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
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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: http://www.nzma.org.nz/journal/119-1238/2084/
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: http://www.nzma.org.nz/journal/119-1240/2139/ © NZMA