Department of Medicine

Department of Medicine

The Harm Reduction Debate

• Current context of the debate

- Snus enthusiasts vs. pessimists

• Switching from cigarettes to snus alone will reduce individual risk

• But: What will happen on a population basis?

Department of Medicine

Current Smokeless Advertising• Cigarette-branded smokeless tobacco products

• Appear to promote dual use

• Free with purchase of cigarette pack

• Marketing messages

– Convenient, discreet, for smokefree places

– New demographic groups?

UST Conference for Investors December 19, 2007

Department of Medicine

Data used in Modeling

• CDC MMWR reports

• National Health Interview Survey data

• U.S.T. marketing documents and shareholder presentations

• Phillip Morris documents

• IARC Monographs

• Peer Reviewed Literature

• Tobacco trade journals

Department of Medicine

Modeling Assumptions

• Four mutually exclusive groups of smokers

– Stable

– Health concerned

– Smoke-free environment

– Price sensitive

• Non-users do not initiate tobacco use as dual users

• Snus use is not widely prevalent in the U.S. population

• Changes arise from the current pattern of use

• Smokeless not used as a cessation aid

Stable

Department of Medicine

Health Effect: Base Case

Condition Prevalence

Never User 56%

Quit 19.8%

Cigarettes 21.6%

Smokeless 1%

Dual 1.6%

Total

Department of Medicine

Health Effect: Base Case

Condition Prevalence Risk

Never User 56% 0

Quit 19.8% 5

Cigarettes 21.6% 100

Smokeless 1% 10

Dual 1.6% 90

Total

Department of Medicine

Health Effect: Base Case

Condition Prevalence Risk Effect

Never User 56% 0 0

Quit 19.8% 5 0.99

Cigarettes 21.6% 100 21.6

Smokeless 1% 10 0.1

Dual 1.6% 90 1.44

Total 24.1

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Results

Health Effect: 24.2 (21.5, 27.2)

Scenario Transition ProbabilitiesAggressive smokeless promotion

Increase smokeless initiation x10

Health concerned: Increase smokeless use x 10 (half from cigarettes, half from quitters)

Dual use among new users .25

Smoke-free environments: Quitting cut in half

Cigarette users to smokeless .50

Dual use among new users .75

Price sensitive: Quitting cut in half

Cigarette users to smokeless .50

Dual use among new users .25

UST Increase smokeless initiation by 3.7

Aggressive promotion with most new users from smokers

Increase smokeless initiation x 10

75% from smokers; 25% from never users

No effect on initiation No change in initiation patterns

Department of Medicine Scenario Tobacco-related health

effect

(95% CI)

Base Case 24.1

(21.5-27.1)

Aggressive smokeless promotion

30.5

(25.8-35.6)

UST 24.8

(21.8-27.9)

Aggressive promotion with most new users from smokers

25.9

(22.7-29.4)

No effect on initiation 22.3

(19.8-25.1)

Department of Medicine

Conclusions

• Promotion of smokeless as a safer alternative to cigarettes unlikely to provide population health benefits

• Promotion of smokeless may actually lead to an increase in harm at the population level

Department of Medicine

Public Health Implications

• Other risks of promotion of smokeless as less harmful than cigarettes include:

– Undermining effective policies

– Confusing public messages

– Legitimizing tobacco companies

• Focus on proven harm reduction strategies that rapidly reduce tobacco use and disease

• Taxes, regulation, litigation

Department of Medicine

Department of Medicine

What would have to happen to cut health effects in half?

• Increase smokeless initiation by 5x, all from cigarettes

• Cut dual use in smokeless initiators from .40 to .15

• Cut smokeless to cigarettes from .17 to .03

• All smokers health concerned

– Increase smokeless 15x

– 75% from cigarettes, rest from quitters

– 25% become dual users

• Reasonable assumptions?