Suggested Talking Points on State Harm Reduction Proposals
- State elected officials should be working to reduce the death, disease and health care costs caused by tobacco use, not helping tobacco companies to sell more tobacco products and increase their profits. The best ways to reduce the harm caused by tobacco use are to prevent kids from starting to use ANY tobacco products, help current tobacco users to quit and protect non-smokers from secondhand smoke. As the new Surgeon General’s report reminded us, the science is clear about what policies work to achieve these goals: Higher tobacco taxes on all tobacco products, strong smoke-free laws and well-funded tobacco prevention and cessation programs. State officials should be supporting these policies and not allow themselves to be diverted by the unproven approaches advocated by the tobacco industry.
- Smokeless tobacco is harmful to health. The National Cancer Institute, the American Cancer Society, the U.S. Surgeon General and the U.S. Public Health Service have all concluded that smokeless tobacco products as sold in theUnited States are addictive and cause serious disease, including cancer. We should not be sending a message to our children that smokeless tobacco use is acceptable.
- There is no evidence that smokeless tobacco products help smokers quit. The 2008 Update of the U.S. Public Health Service Clinical Practice Guidelines regarding tobacco cessation concluded, “the use of smokeless tobacco products is not a safe alternative to smoking, nor is there evidence to suggest that it is effective in helping smokers quit.” In fact, many new smokeless tobacco products are being marketed as a way to get a nicotine fix when smokers cannot smoke. Such marketing discourages smokers from taking the one step that is sure to protect their health, which is to quit smoking entirely. Far from reducing the harm from smoking, this kind of marketing perpetuates harm. In addition, a 2009 study found that it was more likely for American smokeless tobacco users to switch to cigarettes than for smokers to switch to smokeless.
- Smokeless tobacco can be a gateway to smoking for kids, and state officials should not be making it easier for tobacco companies to market these products to our kids. Research has shown that adolescent boys who use smokeless tobacco products have a higher risk of becoming smokers within four years. Tobacco companies have a long history of user cherry and other sweet flavors and aggressive marketing campaigns to market smokeless tobacco products to kids. In recent years, tobacco companies have doubled their marketing of smokeless tobacco and introduced an array of new products, some of which look, taste and are packaged like candy (and even dissolve in your mouth like mints). It’s no wonder smokeless tobacco use among high school boys increased by 36 percent between 2003 and 2009.
- Tobacco companies have a long history of making deceptive claims about the health risks of their products, including smokeless tobacco, in order to discourage smokers from quitting and send a message to kids that they can use certain tobacco products without serious risk. Most notoriously, they fraudulently marketed “light” and “low-tar” cigarettes as safer than regular cigarettes despite knowing from their own research that this was not the case. Their goal was to get smokers to switch rather than quit and truly protect their health. In contrast to the proven policies that reduce tobacco use, “harm reduction” as promoted by the tobacco industry has never reduced the number of Americans who die from tobacco use and has frequently led to an increase in tobacco use. State officials should not help tobacco companies to repeat this fraud on the American people.
- The tobacco industry’s “harm reduction” campaign is an effort to circumvent and undermine the Family Smoking Prevention and Tobacco Control Act enacted by Congress in 2009. This law established criteria to protect public health and requires tobacco companies to seek independent review by the FDA before being allowed to make harm reduction claims (called “modified risk” claims) about their products. The 2009 Act properly requires tobacco companies to first provide the FDA with the scientific evidence to support such claims, including evidence about how the products will be marketed. The FDA’s Center for Tobacco Products has just issued draft guidance on the requirements for modified risk claims under the new law. If the tobacco companies have the evidence to support harm reduction claims about any of their products, they are legally required to provide that evidence to the FDA, a science-based agency with the expertise to evaluate these claims. The tobacco companies’ latest efforts are a blatant effort to make an end run around the federal law by getting state legislators to promote their claims. Legislators who support these efforts are being deceived by the tobacco companies into helping them sell more tobacco products and avoid the requirements of the new law.
- Tobacco companies earn billions of dollars in profits each year and don’t need taxpayer money to fund the scientific research the FDA requires to support harm reduction claims. It would be a special-interest giveaway of the worst kind for states to help tobacco companies fund this research. It would be especially irresponsible for states to divert resources from severely underfunded tobacco prevention and cessation programs to fund research that benefits the tobacco industry – and that the industry should be funding itself. The states should be funding programs to protect kids from tobacco, not to help the tobacco companies come up with new ways to go after our kids.
- Harm reduction involves more than the simple question of whether one product is less harmful to an individual user than another. How a so-called “harm reduction” product is marketed impacts whether it causes more kids to start using tobacco or fewer tobacco users to quit. The FDA law provides a path for tobacco companies to make modified risk claims about a product. They have to show not only that the product is less harmful to the individual user, but also that the product and its marketing don’t cause so many more people to start using tobacco or so many fewer to quit that any benefits to the individual user are negated. Congress gave this authority to FDA because it has the resources and expertise to make these decisions. State legislatures do not have the authority or expertise to determine which, if any, tobacco products should be marketed as modified risk products.
- A number of products have been approved by the FDA as safe and effective for tobacco cessation. No smokeless tobacco product has ever been proven either safe or effective for this purpose. Before any product can be marketed for tobacco cessation, federal law requires manufacturers to provide the FDA with scientific evidence demonstrating the product is safe and effective for this purpose. The promotion of unapproved products for cessation can cause health problems and also steer tobacco users from products that we know work. The science must rule the day in these decisions
ADDITIONAL BACKGROUND INFORMATION
Smokeless Tobacco is Harmful to Health
- The Surgeon General has determined that the use of oral snuff can lead to oral cancer, gum disease, and nicotine addiction.[i]
- The U.S. Surgeon General, National Toxicology Program, and the World Health Organization (WHO) recognize that using smokeless tobacco products can cause oral cancer.[ii],[iii],[iv] The National Cancer Institute has identified 28 carcinogens in smokeless tobacco products produced in the U.S.,[v],[vi] at levels much higher than in smokeless tobacco products from countries such as Sweden.[vii] Smokeless tobacco users are at a heightened risk for oral cancer compared to non-users and these cancers can form within five years of regular use.[viii]
- Smokeless tobacco products are as addictive as cigarettes and can cause the same type of dependence, which makes quitting smokeless tobacco very difficult.[ix] Furthermore, nicotine may factor into coronary artery disease, peripheral vascular disease, hypertension, peptic ulcer disease, and fetal effects.[x]
- Gum disease (gingivitis) is caused by smokeless tobacco.[xi]
- See TFK factsheet for more information on the health harms of smokeless tobacco use: http://www.tobaccofreekids.org/research/factsheets/pdf/0319.pdf.
Smokeless tobacco is not a safe or effective way to quit smoking
Smokeless tobacco is not a safe alternative to smoking. Nor is there any evidence that it is an effective smoking cessation device. On the contrary, it is marketed in a way and used in a way that KEEPS smokers smoking, and it can serve as an entry product for kids into broader tobacco use.
- The 2008 Update of the U.S. Public Health Service Clinical Practice Guidelines regarding tobacco cessation concluded, “the use of smokeless tobacco products is not a safe alternative to smoking, nor is there evidence to suggest that it is effective in helping smokers quit.” Promoting products that are not safe or effective as ways to quit smoking will only serve to discourage smokers from using those products that have been approved by the FDA as safe and effective.
- Far from helping smokers quit, smokeless tobacco products may just give smokers a way to continue their addiction. In fact, many of the new smokeless products are marketed as the way to get a nicotine fix when smokers cannot smoke. In doing so, tobacco companies are discouraging quitting and undermining our public health efforts to help people quit.
- A 2009 study found that it was more likely for American smokeless users to switch to cigarettes rather than smokers to switch to smokeless.[xii] The only evidence one can cite for using smokeless tobacco to quit comes from Sweden, and even that evidence is debatable. Importantly, in Sweden, the product is manufactured according to very strict standards, unlike smokeless tobacco products in the U.S., and there is NO marketing of the product allowed.[xiii]
- Now that the major U.S. cigarette companies produce their own smokeless tobacco products, they have an even greater financial incentive to market these products to keep smokers smoking and lure kids into tobacco use. Just like cigarettes, smokeless tobacco products have long been used to target kids. Industry documents revealed a graduation strategy in which youth were targeted with flavored smokeless products in forms like pouches for easy use and then transitioned to stronger products.
- After reviewing the available research and evidence on dissolvable tobacco products (DTPs), a recent report from the Tobacco Products Scientific Advisory Committee (TPSAC) of the FDA’s Center for Tobacco Products concluded the following:[xiv]
- “Beyond some anecdotal reports, TPSAC found no information on whether DTPs would increase the likelihood of cessation of cigarette use.”
- “…the TPSAC concluded that the available evidence, while limited, leads to a qualitative judgment that availability of DTPs could increase the number of users of tobacco products.”
- “The TPSAC could find no basis for the contrary finding—that availability of DTPs would decrease tobacco product initiation.”
Smokeless tobacco can be a gateway to smoking for kids
National surveys suggest that smokeless tobacco use does not appear to be replacing smoking, but instead serving as an entry to smoking or as a way for smokers to get their nicotine when they cannot smoke, thus helping to keep them addicted. This is indicated by the fact that smokeless tobacco use among high school students was going down pretty rapidly when cigarette smoking was declining dramatically, but has increased as smoking has leveled off among high school students.[xv] Smokeless tobacco use among high school boys increased by 36 percent between 2003 and 2009 – the same time declines in smoking were slowing.
- These increases have occurred as smokeless tobacco companies have increased their spending on product marketing. From 1998 to 2008 (the most recent year for which data are available), the top-five smokeless tobacco companies in the U.S. increased their marketing spending by 276.6 percent. In 2008, they spent a record $547.9 million to advertise and market their products, a 33.2 percent increase from the previous year and more than double what they spent only three years before ($250.8 million in 2005).[xvi]
- Tobacco companies have a long history of using cherry and other flavors and aggressive marketing campaigns to market smokeless tobacco products to kids. These strategies were successful in transforming smokeless tobacco from a habit primarily of older men to one of younger men. From 1970 to 1991, the regular use of moist snuff by 18 to 24 year old men increased almost ten-fold while use among men 65 and older declined by almost half.[xvii]
- And a new generation of smokeless tobacco products has hit the market – test-marketed in various cities around the country. Many of these new products are clearly “starter products” that appeal to young people – which makes them the guinea pigs in the test market. Some of them look, taste and are packaged like candy, and kids can use them without parents or teachers knowing because they do not require spitting or exhaling smoke. The newest products – sticks, orbs, and strips – are actually dissolvable tobacco products that can be swallowed.
With this continuing innovation, smokeless tobacco products can serve as an entryway into tobacco use for kids. Evidence shows that adolescent boys who use smokeless tobacco products have a higher risk of becoming cigarette smokers within four years.[xviii]
Raising smokeless tobacco tax rates reduces youth use
The new Surgeon General’s report, Preventing Tobacco Use Among Youth and Young Adults, states, “Clearly, making smokeless tobacco products available more cheaply could promote their use among price-sensitive youth. In addition, disparities in tobacco taxation (i.e., higher taxes for cigarettes than for smokeless tobacco) could result in a switch to smokeless tobacco among young males.”[xix]
As with cigarettes, raising the price of smokeless tobacco products through state tax increases or other means will prompt a reduction in smokeless tobacco use, especially among adolescents and young adults. One study found that a 10 percent increase in smokeless tobacco prices reduces adult consumption by 3.7 percent and reduces male youth consumption by 5.9 percent, with two-thirds of that reduction coming from kids stopping any use of smokeless tobacco.[xx]
It’s also important to keep all tobacco product tax rates equally high to discourage tobacco users from evading the higher cigarette tax rates by substituting smokeless tobacco for cigarettes. In the 1980s, for example, when state cigarette taxes climbed much higher and faster than smokeless tobacco taxes, there was a substantial increase in smokeless tobacco use, especially among young males, who make up 90 percent of adolescent smokeless tobacco users.[xxi] And, as mentioned previously, youth smokeless use rates have risen in recent years while cigarette taxes, but not necessarily smokeless tobacco taxes, have also increased.[xxii]
The CDC Task Force on Community Preventive Services, the Surgeon General, the World Health Organization, and many others know that increasing the price of tobacco products will reduce use, resulting in fewer diseases, fewer deaths, and less health care costs. Even the tobacco companies know it, and that’s why they and their allies fight against the increases.
Tobacco prevention funds should not be diverted for harm reduction research
The state should not be using taxpayer resources from severely under-funded tobacco prevention programs to conduct research on harm reduction for the tobacco companies. Instead, state programs should be using their scarce resources to prevent kids from starting and to encouraging users to quit the products that kill more than 400,000 Americans every year.
Not only do tobacco companies have billions of dollars to devote to research, but the new FDA law provides a path for using this research to support modified risk claims. If the companies can demonstrate that the product and the way it is marketed will actually reduce risk to the individual, while not increasing initiation and/or discouraging cessation, then modified risk claims can be allowed.
Most states lack the resources and capacity to do the type of research needed to fully evaluate harm reduction claims about tobacco products. In contrast, the FDA Center has the capacity, the expertise and the resources to review these applications.
Harm reduction resolutions are a smoke screen
State legislatures should not be doing the bidding of tobacco companies by passing resolutions supporting using tobacco products for harm reduction, especially when the science does not warrant such an approach. Congress passed the FDA law to give a science-based regulatory agency the authority to regulate tobacco, including any efforts by the tobacco companies to make modified risk claims. State legislators should remember that the companies pushing them to make resolutions are the same ones that:
- Spend $10 billion each year promoting the products that kill more than 400,000 American every year and that 90 percent of users first started as teens or younger;
- Are responsible for using cherry flavors, pouches, and aggressive marketing campaigns to as part of a “graduation strategy” to lure young males into tobacco use;
- Used marketing campaigns like Joe Camel and the Marlboro Man to lure millions of youth into smoking, with untold impact on public health;
- Have marketed light and low-tar cigarettes to convince smokers not to quit when they knew the products were no less harmful; and
- Have been found to be racketeers by the U.S. Federal Courts, as well as serial violators of the marketing restrictions in the 1998 Master Settlement Agreement with the states.
These decisions and resolutions about harm reduction, its effectiveness, and its problems, should be evaluated by a science-based agency – and the FDA is prepared to do so.
[i] U.S. Department of Health and Human Services (HHS), The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General, Bethesda, MD 20892, NIH Publication No. 86-2874, April 1986, http://profiles.nlm.nih.gov/NN/B/B/F/C/.
[ii] HHS, The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General, Bethesda, MD: Public Health Service, NIH Publication No. 86-2874, April 1986, http://profiles.nlm.nih.gov/NN/B/B/F/C/
[iii] National Toxicology Program, 10th Report on Carcinogens: Revised December 2002, Public Health Service, HHS, December 2002, http://ehp.niehs.nih.gov/roc/tenth/profiles/s176toba.pdf.
[iv] World Health Organization (WHO) Scientific Advisory Committee on Tobacco Product Regulation, Scientific Advisory Committee on Tobacco Product Regulation Recommendation on Smokeless Tobacco Products, 2003.
[v] National Institutes of Health (NIH), National Cancer Institute (NCI), Smoking and Tobacco Control Monograph 2: Smokeless Tobacco or Health: An International Perspective, September 1992, http://cancercontrol.cancer.gov/tcrb/monographs/2/m2_complete.pdf.
[vi] NIH, NCI, Smoking and Tobacco Control Monograph 2: Smokeless Tobacco or Health: An International Perspective, September 1992, http://cancercontrol.cancer.gov/tcrb/monographs/2/m2_complete.pdf.
[vii] Brunnemann KD, Qi J, & Hoffmann D, Aging of Oral Moist Snuff and the Yields of Tobacco-Specific N-Nitrosamines (TSNA): Progress Report, American Health Foundation. Prepared for the Massachusetts Tobacco Control Program, Department of Public Health, June 22, 2001.
[viii] The S.T.O.P. Guide (The Smokeless Tobacco Outreach and Prevention Guide): A Comprehensive Directory of Smokeless Tobacco Prevention and Cessation Resources. Applied Behavioral Science Press, 1997; Hatsukami, D & Severson, H, “Oral Spit Tobacco: Addiction, Prevention and Treatment,” Nicotine and Tobacco Research 1:21-44, 1999.
[ix] HHS, The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General, Bethesda, MD 20892, NIH Publication No. 86-2874, April 1986, http://profiles.nlm.nih.gov/NN/B/B/F/C/.
[x] HHS, The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General, Bethesda, MD 20892, NIH Publication No. 86-2874, April 1986, http://profiles.nlm.nih.gov/NN/B/B/F/C/.
[xi] “The Smokeless Tobacco Outreach and Prevention Guide,” Applied Behavioral Science Press, 1997.
[xii] Zhu, S-H, et al., “Quitting Cigarettes Completely or Switching to Smokeless Tobacco:
Do U.S. Data Replicate the Swedish Results?” Tobacco Control 18(2):82-7, April 2009.
[xiii] Swedish Food Regulations website accessed April 16, 2003. Sweden National Tobacco Act (1993:581), Section 14, http://www.sweden.gov.se/content/1/c6/08/62/43/ea7210ac.pdf.
[xiv] U.S. Food and Drug Administration (FDA), The Nature and Impact of the Use of Dissolvable Tobacco Products on the Public Health: A Report from the Tobacco Products Scientific Advisory Committee, March 1, 2012.
[xv] U.S. Centers for Disease Control and Prevention (CDC), “Youth Risk Behavior Surveillance—United States, 2009,” Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries 59(SS-5), June 4, 2010, http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf.
[xvi] U.S. Federal Trade Commission (FTC), Smokeless Tobacco Report for 2007 and 2008, 2011, http://www.ftc.gov/os/2011/07/110729smokelesstobaccoreport.pdf. Data for top 5 manufacturers only.
[xvii] CDC, “Surveillance for Selected Tobacco-Use Behaviors – United States, 1900-1994,” MMWR 43(SS-03), November 18, 1994.
[xviii] Tomar, S, “Is use of smokeless tobacco a risk factor for cigarette smoking? The U.S. experience,” Nicotine & Tobacco Research 5(4):561-569, August 2003.
[xx] Chaloupka, FJ, et al., “Public Policy and Youth Smokeless Tobacco Use,” Southern Economic Journal 64(2):503-516, 1997, http://tigger.uic.edu/~fjc/Presentations/Scans/Final PDFs/sej1997.pdf.
[xxi] Chaloupka, FJ & Warner, K, “Section 2.4: Econometric studies of the demand for other tobacco products,” Economics of Smoking, 36-37, January 12, 1999, http://tigger.uic.edu/~fjc/Presentations/Papers/handfinal.pdf. U.S. Department of Health and Human Services (HHS), Preventing Tobacco Use Among Young People: A Report to the Surgeon General, 1994, http://www.cdc.gov/tobacco/data_statistics/sgr/1994/index.htm.
[xxii] CDC, YRBS.