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| Journal of the New Zealand Medical Association,
15-June-2007, Vol 120 No 1256
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Snuffing out cigarette sales and the smoking deaths
epidemic
Murray Laugesen
Smokers continuing to smoke face a one-in-two (50%) risk of
early death.7 They are entitled to be told
officially that although quitting tobacco entirely is best, switching to snuff
will save them as many years of healthy life expectancy as quitting entirely,
minus 1 to 5 months.1 Switching is limited,
however, to nasal snuff, since the
Smoke-free Environments Act (1990) bans sale of oral snuff, permitting its import for personal use only. In 2007, Swedish Match (a company that also sells cigars and
pipe tobacco) began test-marketing nasal snuff through 20 tobacconists. Nasal
snuff, a finely ground tobacco powder, currently priced at $3.95 per 3.5g can (a
day’s supply), will cost about the same as hand-rolled smoking. It is the
only product on sale that can mimic smoking by raising blood nicotine levels by
10 to 12 ng/ml within 10 minutes.8 It quells
cigarette cravings equally rapidly.
Like the first puff of a cigarette, the first sniff of snuff
creates new sensations. Judging the two-finger pinch per nostril requires
practice. Menthol, if present, clears the nose; the nicotine may sting, and in
some cases the finely ground tobacco may induce sneezing.
Snuff as a stop-smoking aidSnuff is not a recognised stop-smoking aid—a
randomised controlled trial (RCT) is yet to be carried out. However, among
14,715 Swedish ever-smokers, ever-snuff users were 2.7 times more likely to have
quit, a higher ratio than for 11 other
factors.9 Among Stockholm adults reporting on
their most recent quit attempt, snuff was more popular and 2 to 4 times more
effective than NRT (nicotine replacement therapy). Of primary smokers surveyed
(those whose first use of tobacco was by smoking), just over half had so far
quit smoking entirely. But if they had ever used snuff, 92% had quit smoking,
compared with 56% who had not used snuff.10
The risks of snuffingA recent Ministry of Health-commissioned
review4 shows snuffing is not risk-free, but
the risks are (in every case) much lower than for smokers. Snuff does not cause
lung or oral cancer.11 Nasal and oral snuff are
assumed to have similar risks, as they have a similar chemical content and a
similar mucosal route of absorption. Nasal snuff is inhaled into the nose not
the lung, and does not cause lung damage. Neither does oral snuff.
Addiction to smoking carries high health and
financial costs, which is of particular concern to Māori families.
Switching addictions from smoking to snuff may not reduce the addiction, but it
cuts mortality risk by at least 95%, and cuts financial costs by at least 60%.
Snuff is nothing new—it has the same chemical content as (unburnt)
cigarette tobacco. Smokers who switch soon enough, survive to deal with snuff
addiction at their leisure.
For youth, to the extent that snuff is cheaper than
smoking, it will make smoking less popular. In Sweden, tobacco users’ life
histories show that those who started using tobacco as snuffers were 28% as
likely to be smokers as primary smokers.10
In Sweden where snuff is not considered as dangerous as
smoking, it is a gateway away from smoking. In the United States, where all
smokeless tobacco carries cancer warnings, it does not lower youth smoking,
because youth will say, “I might as well smoke.” In New Zealand, if
snuff can labels reflect the science, that snuff is much less dangerous than
smoking, smoking rates could be expected to fall.
With regards to cardiovascular disease, the
epidemiological studies are ambivalent.4 Snuff
like other unburnt tobacco contains nicotine and 1 part per billion (ppb) of
arsenic,12 whereas cigarette smoke also
contains the cardiotoxicant gases (hydrogen cyanide, carbon monoxide, and
benzene).13,14
Smoking, but not snuffing, induces thomboxane A2 formation,
which makes platelets in the blood sticky. Snuff avoids cigarette
smoking’s 10-fold excess sudden-death risk, and its 3.6 fold excess risk
of myocardial infarction.15 If snuff increases
the risk of cardiovascular death more than in non-tobacco users, but less than
in light smokers—as noted in one Swedish
study16—the active cardiac toxicant in
snuff could possibly be nicotine itself, absorbed at high blood levels in heavy
users over many years.
Carcinogenicity: Swedish Match reports
approximately 3 ppm dry weight of tobacco specific nitrosamines in its tobacco
snuffs.12 Low nitrosamine snuff (under 10 ppm)
has been exonerated as a cause of mouth
cancer.4 For nasal snuff, evidence of
carcinogenicity is insufficient.17
Naso-pharyngeal cancer has an incidence of 0.7 per 100,000 per year in Lesotho
women18—27% of whom use snuff, and have
done so for many years.
Lung cancer incidence is 50 times higher in New Zealand
Māori women (half of whom smoke) than in Lesotho women (of whom only 1%
smoke).18,19 Among 280,000 Swedish construction
workers, pancreatic cancer incidence was 13 per 100,000 per year in smokers and
9 in snuffers—more than double the 4 per 100,000 incidence in
never-tobacco users.11 Overall, however, the
incident cancer rate of lung, mouth, and pancreas combined was 102 per 100,000
in smokers, 18 in snuffers, and 16 in never users of
tobacco.11
A new comprehensive policy—to end the epidemic, not merely control itThe comprehensive policy to control cigarette smoking
(adopted in 1985 by the Advisory Committee on Smoking and
Health20 proposing tobacco advertising and
sponsorship bans and smoke-free public areas) has now been fully implemented.
Smoking was reduced, but continues to kill 12 New Zealanders a day. This
epidemic is spread by commercial cigarettes, and will persist until society
demands legislation to outlaw their sale. On census trends (23.7% smoking in
1996, 20.7% in 2006) on a business-as-usual basis, smoking will take another 70
years to disappear, and smokers will die of smoking until the end of this
century.
Governmental 5-year plans for “tobacco control”
can only include what is already government policy. To end smoking deaths,
society needs to adopt a new comprehensive policy. The Smoke-free Environments
Act will need amendment to specify a planned shut-down of commercial cigarette
sales. Personal liberties to smoke, grow, and possess smoking tobacco for
personal use would remain intact—a marijuana-type law is not needed.
Phasing in the changes over 5 to 10 years allows smokers, industry, and the
public to adjust to the new comprehensive policy. A longer phase-in could lose
momentum.
The effect of ending cigarette salesIn prevention terms, no single intervention has such as
large effect as ending cigarette sales. Smoking-driven inequity will be
eliminated.5 Taking 21% smoking in 2006 as the
baseline, if 5% of adults still smoke when cigarette sales cease ( say in 2016),
waning to 1% still smoking 5 years later (in say 2021), smoking prevalence will
then be 95% reduced below 2006 levels. Even if all smokers (21%) switched to
snuff, this is risk-equivalent to an extra 1% of adults smoking. Thus 5 years
after the sales ban, in say 2021, the total risk is equivalent to 2% (at most)
of adults smoking. Allowing 17-years lag to allow fully for the delayed
mortality effects of previous smoking21 a (2/
21) 90% reduction in tobacco deaths from 2006 levels is achievable 22 years
after the sales ban, equal to reducing annual deaths by 4000 or 14% of all
deaths,.
The effect of snuffOral snuff sales are currently banned, and snuffers will
likely never outnumber smokers in New Zealand, but snuff’s availability
means smokers can buy reliable protection from cigarette cravings, should they
not be able to buy cigarettes. Humane policy provision for addicted smokers in
this way makes it (ethically and politically) easier to plan the end of the sale
of cigarettes, and fully protect the next generation from the smoking deaths
epidemic.
Proposed interventionsRegulation—Government already has
regulatory powers to regulate now for (i) Warnings on snuff cans—which
could say “Snuff is addictive, can damage your health, but is much less
dangerous than smoking.” Until a regulation is in place this could be
achieved by negotiation with the importers. The Smoke-free Environments Act bans
smokeless tobacco companies from advertising snuff’s lesser risks, placing
extra responsibility on the Ministry of Health to publicise the issue and ensure
smokers are informed. (ii) Ensuring that only low-nitrosamine snuff and
smokeless products can be imported or sold.
Taxation—Risk-based tax rates would
encourage smokers to switch to less risky products, or to quit entirely.
Hand-rolled cigarette smoking costs $4 a day or 25 cents per cigarette;
factory-made cigarettes cost twice as much, and tax is half the cost. Both types
are probably equally hazardous. Instead of the current flat tax across all
tobacco product classes (36 cents a gram in 2007), the mortality risk-ratios
suggest a 20 to 1 ratio of cigarette tax to snuff tax should be inserted into
the Customs Act schedules. The retail price of smoking any type of cigarette
would rise to $10 a day or 50 cents per smoke, and for snuff would decrease to
$3 a day or 15 to 30 cents per snuff.
Legislation—The Smoke-free
Environments Act, strengthened with new aims to end the tobacco mortality
epidemic, will need to:
Oral snuff, already
preferred by Swedish men, is now preferred by younger, 1970s-born Swedes, of
whom 15% use oral snuff and 11% smoke.22 Since
1970, 12% or more of Swedish men have used oral snuff—cigarettes always
had to compete against lower-priced snuff. This may explain why Swedish male
lung cancer mortality rates peaked at half the level of New Zealand’s (38
as against 74 per 100,000 population).2 In
2000, 9% of all Swedish deaths were attributed to smoking, as opposed to 16% in
New Zealand.2
The numbers of people still smoking will
decline with synergistic effect. Smokers will find smoking less affordable, less
satisfying, and cigarettes more difficult to obtain, while snuffs become safer,
cheaper, and easier to obtain. Smoking becomes less fashionable as smokers quit
in increasing numbers well before the sales ban. Media stop-smoking campaigns
encourage more people to quit. As smoking prevalence falls, Parliament finds it
easier to finally approve the legislated ban on sales.
Implementing the sales ban will depend on Parliament and the
amendment bill making the big decisions, while the detailed implementation could
be left with a small, separate government tobacco authority, with toxicological
oversight of tobacco products. It would be unwise if not commercially risky for
the authority to get too involved in the industry it has to regulate.
ConclusionCommercial cigarettes spread the smoking deaths epidemic. A
law to end their sale can save an estimated 4000
lives2 and NZ$22 billion
annually.24 A Ministry of Health discussion
paper is now needed to outline a new comprehensive public policy package,
designed to end cigarette sales within 10 years, and end the smoking mortality
epidemic (not just control it). This would include proposals for legislation
which could lead to a member’s bill or a government bill to amend the
Smoke-free Environments Act, with a sunset date for ending cigarette sales.
Government, however, is likely to first want assurance it
has the support of a wide consortium of medical, academic, health professional,
anti-smoking advocacy and community groups, working in a strong and united
coalition. Adoption of a core aim, such as “Phase out cigarette
sales”, would make the intermediate steps more coherent, unite the sector,
and facilitate public support.
Ending cigarette sales and tobacco deaths by legislation may
seem impossible now, but laws securing the tobacco advertising ban law in 1990,
and the smoke-free bars law in 2003 were also regarded as impossible until late
in the legislative process.
(Further information on these issues is available at www.smokeless.org.nz)
Competing interests: None (SmokeLess
New Zealand does not benefit from any tobacco company; nor does the
author).
Author information: Murray Laugesen, QSO,
Public Health Physician and Chair of SmokeLess New Zealand Trust, Lyttelton,
Christchurch
Correspondence: Dr Murray Laugesen, 36
Winchester St, Lyttelton, Christchurch 8082. Email: laugesen@healthnz.co.nz
References:
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