledge the gross inconsistency of the government’s tobacco use estimates. In all likelihood, the higher NSDUH estimates, which reflect the fact that Americans use tobacco products more irregularly than every day or some days, are closer to reality than those based on the NHIS. Original author: Brad Rodu
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Time for the Government of Sweden to get behind snus and tobacco harm reduction

One of the more puzzling things about snus is the reluctance of Sweden’s government to claim credit for what is by any standards an extraordinary public health achievement. So here I write to the relevant ministers requesting that they acknowledge Sweden’s success, show some leadership and promote the concept of tobacco harm reduction.  The challenge to the EU prohibition of snus brought by Swedish Match and New Nicotine Alliance provides an opportunity for the Government of Sweden to change its approach.  I wrote the following heartfelt plea, attaching the letter that 18 comrades sent sent to the European Commission: Lifting the unjustified European Union ban on oral tobacco or “snus” in the light of ongoing legal action hoping it might encourage a more constructive pro-health, pro-trade, post-enlightenment approach. 

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Smoking May Harm Mental Health

Research has documented a strong link between smoking and various mental health disorders, including anxiety, depression, schizophrenia and bipolar disorder.  The CDC advises that about 20% of American adults had some form of mental illness in 2009-2011, and the smoking rate for that group was 36%, in contrast to 21% for all others (here). There is certainly an association, but there are four distinct possibilities with respect to causality: ·       Mental health problems cause people to smoke. ·       Smoking causes mental health problems. ·       Both pathways exist. ·       Neither pathway exists. My economist colleague Dr. Nantaporn Plurphanswat is the lead author of an innovative analysis that identifies a potential causal pathway for mental illness and smoking; the work appears in the American Journal of Health Behavior (abstract here).  Our co-author is University of Illinois professor Dr. Robert Kaestner.  We used data from people in almost all states participating in the federal Behavioral Risk Factor Surveillance System (BRFSS) from 2000 to 2010.  BRFSS collected information on smoking and asked participants “…for how many days during the past 30 days was your mental health [which includes stress, depression, and problems with emotions] not good?” Recognizing that traditional approaches cannot identify a causal pathway between smoking and mental illness, Drs. Plurphanswat and Kaestner employed an instrumental variable approach, in which variation in smoking at the state level is strongly associated with cigarette excise taxes, but the excise taxes are completely unrelated to outcomes like mental health.  The IV analysis provides information on whether smoking leads to mental health problems, or vice versa. Our results indicate that smoking may harm mental health: it is significantly associated with 14 or more days of poor mental health.  Most of the effect due to smoking is from large increases in the number of mentally unhealthy days and not by small increases among many smokers.  The BRFSS data cannot tell us whether smoking is a form of self-medication practiced by those who suffer from specific mental health disorders.  However, our analysis confirms that smoking may contribute to anxiety, depression and emotional distress.  Thus, policies that reduce smoking may have a positive spill-over effect in improving mental health.   Original author: Brad Rodu
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A critical review of an Australian anti-vaping polemic

John Maynard Keynes: “when the facts change, I change my mind. What do you do sir?”

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Avoiding bureaucratic destruction of the US vaping market – proposals for a new approach by FDA

June 18th, 2017

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EU Snus Ban Costs More Lives

A new report from the Swedish Snus Commission underscores the accelerating human toll of the European Union’s unconscionable ban on smokeless tobacco: “…among men over the age of 30, 355,000 lives per year could have been saved if the other EU countries had matched Sweden’s tobacco-related mortality rate.”  Sweden is the only EU nation in which sales of snus are legal. In 2009, epidemiologist Phil Cole and I, analyzing data from the World Health Organization and the International Agency for Research on Cancer, reported in the Scandinavian Journal of Public Healththat 274,000 smoking-attributable deaths would be avoided if men throughout the EU had the smoking prevalence of men in Sweden (here).  Four years later, I updated that figure to 291,000 (here).        The Snus Commission report, available here, was produced by a distinguished group of Swedes.  The commission’s chairman is Anders Milton, a physician and former President and Chairman of the Swedish Medical Association, President of the Swedish Confederation of Professional Associations from 1993 to 2001, and President of the Swedish Red Cross from 2002 to 2005.  His collaborators are Christina Bellander, a journalist who previously headed business development at Swedish TV4 and was a Board Member of New Wave Group AB, Mittmedia AB and the Swedish Educational Broadcasting Company; Göran Johnsson, a former member of the Social Democratic Party’s Executive Committee, Board Member of Volvo AB and Chairman of Swedish national television broadcaster SVT from 2011 to 2014; and Karl Olov Fagerström, a WHO-recognized nicotine and tobacco researcher who has authored 150 articles in peer reviewed journals. The casualty list from the indefensible and immoral EU snus ban continues to grow. Original author: Brad Rodu
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Pariahs, predators or players? The tobacco industry and the end of smoking

June 12th, 2017

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The Swedish Miracle Continues

 A special report on tobacco and e-cigarettes published by Eurobarometer, the official polling organization of the 28-nation European Union (here), underscores the remarkable success of what researchers call “The Swedish Experience”. According to the report, the prevalence of smoking in Sweden is just 7%, with no other EU country even remotely close.  UK prevalence is 17%, while only Denmark, the Netherlands, Belgium and Ireland are below 20%.  The prevalence of daily smoking in Sweden is a bare 5%, as shown in the chart at left (credit to Lars Ramstrom from Sweden), and the prevalence of former smoking is 41%, the EU’s highest by far.  Eurobarometer provides an array of impressive statistics: “In all but one country, at least eight in ten (80%) of smokers consume tobacco products daily. The exception is Sweden, where only just over half (52%) give this response. In turn, over a fifth (21%) of smokers in Sweden are irregular smokers, consuming listed tobacco products less than monthly.  In all other countries, very few respondents give this answer.” There is only one explanation for Sweden’s remarkable number: the popularity of snus, the sales of which are prohibited in all other EU nations.  The new report reveals that 20% of Swedes use snus daily.  The only other countries with daily smokeless use are Denmark (1%), home of Oliver Twist chewing tobacco pellets, and Finland (2%). The Eurobarometer report should pressure the EU to end its snus ban.  Swedish Match has filed a complaint with the European Court of Justice to compel EU action.  For more on “the worst regulation in the EU,” see Clive Bates’ excellent commentaries, such as this (here). Original author: Brad Rodu
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Chewers and Dippers: Get the Facts on Smokeless from CASAA

Smokeless tobacco users in the U.S. are constantly under attack for their “bad habit”.  Public health officials and organizations deliberately misinform consumers about smokeless health risks, generating undue pressure to quit from friends and families. The truth about smokeless has been hard to come by. Chewers and dippers can watch my informative video interview with Mudjug’s Darcy Compton (here), or they can read or listen to my book, For Smokers Only, How Smokeless Tobacco Can Save Your Life.  Now, there’s another option: a downloadable pamphlet from Consumer Advocates for Smoke-free Alternatives Association (CASAA) titled, “Smokeless Tobacco: Separating Fact from Myth” (available here).  Save it as a pdf and print copies to share. CASAA is a non-profit organization “dedicated to ensuring the availability of reduced harm alternatives to smoking and to providing smokers and non-smokers alike with honest information about those alternatives so that they can make informed choices… We believe that consumers are best served by ensuring diversity in the marketplace and by being provided with truthful and accurate information so that they can make informed decisions regarding their health and lifestyle choices.” CASAA’s 200,000 members are active in tobacco legislation, litigation and regulation.  The group maintains an archive of thousands of testimonials from former smokers who found safer cigarette substitutes (here).  Everyone who cares about smokers, smokeless users and truthful information should become a member here. Original author: Brad Rodu
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Letter to European Commissioner for Better Regulation on the worst regulation in the EU – the snus ban

Eighteen of us have just written a detailed letter to Mr Frans Timmerman, the EU’s Commissioner for Better Regulation (amongst other things) drawing his attention to one of the worst regulations in the EU, the ban on oral tobacco, better known as snus. This ban is now facing challenge in the Court of Justice of the European Union (case C 151/17) by a producer, Swedish Match, and the consumer group, New Nicotine Alliance (see NNA background on the case).

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Democrats press FDA to proceed with destruction of the vaping market – we respond

June 1st, 2017

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A Smokeless Tobacco-Pancreatic Cancer Claim is Refuted

Snus use is not associated with pancreatic cancer, according to a study published in the International Journal of Cancer (abstract here).  Researchers combined data from nine cohort studies that involved 400,000 men in Sweden.  Compared with never users, the risk for current snus users, after adjustment for smoking, was 0.96 (95% confidence interval = 0.83 – 1.11). The new work was conducted by the Swedish Collaboration on Health Effects of Snus Use, which includes researchers from several Swedish universities.  (In the past, snus research was largely performed by the Karolinska Institute, whose flawed studies I have previously documented here, here, here, and here.)  Their results are almost identical to those in a large study of smokeless use in North America and Europe published six years ago (discussed here), and to findings in another analysis published eight years ago (here). Focus on a purported smokeless tobacco-pancreatic cancer link began after publication of a cherry-picked meta-analysis by Paolo Boffetta in 2008 (discussed here).  Dr. Boffetta contradicted his own finding in a later study (here), and epidemiologist Peter Lee refuted it in his comprehensive analysis in 2009 (here).  The fact is that there is no credible evidence that American or Swedish smokeless tobacco is linked to pancreatic cancer.       Remarkably, the National Cancer Institute persists in asserting a pancreatic cancer link in its smokeless tobacco “fact sheet” (here).  That document also asks what should be a rhetorical question: “Is using smokeless tobacco less hazardous than smoking cigarettes?”  The NCI’s answer is grossly misleading: “all tobacco products are harmful and cause cancer…There is no safe level of tobacco use.”  The agency’s source for this obfuscation is a 31-year-old Surgeon General report that has been eclipsed by three decades of epidemiologic studies.   It should be noted that the U.S. Food & Drug Administration is equally culpable. That agency used the bogus smokeless-pancreatic cancer link as a talking point in last year’s $36 million campaign against smokeless tobacco (here). We already knew that moist snuff and chewing tobacco have no measurable risk for mouth cancer (here).  Now there is scientific evidence that smokeless isn’t linked to pancreatic cancer.    Original author: Brad Rodu
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A Long Journey on Tobacco Road, Vindicated

“Current public health policies offer smokers only two choices: to continue to smoke despite knowledge of adverse health consequences, or to quit, which often proves very difficult. “In a review of the avoidable causes of cancer, Doll and Peto observed that ‘No single measure is known that would have as great an impact on the number of deaths attributable to cancer as a reduction in the use of tobacco or a change to the use of tobacco in a less dangerous way.’  Unfortunately, the second part of this observation has not received attention.  Because smokeless tobacco causes far fewer and considerably less serious health effects than does smoking, it should be promulgated as an alternative to cigarettes for smokers unable or unwilling to overcome their nicotine addiction.” Brad Rodu DDS, Professor, University of Alabama at Birmingham July 1, 1994  An Alternative Approach to Smoking Control.  American Journal of the Medical SciencesVolume 308: pages 32-34. (here) “Thus, both the 35-year-old non-user of tobacco and the smokeless-tobacco user will live on average to be 80.9 years of age compared with 73.1 years for the smoker.  Only 67% of smokers will be alive at age 70, compared with more than 87% of smokeless-tobacco users and nonusers of tobacco. “…abstinence is not the only approach to reducing tobacco-related mortality: for smokers addicted to nicotine who would not otherwise stop, a permanent switch to smokeless tobacco could be an acceptable alternative to quitting.” Brad Rodu DDS and Philip Cole MD, DrPH, Professors, University of Alabama at Birmingham July 21, 1994 Tobacco-related mortality.  Nature Volume 370: page 184. (here) “Among these and many other opportunities, there’s probably no single intervention, or product we’re likely to create in the near future that can have as profound an impact on reducing illness and death from disease as our ability to increase the rate of decline in smoking.  “We need to redouble efforts to help more smokers become tobacco-free.  And, we need to have the science base to explore the potential to move current smokers – unable or unwilling to quit – to less harmful products, if they can’t quit altogether.” Scott Gottlieb MD, Commissioner, US Food and Drug Administration May 15, 2017 Remarks to FDA Staff (here) Original author: Brad Rodu
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Vaping in the U.K.

Comedian-cum-philosopher Stephen Colbert has opined, “Facts matter not at all. Perception is everything.”  Actual British researchers have gone a step further, finding that, with e-cigarettes and vaping, perception changes behavior. British health authorities have consistently told smokers the truth about vaping since 2011 (here, here, here and here), while American officials, in their pursuit of a “tobacco-free society” or a “tobacco endgame,” have emphasized the negative, or simply perpetuated untruths and urban myths.  Survey data in the U.K. and U.S. demonstrate that truth-telling results in more accurate perceptions about vaping than do obfuscation and scaremongering (here).  Now, a survey from the U.K.’s Action on Smoking and Health (ASH) (here) shows that favorable perception translates into positive behavior. In this case, facts do matter.  The U.K. vaping population has ballooned, from 700,000 in 2012, to 2.9 million this year.  Importantly, the majority (52%) are former smokers – a sharp contrast to American data showing that most vapers are current smokers (here). Within these encouraging U.K. figures are reasons for concern.  First, the prevalence of vaping is currently 5.8%, which is only a 12% increase since 2015.  This suggests that e-cigarette use may be leveling out.  With some nine million Brits smoking today (here), vaping momentum will have to grow in order to drive down smoking. A major barrier to the success of e-cigarettes is misinformation (here).  The ASH report documents that 22% of smokers believe that e-cigarettes are more or equally harmful than cigarettes – a 9% increase from four years ago.  Anti-vaping propaganda, discussed here, may be a contributing factor.  Interestingly, 16% of smokers who tried but don’t use e-cigs said they would try them again if they were sure they were safe to use. The ASH report also documents that e-cigs don’t work for all smokers.  Of smokers who tried but no longer use e-cigarettes, 25% said the devices didn’t feel like smoking, and 20% said they didn’t help with cravings.  Smokers should be given access to a range of safer smoke-free substitutes, including smokeless tobacco and heat-not-burn products, in order to help them quit their deadly smoking habit.            Original author: Brad Rodu
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U.S. E-cigarette Summit Survival Guide

It’s the US E-cigarette Summit …and it’s going to get weird

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Sticking to the Facts On E-Cigarettes & Nicotine Medicines

A dentist colleague notes that the American Dental Association was one of 28 medical societies that signed a letter to the FDA in opposition to a change in the deeming date for e-cigarettes (here):  “Changing this date would significantly weaken FDA’s ability to take prompt action to protect children from thousands of fruit and candy flavored e-cigarettes and cigars, including products in flavors such as cotton candy, gummy bear and fruit punch that clearly appeal to kids.” Ironically, nicotine medicines also come in appealing flavors, like cinnamon surge, fruit chill, fresh mint, spearmint burst and white ice mint (here).  Evidently, marketers of both product categories view flavoring as a necessary and effective device to attract adult smokers. While e-cigarettes are often tagged with groundless or exaggerated claims of health threats, my colleague cites specific health issues associated with nicotine medicines, as reported by a reputable clinical drug information service: Adverse Effects that Occur >10% of the Time: Headache (18% to 26%), Mouth/throat irritation (66%), dyspepsia (18%), cough (32%), rhinitis (23%). Adverse Effects that Occur 1% to 10% of the Time: Acne (3%), Dysmenorrhea (3%), flatulence (4%), gum problems (4%), diarrhea, hiccup, nausea, taste disturbance, tooth abrasions, back pain (6%), arthralgia (5%), jaw/neck pain, nasal burning (nasal spray), sinusitis, withdrawal symptoms Adverse Effects that Occur : Allergy, amnesia, aphasia, bronchitis, bronchospasm, edema, migraine, numbness, pain, purpura, rash, sputum increased, vision abnormalities, xerostomia Adverse Effects For Which the Frequency is Not Defined: Concentration impaired, depression, dizziness, headache, insomnia, nervousness, pain, aphthous stomatitis, constipation, cough, diarrhea, gingival bleeding, glossitis, hiccups, jaw pain, nausea, salivation increased, stomatitis, taste perversion, tooth abrasions, ulcerative stomatitis, xerostomia, rash, application site reaction, local edema, local erythema, Arthralgia, myalgia, paresthesia, sinusitis, allergic reaction, diaphoresis. Any of these adverse effects could be needlessly exaggerated to condemn nicotine medicines, but they aren’t.  Nicotine can be consumed safely in gum, patches or vapor products.Original author: Brad Rodu
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Smokeless Tobacco 101

Huffington Post has published a discussion Joel Nitzkin and I had with psychotherapist Robi Ludwig (here).  HuffPo was not able to use the large number of resource links we provided, so I am republishing the article with the full complement, below. Two Doctors on A Mission to Set the Record Straight about Smokeless Tobacco and Its Impact on Public Safety By Robi Ludwig, PsyD, Contributor The historical roots of tobacco go way back to almost the beginning of time. Some date it as early as 1 B.C. when the American Indians used it for religious and medicinal practices. Given what we know about tobacco today it’s almost impossible to believe tobacco was ever thought of as a cure-all for everything from dressing wounds to the standard go-to painkiller. By the 1600’s tobacco was so popular that it was even used almost as frequently as money. Some even referred to it “as good as gold”. But some of the dangerous effects of smoking tobacco was starting to become apparent during this time, too. Sir Francis Bacon, the 1st Viscount St Alban, an English philosopher, statesman, scientist, jurist, orator, and author, who served both as Attorney General and as Lord Chancellor of England, admitted to having a very hard time quitting his tobacco use and found it to be an impossible “bad” habit to break. When we fast forward historically to the 1960’s, this is when the Surgeon General reported the various dangers of smoking to our health. And by 1971 Commercial Ads for cigarettes were taken off the air in the United States as an attempt to curb this dangerous and growing habit. Even today, with everything we know about the dangers of smoking, there are still some misperceptions out there about tobacco use, which could negatively impact up to 8 million adult American Smokers, but not if two prominent doctors have their way. Now Dr. Rodu and Dr. Nitzkin are trying to influence the public about Tobacco use by setting the record straight. Dr. Brad Rodu, who has studied the science behind tobacco harm-reduction strategies and has been appointed the first holder of the endowed chair in tobacco harm reduction research at the University’s James Graham Brown Cancer Center and Dr. Joel Nitzkin, public health physician, who is board certified in preventive medicine and has been involved in tobacco control activities since the late 1970’s, have made it their professional mission to reduce tobacco-related illnesses. Dr. Rodu and Dr. Nitzkin strongly believe that smokers who are unable or unwilling to quit cold turkey should be informed about much lower risk smokeless tobacco or e-cigarettes. I spoke with both doctors to find out how they believe adult smokers can potentially be spared from life-threatening smoking-related illnesses. Here’s more about what they both had to say on this topic. Dr. Robi: What exactly is smokeless tobacco, why was it created? Dr. Rodu and Dr. Nitzkin: Anthropologists and historians believe that tobacco has been used by humans for thousands of years.  The plant originated in the New World and was completely unknown outside the Americas until 1492, when Columbus first encountered native Americans using tobacco for ceremonial and medicinal purposes.  They smoked and chewed tobacco, the latter serving as the provenance of modern smokeless tobacco products. Smokeless tobacco dominated the American market prior to the 20th Century, because a day’s supply could be carried and conveniently used in both industrial and agricultural work settings.  In contrast, smoking was uncommon because producing cigars, cigarettes and pipes was labor-intensive and expensive.  In addition, smoking was very inconvenient before a safe and portable source of fire was readily available, which didn’t happen until the widespread use of safety matches in the late 1800s.   Dr. Robi: What are the different kinds of smokeless tobacco? Dr. Rodu and Dr. Nitzkin: In the U.S. there are two main kinds of smokeless tobacco.  Loose leaf chewing tobacco (“chew”) consists of shredded tobacco leaves and stems packaged in foil pouches.  Chew is also heavily sweetened and flavored.  It is used in fairly large quantities, which produces the typical swollen cheek appearance and generates a lot of juice. Moist snuff, also called dip tobacco, is the most popular smokeless product in the U.S.  It is manufactured from dark, fire-cured tobaccos grown in western Kentucky and Tennessee, fermented and ground to the consistency of finely chopped parsley.  Multiple flavors are available, but moist snuff does not contain sweeteners.  It is used in small amounts, generally as much as can be grasped between the thumb and forefinger in a “pinch.”  The tobacco is then placed inside the lower lip between the cheek and gum. Moist snuff is hard to contain in one spot, so manufacturers have packaged pinch-sized portions in small tea-bag type paper pouches.  The pouches are no larger than a piece of chewing gum or a breath mint, making them virtually invisible to place and use.  They also don't disintegrate, which makes the tobacco easy to remove after use. Since 2005 a Swedish version of moist snuff, called snus, has become more popular in the U.S.  Rather than fermented, the tobacco is treated by a pasteurization process that gives it a different flavor than American dip, and somewhat lower levels of unwanted contaminants.  Snus is also marketed in many flavors and small pouches. Americans place moist snuff in the lower lip, where it generates juice and spitting.  In contrast, Swedes don’t have to spit when they use snus, mainly because they place it inside the upper lip. Nicotine is absorbed from all smokeless tobacco products through the lining of the mouth, giving the user a “buzz” very similar to, but with a slower onset than that achieved by smoking a cigarette.  Nicotine is not the major cause of any disease; it is no more harmful than caffeine, which is also addictive but safely consumed in coffee, tea and cola drinks.    Dr. Robi: Are different kinds of smokeless tobacco better for you than others? Dr. Rodu and Dr. Nitzkin: No tobacco product is absolutely safe.  All contain traces of unwanted contaminants in addition to nicotine.  But it’s been known for two decades that, by avoiding smoke, chewers, dippers and snusers eliminate about 98% of the health risks associated with smoking.  The risks are so small that even large epidemiologic studies with hundreds of thousands of users cannot provide indisputable evidence that smokeless tobacco causes any disease.  With risks that small, it is not possible to prove that one kind of dip, chew or snus is safer than the other. Dr. Robi: Why is there so much confusion about smokeless tobacco and if this is a healthy alternative to regular cigarettes? Dr. Rodu and Dr. Nitzkin: Decades of scientific studies document that smokeless tobacco use is vastly safer than smoking with respect to cancer, heart attacks and strokes and many other diseases.  There is no confusion about smokeless tobacco among tobacco research and policy experts.  In 2002 a report by the British Royal College of Physicians, one of the world’s oldest and most prestigious medical societies, stated “As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10-1,000 times less hazardous than smoking, depending on the product.”  The Royal College issued another report in 2007 concluding “…that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved.  In 2008 the American Association of Public Health Physicians became the first medical organization in the U.S. to formally adopt a policy of “…encouraging and enabling smokers to reduce their risk of tobacco-related illness and death by switching to less hazardous smokeless tobacco products.”    Cigarettes are so popular that tobacco controllers incorrectly use the terms “smoking” and “tobacco use” as if they were synonyms, and they have become obsessed with the notion of a tobacco-free society.  They have transformed a legitimate war on smoking into a moral crusade against all tobacco products, a mistake that was tragically made with alcohol almost 100 years ago. When a federal survey asked in 2015 if smokeless tobacco products are less hazardous than cigarettes, only 11% correctly answered “yes”; 67% responded “no” and 22% didn’t know.  In other words, 89% of Americans have no clue that dipping, chewing and snusing are 98% safer than smoking.  They are confused because they have been misinformed for decades by government agencies and medical organizations that all tobacco products are equally harmful.  Misinformation from public health officials should no longer be tolerated.  Recently, two internationally renowned tobacco policy experts, Lynn Kozlowski, professor at the University of Buffalo School of Public Health and Health Professions, and David Sweanor, adjunct professor of law at the University of Ottawa, urged the FDA to end a $36 million campaign against smokeless tobacco “that fails to directly warn about the much greater harms from smoked tobacco (predominantly cigarettes).”  They concluded that “Public health agencies have an obligation to correct the current dramatic level of consumer misinformation on relative risks that they have fostered.”  Dr. Robi: Why do you think the FDA has not informed the public about the whole truth about smokeless tobacco? Dr. Rodu and Dr. Nitzkin: Obsessed with the notion of a tobacco-free society, the FDA so far has taken a hard line, falsely claiming that “To date, no tobacco products have been scientifically proven to reduce risk of tobacco-related disease, improve safety or cause less harm than other tobacco products.”  In other words, no tobacco product is absolutely safe.  The agency is defying a key element of its stated mission – “to provide the American public with factual and accurate information about tobacco products.”  And Congress in 2009 prohibited tobacco companies from any communication with smokers regarding safer smokeless alternatives without the express approval of the FDA.  The FDA has refused to acknowledge that its smokeless warnings are inaccurate.  Even worse, some of its regulations threaten to remove large numbers of smokeless and vapor products from the market.  In some cases the regulations require companies to conduct dozens of unnecessary studies on minute product details and human effects, which could take a decade or more. This is regulatory fundamentalism, a bureaucratic maze that condemns smokeless tobacco products and e-cigarettes, and therefore tobacco harm reduction, to purgatory. With this delay, cigarettes will continue to dominate the American tobacco market, and 440,000 Americans will die from smoking-related disease every year. Dr. Robi: How many adult smokers use smokeless tobacco as a way to quit smoking altogether? Dr. Rodu and Dr. Nitzkin: Federal surveys are usually used to count current, former and never tobacco users.  The surveys generally don’t ask former smokers if they switched, but there was one exception.  In 2000, the National Health Interview Survey asked former smokers if they had quit by switching to smokeless; some 260,000 men said yes, providing the first population-level evidence that smokeless is a viable cigarette substitute.  The 2015 NHIS documented that there were 5.1 million current smokeless tobacco users that year.  Unfortunately, the survey didn’t ask former smokers specifically about switching, but about 1.6 million smokeless users were former smokers, meaning they had switched to safer products like dip, chew or snus.  Almost 1.4 million smokeless users were current smokers; if they were made aware that smokeless was 98% safer, they might have fully switched. Dr. Robi: How many smokers die every year from smoking cigarettes? How about from smokeless tobacco? Dr. Rodu and Dr. Nitzkin: According to the CDC, the annual death toll among smokers is 440,000.  Despite the fact that smoking rates have been plummeting for three decades, the CDC death toll hasn’t changed for nearly 20 years.  In 2013, an FDA scientist concluded that the CDC estimate is too high. One might assume that the CDC tracks smoking deaths throughout the year, but that’s not the case.  Instead, they estimate the number of smokers in the U.S., then they apply secret mathematical formulas based on comparisons between current, former and never smokers.  A reporter years ago tried unsuccessfully to crack the black-box formulas.  Here is her summary: “The computer is fed raw data and... employs various complex  mathematical  formulas  to  determine  how  many people in various age groups, locations, and heaven knows what other categories are likely to get sick or die from what diseases and how many of these can be assumed to be smoking related.” The CDC provides death counts among smokers with single-digit precision (the current number is 439,033), but when it comes to deaths from smokeless use, the agency claims it can’t be done.  In fact, the CDC has the necessary data; its disinclination is likely due to the very low number that would result.  British researchers are not so inhibited; they reported in 2015 that there were no cancer deaths due to smokeless tobacco in the U.S. and Canada.  Last year, U.S. government-sponsored research revealed that the number of mouth cancer deaths among men who use dip or chew is zero.         Dr. Robi: What is the “Swedish Experience” and how does it connect to tobacco harm reduction? Dr. Rodu and Dr. Nitzkin: In virtually all developed countries, cigarette smoking has been the dominant form of tobacco consumption for over 100 years.  Sweden is a remarkable exception.  Smoking rates among men in Sweden have always been lower than in any other developed country, resulting in the lowest rates of lung cancer – indeed, of all smoking-related deaths.  The reason is that, instead of smoking, Swedes enjoy nicotine and tobacco by using snus, a 200-year old smokeless product. A study published in the Scandinavian Journal of Public Health examined lung cancer – the sentinel disease of smoking – among men and women in all European Union countries.  It concluded “that snus use is inversely correlated with cigarette consumption among men in Sweden, resulting in the lowest [lung cancer mortality rates] in Europe for most of the past 50 years.”  Numerous published studies have documented that male smokers in Sweden have used snus as a gateway to a smoke-free life, but that is only part of the story.  Snus use has also played a valuable role in steering tobacco initiators away from cigarettes.  Any tobacco use among children should be discouraged, but Swedish boys who experiment with tobacco choose snus, the product their fathers use.  This fact is well-received by tobacco research and policy experts who focus on eliminating deaths from smoking, not on eliminating tobacco. With respect to tobacco, Sweden is unique in the 28-country EU, which bans snus everywhere else.  The effect of this prohibition is profound.  If men in all EU countries had the smoking rate of Swedish men, nearly 300,000 deaths from smoking could be avoided each year.     The Swedish experience also has implications for its neighbors Norway and Finland.  In 1995, when Sweden and Finland joined the EU, Sweden applied for and received a waiver on the EU’s existing snus prohibition, thereby allowing Swedes to continue producing and selling within the country.  Finland adopted the ban, and since Norway never joined the EU, snus remained available there. Norwegian tobacco research experts have documented that snus suppressed smoking rates there.  In Finland, the decline in smoking levelled off after the 1995 snus ban, while the decline in Sweden continued. The Swedish experience wasn’t launched as a government program or anti-tobacco campaign.  It arose organically as tobacco users in Sweden made rational choices to use snus instead of cigarettes.  Dr. Robi: If you had to state a clear message to the public about smokeless tobacco, what would it be? Dr. Rodu and Dr. Nitzkin: The Swedish experience exemplifies harm reduction: consumers making rational choices to use smokeless instead of cigarettes, based on accurate perceptions and preferences.  The 40-50 million Americans who consume tobacco deserve truthful information from government and health organizations about vastly safer smokeless tobacco, e-cigarettes and vapor.  Millions of them could make the switch from combustible to smoke-free and lead longer and healthier lives.  How Swede it could be.    Original author: Brad Rodu
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CDC: E-Cigarettes More Popular Than FDA-Approved Quitting Aids

Cigarette smokers prefer e-cigarettes to FDA-approved quit methods, according to a research brief authored by the CDC Office on Smoking and Health, RTI International and the University of North Carolina (here).Using a nationally representative online survey of 15,943 adult smokers who tried to quit during the past three months, they found that 75% used one or more methods to quit, and 25% used only one method, as shown below..nobr br { display: none } td { text-align: center} Weighted Prevalence (%) of Methods Used By 15,943 Adult Smokers Who Attempted to Quit in Past 3 MonthsQuit MethodOne Method OnlyMultiple MethodsGave up cigarettes all at once14.7%65%Gradually cut back6.662Partially substituted e-cigarettes1.135Switched completely to e-cigarettes1.125Used nicotine gum or patch0.825Used Zyban or Chantix0.412Switched to “mild” cigarettes0.320Sought help – health professional0.215Sought help – websiteless than 0.17Sought help – telephone quitlineless than 0.17All methods25.375E-cigarettes were far more popular single quit aids for partial or complete substitution (2.2%), compared with nicotine patches/gum (0.8%) or other prescription medicines (0.4%).  They were also more popular when more than one aid was used.Of note, telephone quitlines were rarely used.  The government has poured millions of dollars into this mini-industry, yet quitlines were used by a mere 0.02% (unweighted, n=3) of smokers as single quit aids in this study.Participants here were current smokers.  A similar analysis performed on former smokers will show even more impressive effects from vaping. Despite the current study’s evidence of vaping’s popularity among smokers, the authors’ summation was understated: “Given that our data show that e-cigarettes are more commonly used for quit attempts than FDA-approved medications, further research is warranted on the safety and effectiveness of using e-cigarettes to quit smoking.”The fact is that the CDC has documented with real-world data that e-cigarettes are preferred smoking cessation aids, negating the argument that evidence is merely “anecdotal” (here).  Our government should adopt the UK Royal College of Physicians’ position that “the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.” (here).  In Britain e-cigs have been the leading quit-smoking aid since 2013 (here, page 46).Original author: Brad Rodu
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Age Restrictions on Smoking, Drinking and Driving

State legislatures have been lobbied in a coordinated effort, called Tobacco 21 (here), to raise the minimum age for tobacco sales from 18 to 21 years.  Hawaii, California and the District of Columbia have adopted the higher age limit, but numerous city and county ordinances have been passed.As an advocate of tobacco harm reduction, I strongly oppose any tobacco use by teenagers.  However, I am unconvinced that implementing a smoking ban for those under 21 is an effective strategy. One of the arguments for Tobacco 21 is that the same age limit has reduced teenage drinking.  The National Minimum Drinking Age Act was passed in 1984.  By 1988, all states prohibited alcohol purchase by those under 21.  The impact on underage drinking is debatable.  It has been on the decline for many years, but rates remain disturbingly high (here).  The chart above shows past-month (i.e., current) cigarette smoking, marijuana use, alcohol consumption and binge drinking (5 or more drinks on one occasion) among 16-17, 18-20 and 21-25 year olds in the 2014 National Survey on Drug Use and Health.  Despite almost 30 years of Alcohol 21 across the county, nearly a quarter of 16-17 year-olds and 44% of 18-20 year-olds were currently drinking, compared with 11% and 24% who were smoking.  In addition, a majority of drinkers were binging.  In 2014, recreational marijuana wasn’t legal for anyone, yet 15% of 16-17 year-olds and 21% of 18-20 year-olds were using that drug.  We can also compare these figures with those from 10 years earlier.  Here are the changes in current use from 2004:.nobr br { display: none } td { text-align: center} Percentage Change From 2004 to 2014 in Prevalence of Youth and Young Adults Who Currently Smoke, Toke, Drink or Binge DrinkAge (yrs)SmokeToke(%)DrinkBinge Drink16-17-51+6-28-4118-20-36+17-14-2321-25-25+25+4-1With Alcohol 21 in force for almost 30 years, drinking and binge drinking declined moderately among 16-17 year olds.  But smoking saw the steepest declines in all age groups, even in the absence of a ban for 18-20 year-olds.Alcohol 21 and Tobacco 21 laws are promoted to save lives.  In the case of smoking, the lives saved are far in the future, as smoking generally takes a toll in advanced age.  With alcohol, the lives saved are primarily from traffic accidents.  With or without alcohol, traffic accidents are the number one killer of youth and young adults (age 16-24 years), with about 7,000 deaths each year (here).  Legislators seeking immediate life-saving impact should consider further age-restricted driving licenses.  Original author: Brad Rodu
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