"Men were more than 2.5 times as likely to have switched from snuff to cigarettes than to have switched from cigarettes to snuff," said Dr. Scott Tomar, a professor of public health services and research at UF's College of Dentistry who tracked snuff and cigarette use among more than 14,000 U.S. men. Tomar's study appears in the current issue of the American Journal of Preventive Medicine.
Tomar assessed data gathered from the 1998 National Health Interview Survey, which is conducted by the Centers for Disease Control and Prevention and updated approximately every four years.
"Snuff may be a gateway form of nicotine dosing among U.S. males that may lead to subsequent cigarette use," added Tomar, also a member of the UF Shands Cancer Center. "More than 40 percent of men who had been snuff users continued or started smoking."
Snuff is finely milled tobacco that rapidly delivers high doses of nicotine to the bloodstream. Users commonly place a pinch of snuff between their front teeth and lower lip.
The survey found 26 percent of the study participants smoked, whereas 4 percent used snuff. One percent used both forms--equivalent to approximately 1 million American men when the findings are extrapolated to the general population. Men who reported using snuff "on some days" were more likely to smoke--and less likely to quit--than those who used snuff daily, Tomar said. On average, they also smoked as many cigarettes per day as those who did not use snuff--about 18.
Tomar's findings are comparable to the results of a national longitudinal study he conducted of adolescent and young adult males in the United States. His findings also support former U.S. Surgeon General's C. Everett Koop's 1986 warning that the use of smokeless tobacco "is not a safe substitute for smoking cigarettes ...and can lead to nicotine addiction and dependence." The National Cancer Institute, meanwhile, has identified 28 known carcinogens in snuff.
Each year, more than 440,000 Americans die because of cigarette smoking, Tomar said. Annual smoking-attributable personal health-care expenditures exceed $75 billion, with nearly $82 billion in mortality-related productivity losses linked to the habit. Estimates for deaths or costs associated with snuff use are not available, he said.
As news of the hazards of second-hand smoke spreads, and as a growing number of restaurants and other businesses adopt clean-air policies and restrict smoking in their buildings, smoking is becoming increasingly taboo. In turn, tobacco companies--and even some researchers--are promoting snuff and smokeless tobacco as safer alternatives to cigarettes, a practice Tomar said may be keeping smokers in the market who otherwise might have quit.
The U.S. Smokeless Tobacco Company, the nation's leading manufacturer of smokeless tobacco products, and others "continue to promote the use of snuff as a method of harm reduction for smokers despite the fact there is no scientific evidence to support their claim," Tomar said.
"They recently petitioned the Federal Trade Commission for permission to make explicit claims that snuff products are less hazardous than cigarettes," he said. "This is just irresponsible in light of credible research demonstrating that snuff users risk developing cancers of the mouth and pharynx."
Numerous studies indicate snuff and smokeless tobacco users also increase their risk of cancers of the larynx and esophagus. In addition, oral cancer can include tumors of the lip, tongue, cheeks and gums. Smokeless tobacco also has been linked to gum disease, bone loss in the jaw, tooth decay, tooth loss, chronic bad breath, high blood pressure and increased risk of heart disease, among other problems.
"The public health implications and financial costs are many," Tomar said. "A major concern should be that the promotion of a dangerous product as less harmful than another undermines the efforts to achieve tobacco cessation. Also, these products could increase smoking initiation among people who probably would not have started."
Jack E. Henningfield, an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine, said Tomar's findings raise questions and provide additional reasons for caution.
"The use of smokeless tobacco and cigarettes is becoming more prevalent, and this is a growing concern for public health because it has potential to undo the progress of workplace smoking restrictions," said Henningfield, who also is vice president of research and health policy for Pinney Associates, a health consulting, issues management, and research and data analysis firm located in Bethesda, Md. "These restrictions have been an important source of motivation for people to quit smoking, which is proven to reduce the risk of disease. This new era in tobacco product development and promotion should be approached with caution, research and paramount concern for public health. Providing a green light to snuff manufacturers on the basis of a theoretical benefit for their products would certainly be premature." Tomar said health officials and researchers should encourage smokers wanting to quit to seek traditional methods widely available to the public.
"Nicotine patches, gum, inhalers and nasal sprays are cleaner forms of nicotine compared with snuff, which also contains carcinogens," Tomar said. "These products weaken the argument for using snuff. "The primary interest of (tobacco) companies is not the health of the country," he added. "Their ultimate goal is to maximize profits."