Quantifying the effects of promoting smokeless tobacco as a harm reduction strategy in the USA

Abstract

Background: Snus (a form of smokeless tobacco) is less dangerous than cigarettes. Some health professionals argue that snus should be promoted as a component of a harm reduction strategy, while others oppose this approach. Major US tobacco companies (RJ Reynolds and Philip Morris) are marketing snus products as cigarette brand line extensions. The population effects of smokeless tobacco promotion will depend on the combined effects of changes in individual risk with population changes in tobacco use patterns.

Objective: To quantitatively evaluate the health impact of smokeless tobacco promotion as part of a harm reduction strategy in the US.

Methods: A Monte Carlo simulation of a decision tree model of tobacco initiation and use was used to estimate the health effects associated with five different patterns of increased smokeless tobacco use.

Results: With cigarette smoking having a health effect of 100, the base case scenario (based on current US prevalence rates) yields a total health effect of 24.2 (5% to 95% interval 21.7 to 26.5) and the aggressive smokeless promotion (less cigarette use and increased smokeless, health-concerned smokers switching to snus, smokers in smokefree environments switching to snus) was associated with a health effect of 30.4 (5% to 95% interval 25.9 to 35.2). The anticipated health effects for additional scenarios with lower rates of smokeless uptake also overlapped with the base case.

Conclusions: Promoting smokeless tobacco as a safer alternative to cigarettes is unlikely to result in substantial health benefits at a population level.

Figure 1

The Camel Snus marketing web site (http://www.camelsnus.com accessed April 2008) includes interactive images. Once a user is logged onto the Camel Snus website, they can learn what snus is, how to use snus and the fact that it can be used where it is not possible to smoke cigarettes. When the user scrolls over various images, text appears that says ‘Yes!’ in response to the questions ‘Can you snus at a club?’ and ‘Can you snus on an aeroplane?’. Marlboro Snus direct mail promotion (bottom) distributed in December 2009, which promotes snus as an alternative way for smokers to use tobacco ‘whenever smoking isn't an option’. The text states, ‘You are now free to enjoy Marlboro without matches’ and ‘The foilpack fits perfectly alongside your smokes’. This mailer specifically promotes dual use; it includes coupons to receive either one or four free packs of Marlboro snus when the recipient buys Marlboro cigarettes.

Figure 2

Model of use patterns of cigarettes and smokeless tobacco. The numbers indicate the transition probabilities for the base case (current US). The sources for the values and their standard errors are in table 1. The smokeless node in this figure presents the transition estimates from Oregon, USA. As noted in the text and table 1, we also consider an alternative set of transition probabilities for the Smokeless node with low levels of dual use. The structure of the model is the same for each of the alternative scenarios, with the different transition probabilities listed in table 1. A spreadsheet containing the full model for the base case and the alternative scenarios is available as supplementary material.

Figure 3

Distribution of estimated health effects under the case based on current US tobacco use patterns (figure 2).