Should doctors suggest alternative sources of nicotine to people who are unable to give up cigarettes, asks this week's BMJ?
Smoking currently kills over 100,000 UK citizens each year, predominantly from lung cancer, heart disease, and chronic obstructive pulmonary disease, writes John Britton, Professor of Epidemiology at City Hospital, Nottingham. Currently 77% of UK smokers want to quit, and 78% have tried and failed, mainly because of nicotine addiction.
He argues that health professionals should strongly advise smokers to quit all nicotine use, and do all they can to support this. However, for those who try repeatedly and fail, or for those who are not ready to stop using nicotine, switching to a medicinal nicotine product is the logical best option. By far the safest alternative is the current range of nicotine replacement products, he says. But, if all else fails, there is a case for individual smokers trying smokeless tobacco, or snus, which is substantially less hazardous than smoking.
Recent data from Sweden, where snus has been available for years, suggests that smokeless tobacco is an acceptable smoking substitute for some smokers. Yet, in the UK, it is illegal for a doctor or anyone else to supply snus.
Britton believes that, as a measure of last resort in smokers who have tried all other cessation and substitution options, doctors would be justified in suggesting an individual trial of snus. Whether this approach will prove effective remains to be seen and desperately needs to be tested in clinical trials, he concludes. But Alexander Macara, President of the National Heart Forum, argues that this could result in increased use of tobacco.
He points to evidence that smokeless tobacco is carcinogenic to humans. Studies have also shown increases in the risk of oral and pancreatic cancers and heart attacks related to the use of various smokeless tobacco products. He acknowledges that smokeless tobacco is less addictive than smoked tobacco, but warns that at least 60% of people who use snus to quit smoking become chronic snus users.
Both Action on Smoking and Health and the Royal College of Physicians of London have considered providing safer sources of nicotine as a harm reduction option, but Macara fears that, 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.
The tobacco industry's constant defence is that tobacco is a legal product, he says. But if we had known before tobacco was ever used, how disastrous it would prove to be, would it not have been banned in all its forms?