Editorial : The Lancet (Medical Journal)

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  • Zero
    Member
    • May 2006
    • 1522

    Editorial : The Lancet (Medical Journal)

    Many thanks to Darkwing for pointing out and providing the article! The Lancet is one of the oldest scholarly medical journals in the world. This was the editorial in their most recent issue, which also featured several academic papers which were related.


    Adding harm reduction to tobacco control

    “There is no good reason why a switch from tobacco
    products to less harmful nicotine delivery systems
    should not be encouraged.” So stated a 1991 Lancet
    Editorial, yet 16 years later cigarettes continue to
    dominate the nicotine-delivery system market, despite
    their clear health risks. Most smokers want to quit but
    continue to smoke because they are addicted to nicotine,
    and cigarettes deliver high doses of the drug rapidly to
    the brain. But the adverse health effects come mostly
    from nitrosamines and other carcinogens in the tar and
    carbon monoxide and nitrogen oxides in the smoke.
    Half of all smokers will die prematurely if they continue
    smoking. With 1·6 billion smokers expected worldwide
    by 2025, all opportunities to reduce the harm caused by
    tobacco smoking must be seized.

    Current tobacco control policies as outlined in the
    WHO Framework Convention on Tobacco Control
    (including price and tax increases, and prevention
    of smoking in public and work places) have typically
    achieved reductions in smoking prevalence of at best
    1% per year in countries where cigarette smoking is
    common. Given the limitations of tobacco control,
    argue John Britton and Richard Edwards in a Viewpoint
    published online on Oct 5, radical reform of nicotine and
    tobacco product regulation is needed. Based on a report
    published by the UK’s Royal College of Physicians (RCP),
    Britton and Edwards apply harm-reduction principles
    to smoking and conclude that a wide range of nicotine
    products, including medicinal nicotine (currently
    marketed as nicotine-replacement therapy) and low-
    nitrosamine smokeless tobacco products, such as snus,
    should be developed, regulated rationally in relation to
    each other, and made available in inverse proportion
    to their hazards. They argue that as smoked tobacco
    (cigarettes, cigars, pipes) causes far more disease than
    most forms of smokeless tobacco, which in turn are
    more hazardous than medicinal nicotine, efforts should
    be channelled into developing low-risk products capable
    of delivering nicotine as efficiently as cigarettes, while
    subjecting smoked tobacco products to increasing
    restrictions. Stopping smoking and cessation of nicotine
    product use is the ultimate goal, but for those who
    cannot quit, or who want to reduce the harm related to
    smoking, less hazardous methods of obtaining nicotine
    should be available.

    However, Martin McKee and Anna Gilmore argue in
    our Correspondence section that snus has not been
    proven to be an effective aid to quitting smoking and
    that the risks of dual snus and cigarette use have to
    be considered. They are correct. Controlled trials are
    needed to confirm the Swedish observational studies
    that suggest snus helps quitting. Moreover, widening
    access to snus could increase the profits of tobacco
    manufacturers who are now busily marketing snus as
    a harm-reduction product. British American Tobacco,
    for example, has introduced Lucky Strike snus into
    Sweden and South Africa. Meanwhile, Marlboro snus
    and Camel snus are being marketed by Philip Morris USA
    and R J Reynolds, respectively. In McKee and Gilmore’s
    view, permitting such snus branding might encourage
    continuing nicotine addiction which could mitigate
    the effects of smoke-free legislation. Allowing tobacco
    companies to get yet another wedge in the tobacco
    market is a serious concern. But so long as there are
    progressively increased restrictions on smoked tobacco,
    effective and familiar branding of harm-reduction
    products may help smokers to switch.

    No tobacco product has been shown to be totally risk-
    free. Observational data suggest, for example, that snus
    is associated with an excess risk of pancreatic cancer, but
    not oral or lung cancer, in Swedish male construction
    workers who were followed up for 20 years. The gener-
    alisability of such data remains to be tested in other
    populations, and long-term follow-up of users of nicotine
    and smokeless tobacco products is needed to identify all
    possible risks. Of relevance here too is the likelihood that
    medicinal nicotine and low-toxicity smokeless tobacco will
    be far less hazardous to non-users than smoked tobacco.
    Quantifying this relative benefit would be useful.
    Britton, Edwards, and the other members of the
    RCP’s Tobacco Advisory Group advocate a courageous
    approach to nicotine addiction. Greater availability of
    medicinal nicotine, and perhaps even of low-toxicity
    smokeless products, along with increasing restrictions
    on smoked tobacco, is likely to reduce tobacco-related
    mortality and morbidity. Given the known hazards of
    smoked tobacco, and the numbers of people who smoke,
    innovative thinking is needed. We support tobacco harm
    reduction alongside rigorously applied tobacco control
    policies.

    ■ The Lancet
  • The Cook
    Member
    • Aug 2007
    • 166

    #2
    It's encouraging to read even a tentative nod towards snus and other forms of nicotine replacement therapies (NRT) in the Lancet. Maybe some of that thinking will make it here to Canada.

    I have a couple gripes with the article, though. In it, the authors say that snus is implicated in increased pancreatic cancer. This is based on the study of construction workers in Sweden, I think the study group was at least 200,000 men. What I remember reading ( I don't have the citation, I think it was in the Gothiatek papers) that the level of pancreatic cancer was in the order of 40 extra cases than the normal rate for a group that size.

    My other gripe is their reluctance to see snus (and other NRTs) as an effective method in which to quit smoking. I believe that the Swedes have statistics on the cigarette to snus transition. It must be high, because of the low rate of smoking amongst men in Sweden.

    Otherwise, an encouraging article.

    Comment

    • The Cook
      Member
      • Aug 2007
      • 166

      #3
      It would be interesting to run a poll here - "Did you use snus to quit cigarettes?" I'd do it, but I don't know how to create a poll on this forum.

      Comment

      • Coffey
        Member
        • Feb 2007
        • 150

        #4
        To The Cook, poll added in the health section.

        Comment

        • darkwing
          Member
          • Oct 2007
          • 415

          #5
          Blog entry about snus from delegate at European conference

          Day 2 Session 1 - Harm reduction
          Another interesting discussion over breakfast (Mental Health and cessation and how to engage with minority communities)

          The first session of the day was likely to be the most controversial. Following the RCP report of last week Harm Reduction is a hot issue in the UK and the session attracted a good sized audience.

          Detailed presentations from fellow blogger Jonathan Foulds and Dorothy Hatsukami concentrated on the relative risks of SNUS and other oral tobacco products. These were followed by a debate.

          Ann Mc Neill as chair said that she wanted to try and avoid the `usual slanging match` that the discussions on harm reduction have previously been and steered the audience through a set of questions. Unfortunately the debate didn`t get going and the overwhelming vote at the end of the session was one of abstention.

          Is it that the public health community cannot agree on this issue? or are we frightened to allow another product onto the market and increase the complications? On the one hand it seems sensible to be able to offer a less dangerous product to smokers and thereby reduce thier risk of dying early. So why are our colleagues from Sweden (where SNUS is readily available) so against this? Are we worried that if the tobacco industry is so in favour of something then it can not be the right decision.

          In a room of health professionals we had strong views on both sides. The clearest majority vote was for lifting the ban on smokeless products within a regulatory framework but this was by no means unanimous. Until we can get consensus amongst ourselves I would feel very uncomfortable trying to sell our position to the public.

          I have not read the entire RCP report yet. Hopefully when I do I may be clearer in my own mind.

          12 October 2007 in Paul Hooper | Permalink
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          • Gangleri
            New Member
            • Oct 2007
            • 3

            #6
            I think what the Lancet is getting at is that there are no controlled studies that show snus helps people quit; only observational data from Sweden, which is strong evidence, but not proof.

            It does always annoy me that anti-snus:ers always say "There are no controlled studies that show", as if that in itself was proof that Snus did NOT have this effect.

            The editorial in the Lancet is calling for a controlled study to be conducted. Which is fair and even-handed, if you ask me :-)

            Comment

            • Zero
              Member
              • May 2006
              • 1522

              #7
              I agree. Still, I think the aggregate Swedish population and health statistics are telling in themselves. Then again, maybe it's an occasional portion of surströmming that keeps the cancer away :lol:

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