Working with what we have


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Working with what we have

  1. 1. THE NEW ZEALAND MEDICAL JOURNAL Vol 119 No 1240 ISSN 1175 8716 Working with what we have before getting into bed with the tobacco industry New Zealand tobacco control strategies have been successful in reducing overall smoking prevalence, but there is still a way to go. For a long time the approach of the tobacco control community has been one of ‘quit or die.’ Although most smokers want to quit, many find this difficult. For half of all smokers their dependence upon tobacco will be directly responsible for future morbidity and premature death.1 We welcome the debate about smoking harm reduction opened by McCormick et al.2 They propose that new strategies to reduce the harm associated with smoking be considered, and they suggest Swedish snuff (‘snus’, a form of oral ‘smokeless’ tobacco) as a substitute for cigarettes that provides the nicotine smokers require without the many harmful products contained in cigarette smoke. We wholeheartedly agree that increasing the options for smokers who find quitting difficult or who do not want to quit is a matter of some urgency. However, there is still much more that could be done with existing and emerging therapies before introducing new tobacco products such as snus. Our concerns with snus include: • Insufficient evidence that this would be an effective intervention to reduce smoking in New Zealand. While there is ecological evidence from Sweden that introducing smokeless tobacco might lead to a reduction in the prevalence of people using smoked tobacco, no randomised controlled trials have been published showing that snus promotes quitting. • Second, the implications and impacts for Māori of introducing another form of tobacco must be thoroughly considered. • Third, introducing snus would involve an alliance with the tobacco industry, with its well-documented history of deception and manipulation. • Fourth, Swedish snus may be safer than smoking but it is not completely without risk. It contains tobacco-specific carcinogenic nitrosamines (2.0 µg/g product wet weight), which, while at levels lower than cigarettes (e.g. Marlboro Full Flavour 6.3 µg/g) cannot compare with the undetectable levels in nicotine replacement therapy (NRT).3 NRT has been available for the past two decades and has been shown to be effective in aiding smoking cessation.4 NRT’s potential for helping smokers goes beyond smoking cessation, for example in reducing cigarette consumption in smokers not motivated to quit.5 Some of these smokers actually go on to stop smoking completely. How can we improve NRT-based approaches to reducing tobacco-related harm? First, NRT product licenses generally recommend a 3–6 month treatment period only—but, given that smoking is a chronic disease of dependence, longer-term NRT could be considered for some smokers. Second, we support McCormick et al’s suggestion that evaluation of faster-acting NRT products be undertaken. NZMJ 18 August 2006, Vol 119 No 1240 Page 1 of 2 URL: © NZMA
  2. 2. Most currently available NRT products deliver significantly lower quantities of nicotine less rapidly than cigarettes,2 and under-dosing is also common. We would like to see this avenue explored first before introducing another unregulated tobacco company product that is of unproven benefit and of potential harm. New, faster-acting NRT products are currently in development and there is much more that can be achieved from products already available if only smokers and healthcare professionals could overcome their fear of NRT and be more liberal with its application. Chris Bullen Associate Director Hayden McRobbie Research Fellow Simon Thornley Public Health Registrar Natalie Walker Senior Research Fellow Robyn Whittaker Research Fellow Clinical Trials Research Unit, School of Population Health, University of Auckland References: 1. Peto R, Lopez A, Boreham J, Thun M. Mortality from Smoking in Developed Countries 1950- 2000. 2nd ed. Oxford: Oxford University Press; 2004. 2. McCormick R, Sellman D, Robinson G. Where to next with tobacco smokers? [editorial] N Z Med J. 2006;119(1238). URL: 3. Stepanov I, Jensen J, Hatsukami D, Hecht SS. Tobacco-specific nitrosamines in new tobacco products. Nicotine Tob Res. 2006;8:309–13. 4. Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2004(3):CD000146. 5. Hughes JR, Carpenter MJ. The feasibility of smoking reduction: an update. Addiction 2005;100:1074–89. NZMJ 18 August 2006, Vol 119 No 1240 Page 2 of 2 URL: © NZMA