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[6.0] Are products other than Western moist snuff (ST) or e-cigarettes good substitutes for cigarettes?

Though many products contain nicotine, we emphasize electronic cigarettes and moist snuff, particularly the kind in packets or hard lozenges, because they provide nicotine in a way that can satisfy most smokers, with minimal health risks, and are easy to use. Chewing tobacco and loose moist snuff have the same low health effects, but are harder for most smokers to consider using because of the appearance and the need to spit. There are some other products that are worth mentioning.

[6.1] Are pharmaceutical nicotine products as good a substitute for smoking as ST or e-cigarettes?

Pharmaceutical nicotine products (also known as nicotine replacement therapy or NRTs) include the nicotine patches and gums that are available without a prescription in many places. They also include a variety of inhalers, nasal sprays, topical gels, and lozenges that range in availability depending on where one resides.

These products are specifically designed to help people quit smoking and all other nicotine use, by tapering down the amount of nicotine consumed. If someone wants to quit using nicotine entirely, and these products can help, then that is great. Unfortunately, the research shows that using pharmaceutical nicotine products to quit smoking results in failure more than 90% of the time.

More and more people are using NRTs as a substitute for smoking, in much the same way they might use ST. Instead of using the products for a few weeks or months to try to quit entirely, they use them for a long time to get the nicotine without the smoke. Unfortunately, because the products are designed for quitting nicotine entirely, they are designed to provide a slow dose of nicotine that most smokers do not consider sufficiently satisfying. Furthermore, they are usually much more expensive than tobacco products. That said, for any smoker that finds them to be adequate (and does not mind the price), we encourage him or her to use them instead of smoking.

It may be that pharmaceutical companies might start marketing products with doses that better mimic smoking and lower prices, and try to provide a good long-term substitute for smoking that competes with ST and e-cigarettes. We hope they do, because the more alternatives to smoking that exist, the better. But until then, smokers are likely to find ST and e-cigarettes more satisfying substitutes than pharmaceutical products.

[6.2] Are pharmaceutical nicotine products less harmful than ST?

They may be a bit less or a bit more harmful. Either way, the difference is almost certainly very small, so if someone can use one of them as a substitute for smoking, it really does not matter which.

Some nicotine prohibitionists pretend to support harm reduction, but say that smokers should only use pharmaceutical products as a reduced-harm alternative (knowing that available products are unsatisfying and expensive). Other anti-tobacco advocates simply claim that pharmaceutical products are less harmful than smokeless tobacco. They are misleading you. We say this not because their claim is wrong, but because there is no evidence one way or another, and they are lying when they imply there is. Researchers simply have not had the opportunity to study the health of long-term users of NRTs, like they have long-term ST users (or smokers).

In contrast to the evidence that any risks from ST are small, claims about risks from NRTs are speculation. Indeed, the best reason to believe that the health risk from long-term use of NRTs is small is the fact that the risk from ST is small. We can guess that the risks are about the same. NRTs might be a little bit less risky (only a little bit, since the risk from ST is already so small), or a little bit more risky (it is possible that the different doses or other effects of the medical devices cause some risk, or that other chemicals in tobacco reduce certain risks). There is no evidence to support speculation one way or the other. Since, as we noted above, if there is a risk of deadly disease from smokeless tobacco use, it probably is mostly heart disease and stroke, which are probably caused by the nicotine itself, it seems unlikely there is much difference in risks.

Fortunately, the risk from either ST or NRTs (or e-cigarettes) is very low compared to smoking, and so it really does not matter that we do not know which one is slightly safer. If any form substitutes successfully for someeone's smoking, it is a good choice.

[6.3] Are smoking cigarettes made with pure tobacco or using hookahs any healthier than smoking regular cigarettes? -Not really.

So far, none of these products reduce the risks nearly as much as ST. Since the most dangerous thing about smoking is inhaling smoke, any alternative that still requires inhaling smoke is going to be about as bad as cigarettes. Previous attempts at creating lower-risk cigarettes have proven to be not much safer, and sometimes more harmful, than regular cigarettes. (Many anti-tobacco advocates still feel embarrassed and angry because they think that cigarette companies tricked them into supporting these supposedly-reduced-risk cigarettes. This may be one reason why they resist the huge potential benefits of real tobacco harm reduction.)

It is unlikely that any new cigarette products that require inhaling smoke can be much better than current cigarettes. It is possible to imagine new products reducing risks by 10% or 20%, but that still leaves a lot of risk, and is not very impressive compared to over 95%. Cigarette companies have experimented with substitute cigarettes that heat the tobacco, rather than burning it, to release the nicotine, which is then inhaled. It is possible that the risks from these would be much less than from burning tobacco, but we will never really know unless they become popular and we can actually observe the health effects.

Hookah pipes, traditionally used in some Middle Eastern cultures, have become popular among some people in the West. Some of the users apparently believe that because the tobacco they smoke is pure and minimally processed, with nothing added by cigarette companies, that it is much less harmful. But, again, since the problem is inhaling smoke, it does not matter much if the smoke is from pure tobacco, cigarette tobacco, or dried broccoli for that matter. Hookah smoking might be a little bit better or a little bit worse than cigarette smoking, but the difference is likely fairly small.

Cigars or standard Western pipes are typically used without inhaling, taking the smoke only into the mouth. This still exposes the user to smoke, but does not involve the lungs to such an extent. This is certainly better than inhaling the smoke, but not nearly as good as avoiding smoke altogether.

[6.4] You limited some of what you have written to modern Western smokeless tobacco products. What other products are there, and how are they different?

We emphasize that limitation mainly because the research and comparative risk information we give applies to currently-available moist snuff and chewing tobacco products. Since most of our readers will not have easy access to other smokeless tobacco products, this is mostly a technical point. But for those who might use other products you should know that they might entail a greater risk.

Products that include tobacco are dipped as snuff in and near India, Sudan (where it is called toombak), and elsewhere in the world. Some of these products include other major ingredients, like betel nut, and the manufacturing processes probably vary substantially. The scientific evidence suggests that some of these products pose a high risk for oral cancer, possibly as high as the oral cancer from smoking. They may also cause other risks that have not yet been studied. The reason this differs from U.S. and Swedish products is not known; it could be due to the other ingredients, or something about the processing.

Health risks from these products appear to be high enough that they seem like poor choices for anyone who can get the Western products. It still might be a good public health policy to encourage use of these native products instead of smoking (which continues to gain popularity through much of the world), particularly when Western products are far too expensive compared to local products. This is a largely unexplored question, so we will not venture an answer.

Another class of products are non-modern Western products, particularly dry snuff. Dry snuff is no longer popular or widely available, so there is not much point in suggesting it as a substitute for smoking. There is some speculation that older dry snuff products created greater health risks than modern moist snuff. The one large study that found an association with oral cancer looked at subjects who used dry snuff in the early- and mid-20th century. There are many explanations for that study result, and we will never know if that old product really did cause disease risks that current products do not. Fortunately, it hardly matters: no one is using mid-20th century dry snuff anymore.

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