Guardians of the Public's Health

Smokeless Tobacco Warnings

  • 18 Sep 2011 7:12 PM
    Message # 702884
    The email below was submitted by a member responding to Joel Nitzkin's comment on smokeless tobacco warnings.

    Clearly the issues you raise concerning smokeless tobacco deserve a lot of discussion; but is AAPHP the appropriate forum?  Should these issues not be raised in articles in AJPH, JAMA, NEJM, etc., encouraging professional debate?  I have not looked at the recent literature on mouth cancer as it relates to chewing tobacco, but I am aware of a lot of anecdotal evidence that chewing tobacco is a risk factor in buccal cavity disease.  I would appreciate the references to the contrary.

    As for nicotine, my understanding is that in any form, nicotine is bad for the heart and a major risk factor in arterial disease and other aspects of heart disease (conduction problems, etc.).  If the nicotine in smokeless tobacco does not increase heart disease risk, is it a dose relationship, or some other factor that is being missed?  I know that nicotine is absorbed through the oral mucosa, because, when I smoked a pipe, I could recognize its effect; and I did not inhale pipe smoke so there was no lung absorption.  

    The real question, however, is not the relative risk of one form of tobacco over another, but do we wish to condone any form of nicotine addiction whether smoked or smokeless?  I understand the use of smokeless tobacco for those addicts trying to get away from cigarettes; but I can never support the use of smokeless tobacco by kids and adolescents regardless of the relative risk.  If a kid reads the warning labels on SNUS and it keeps him or her from initiating its use, I am willing to support a little disingenuous propaganda.

  • 18 Sep 2011 7:13 PM
    Reply # 702885 on 702884
    Dr. Nitzkin provided this response:



    The questions you raise are addressed in the 2011 Harm Reduction Update by Brad Rodu, posted on  If you go to that page, click on the top item on that page, and download the full 22 page text, you will find the following:


    1. Re smokeless tobacco and cancer of the oral cavity:  This is presented in Table 1, on page 2, and the narrative running from the bottom of column 1, page 2 to the middle of column 1, page 3.  The most recent reviews of this topic are presented in papers published in 2008 and 2009 by Boffetta and Lee, references 3, 4 and 5.  Basically, the only major current (since the 1980’s) risk factors for mouth cancer in the USA and Scandinavia are smoking and alcohol consumption. Once these confounding variables have been properly adjusted for, any risk posed by smokeless tobacco disappears. This is not the case relative to Bidi’s and other smokeless tobacco products in India, other Asian nations and part of Africa – but this risk appears associated with gross contamination of the tobacco products by other substances and gross bacterial contamination.  Prior to the 1980’s in the USA, there did appear to be a risk of moth cancer from smokeless tobacco in the USA, but, for reasons not clear at this time, possibly related to differences in manufacturing practices or other factors, this risk has long since disappeared.


    1. There are huge misconceptions about the risks posed by smokeless tobacco products, misconceptions shared by physicians, tobacco control staff and the general public.  These are discussed on page 7 of this update paper. In most physician’s minds – if presented with a case of mouth cancer – that cancer is erroneously considered due to smokeless tobacco if the subject had even once used a smokeless product, without regard to use of cigarettes or alcohol. 


    1. So strong is the effect of tobacco control dogma, that, as I noted in my September 7 posting to this blog, that three of the four mandated warnings on smokeless tobacco are technically incorrect. For this same reason, it is exceptionally difficult to secure publication of either a paper on this topic or even a letter to the editor of a major non-tobacco-oriented medical journal that conflicts with the conventional wisdom on this topic. I know, as I have tried. They are rejected as either “not suitable for publication in this journal” or on the basis that they disagree with the conclusions of papers supportive of the conventional wisdom.


    1. Neither I nor other proponents of tobacco harm reduction claim that either smokeless tobacco or nicotine are totally risk free, especially for adolescents and young adults most vulnerable to nicotine addiction. Our claim is that, compared to cigarettes, smokefree tobacco products are far lower in risk, posing  risk of fatal cancer, heart or lung disease less than 1% the risk posed by cigarettes. In fact, as summarized in this 2011 harm reduction update, there is no measurable increase in risk of death from any cause, save a miniscule and non-statistically significant increase in risk of stroke, and an increase in the risk of prematurity when nicotine products other than cigarettes are used by pregnant women. (The risks posed by smoking in pregnant women are much higher – but that is topic for another set of references).


    1. I, and other proponents of tobacco harm reduction, urge the same bans on marketing and sales of smokeless tobacco products to teens, as imposed on cigarettes. The issue here is the significant but far less substantial harm posed by addiction to nicotine. We also feel that these same restrictions should be imposed on Nicorette, Committ, and other pharmaceutical nicotine products widely available on open drugstore and discount store shelves, in candy flavors and with no age restrictions on sales in many, if not all, states.


    Please keep in mind that, given the 15-25 year incubation period between starting smoking and onset of potentially fatal cancer, heart and lung disease in smokers, almost all of the 8 million (400,000 per year x 20 years) persons who will die of a tobacco-related disease (not counting deaths due to environmental tobacco smoke) are currently adults over 35 years of age. Those of us supportive of tobacco harm reduction believe that a well coordinated tobacco harm reduction initiative could save the lives of half of those smokers, and do so in a way that will have little or no impact on teen initiation of tobacco/nicotine use. It is that belief that is driving me to bring this topic up for discussion within AAPHP, and, hopefully, through AAPHP to AMA and other health-related organizations.


    The literature supporting the premise that smokeless tobacco is not a gateway to smoking, issues related to dual use and electronic cigarettes are also discussed in the 2011 Harm Reduction Update, with literature references provided.




    Joel L. Nitzkin, MD

    Past co-Chair, APPHP Tobacco Control Task Force

    Last modified: 18 Sep 2011 7:14 PM | Anonymous
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