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Rapid Responses: Rapid Responses published:
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Snus raises issue of health inequalities
- Hugh Whittall (17 February 2008)
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Snus is not a nicotine replacement
- Peter Goggin (17 February 2008)
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Nicotine addiction needs more than just "cessation" interventions
- Andrew J Ashworth (17 February 2008)
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Effectiveness of responses to nicotine and opiate addiction
- Raoul A Walsh (20 February 2008)
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Fear that Kills
- Elaine D Keller (31 August 2009)
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Hugh Whittall, Director Nuffield Council on Bioethics, London, WC1B 3JS
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I have read with interest the head-to-head articles regarding the use of snus (BMJ 16 February 2007), and welcome the discussion of this important subject. One issue not mentioned in these articles is the potential impact of snus on health inequalities and different ethnic and cultural groups. In its recent report, 'Public health: ethical issues', the Nuffield Council on Bioethics suggested that permitting snus might carry the risk of increasing health inequalities as members of certain ethnic groups who already have a culture of chewing stimulants might more readily take up using this substance. This should be an important consideration for health policy-makers and doctors in this context. Competing interests: None declared |
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Peter Goggin, editor Sausalito, CA 94965
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The title of this article is quite misleading ("Should doctors advocate snus and other nicotine replacements?"), as Snus is not at all a nicotine replacement. It would be more accurate to ask, "Should doctors advocate snus as an alternative to smoking?" Competing interests: None declared |
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Andrew J Ashworth, GP Davidsons Mains Medical Centre, EDINBURGH, EH4 5BP
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It is remarkable that the mainstays of treatment for opiate addiction are harm reduction and dose stabilisation while nicotine addiction is addressed on the basis of abstinence from the delivery method: the author declares his prejudice for abstinence as a competing interest and goes on so speculate against other treatment approaches on evidence of their danger against controls (not cigarette smokers), the opinions of anonymous “experts” and the unfounded and radical view that “harm reduction could lead to harm perpetuation”. A matter of three weeks ago you published my observation that “People with drug problems need services that take them through a continuum of making safe (reducing immediate risk of overdose), harm reduction (reducing later risk of blood borne virus), dose stabilisation, detoxification, and relapse prevention.” (1) In the absence of evidence on anything apart from detoxification services to those addicted to nicotine it is virtually inevitable that upcoming NICE guidance will be focussed exclusively on “cessation”. It would be fairly straightforward to measure pulmonary function outcomes in COPD patients who have “failed” smoking cessation interventions (perhaps the reverse is the truth) in a three armed trial of current treatment (nothing) against the use of long term NRT and snus (the protocol might even permit transfer from snus to NRT over time). Future NICE guidance and arguments like this might then be based on evidence rather than conjecture. At the risk of repetition: People with smoking problems need services that take them through a continuum of making safe (reducing immediate harm of, say, fire), harm reduction (reducing later risk of reduced pulmonary function), dose stabilisation, detoxification, and relapse prevention. 1. Heroin prescription to misusers: Treat patients, not communities Andrew J Ashworth BMJ 2008;336:173, doi:10.1136/bmj.39465.512373.3A Competing interests: None declared |
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Raoul A Walsh, Conjoint Associate Professor Centre for Health Research & Psycho-oncology, University of Newcastle, Australia 2308
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Most authorities believe the harm reduction approach involving education and free availabilty of needles and syringes helped head off a potential epidemic of HIV infection amongst intravenous drug users in Australia from the mid-1980's. The evidence for harm reduction's effectiveness in reducing opiate overdose mortality is,however, much less clear cut. Until the advent of the "heroin drought" in Australia around Christmas 2000, heroin mortality rates had been increasing substantially and inexorably during the 1990's. At the same time,places on methadone maintenance programs had also been markedly increasing. Of course, it could be argued that heroin mortality may have been higher without methadone availability. Nonetheless, the evidence is clear that a sudden reduction in heroin supply had a more dramatic effect on heroin mortality in Australia than ever previously witnessed. On the Australian tobacco front, aggressive abstinence-orientated control efforts spear-headed by graphic television advertisements and smoke-free legislation have produced declines in smoking prevalence which have been the envy of many other countries. While nicotine replacement therapies are readily available, these have been promoted as a way of quitting not reducing smoking. Whether snus availability would increase the effectiveness of tobacco control efforts or serve as a distraction and perhaps also confuse the public message about tobacco is by no means clear. Competing interests: None declared |
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Elaine D Keller, Writer Free-Lance
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Dr. McCara states, "If legalised, snus might be taken up by people, especially the young, who might never have smoked tobacco but who may then progress to doing so." Let us examine two questions concerning the risk: 1. Is this fear justified? 2. If so, can anything be done to mitigate the risk? The National Survey on Drug Use and Health (NSDUH) Report (sponsored by the Substance Abuse and Mental Health Services Administration, an agency of the U.S. Public Health Service) March 5, 2009: Smokeless Tobacco Use, Initiation, and Relationship to Cigarette Smoking: 2002 to 2007, states that 65.5% of smokeless tobacco users started using cigarettes first. Therefore, many more Americans are reducing their risk by switching to smokeless than are increasing their risks by switching to smoking. Now let's examine why, according to the NSDUH report, 31.8% did progress to smoking. Only 15% of the U.S. population realizes that smoking presents vastly greater health risks than using smokeless tobacco. One of the required warning labels on smokeless products is "This product is not a safe substitute for smoking." Obviously, the majority of people have interepreted this message "smokeless tobacco is no safer than smoking." Given the message that "you might as well smoke," many people did just that. If Americans had been provided with complete, accurate information, it is probable that very few would have progressed to the more dangerous form of tobacco use. So providing accurate information to everyone is one way of mitigating the risk. Other ways of mitigating the risks to the young non- tobacco user is to step up programs aimed at tobacco prevention, and to call upon parents to do their part to protect their children. This same fear-for-the-children is being used as justification to ban another harm-reduction tool that might prove to be even safer than snus, since it contains no tobacco: the electronic cigarette. Finally, let us examine a different risk, not mentioned in Dr. McCara's article: If harm reduction products are not made available, they will not be taken up by people who are unable to quit smoking. Millions will sicken and die horrible, painful deaths. Competing interests: None declared |
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