1484
Banning oral snuff SIR,- The European Commission (EC) has proposed a ban on oral snuffy a fmely ground tobacco that is placed between the cheek and gum. The proposal is based on the findings of the International Agency for Research on Cancer that oral snuff is a carcinogen and the recommendation of the World Health Organisation3 that nations ban oral snuff before use becomes widespread. Outside Denmark, oral snuff is not popular within the EC. The proposal has been criticised by the United States Tobacco Company and the Swedish Tobacco Company, manufacturers who hope to open a new market for oral snuff in the region. The Swedish company claims that their brands have not been shown to cause cancer in man and cites the low levels of cancer-causing nitrosamines in their brands in comparison to the high levels found in US snuff as a possible reason.4 Tests of three Swedish brands found total nitrosamine content to range from 9-3 to 95 )µg/g5, and the most popular US brands contain 20-6-22-3
µg/g. However, this claim may be just a smokescreen. Swedish Tobacco acquired the US based Pinkerton Tobacco Company in 1987 .6 Before that time, Pinkerton manufactured chewing tobacco with very low nitrosamine levels (0-6-8-9 µg/g) and it did not advertise its product widely. In 1990, the newly acquired Swedish subsidiary introduced its first oral snuff brand, ’Red Man Snuff, which has been heavily advertised in US sports magazines (a practice that is illegal in Sweden). The new brand contained nitrosamines in the range 48-280 µg/g;7 at those levels the product would probably not be sold in Sweden.8 Swedish Tobacco is part of the holding company, Procordia, which also owns the drug company AB Leo. Leo manufactures nicotine chewing gum to help people quit tobacco use and the tobacco company manufactures snuff to keep people in the hapit. EC officials should apply the non-discriminatory standard of the WHO and ban all oral snuff within the twelve EC countries. Office of Dental Health, 399 Common Street, Belmont, Massachusetts 02178, USA
GREGORY N. CONNOLLY
1. Commission of the European Economic Communities. Proposal for a Council directive amending directive 89/622/EEC. Brussells: EC Commission, 1991. 2. International Agency for Research on Cancer. Tobacco habits other than smoking: betel-quid, areca nut chewing, and some related nitrosamines IARC Monogr Eval Carc Risks Chem Hum 1985: vol XXXVII. Vol.37) and addendum to Vol.37 (1978). 3. World Health Organisation. Smokeless tobacco control: report of a WHO study group. WHO Tech Rep Ser 1988, no 773. 4. Koemer M. Swedish Tobacco: a former monopoly goes international. Tobacco Int
1991, no 191. Hjem L. Is it possible to clearly define "oral moist snuff". Stockholm: Procordia United Brands AB, 1991: 1-13. 6. Curvall M. Biological test of Swedish snuff. In: Sandlund M, ed. Snuffing a health hazard. Stockholm: Sodalstryelson, 1988: 37-50. 7. Hoffman D, Djordjevic MV, Brunneman KD. New brands of oral snuff. Food Chem Toxicol 1991; 29: 65-68. (Decoding of snuff samples provided by Freedom of Information Office, US National Cancer Institute, February, 1991). 8. National Swedish Board of Consumer Policies. Guidelines for marketing of tobacco products. Stockholm: NSBCP, 1987.
5.
proportion of the community.1 Rather, it has been associated with a mix of education, price increases, restrictions on the promotion of tobacco, and, lately, limitations on environmental tobacco smoke exposure. These measures are desirable because they help to prevent the uptake of smoking as well as motivate smokers to stop. In comparison nicotine therapies are expensive. Therefore the tried and true population approach, adapted for local conditions, should be the first priority for developing economies. Nicotine therapies could then be incorporated into the strategy if they can be afforded and are cost-effective. Global promotion of nicotine therapies or safe cigarettes seems to be an example of corporate opportunismnot unlike that shown by the aggressive marketing of American and European tobacco companies in Asia and Africa. Furthermore, tobacco addiction is not synonymous with nicotine addiction. Smokers vary in their level of physical dependence on nicotine and the degree to which their smoking behaviour is determined by habit. To suggest that nicotine use could be countenanced long-term rather than as a short-term aid to smoking cessation ignores the fact that many non-smokers and light smokers could then be encouraged to start a new form of drug addiction. Although evidence based on research in animals generally suggests that long-term use of pure nicotine is safe (and it is certainly safer than smoking) there are concerns about the potential of nicotine as a co-carcinogen, carcinogenic precursor, and activator of the adrenergic nervous system.2 Therefore, it is inappropriate to advise nicotine use unless it is in the context of harm reduction-ie, for tobacco cessation in nicotine-dependent smokers, for which nicotine gum and transdermal skin patches seem to be modestly effective.3 Finally, I dispute that there may be such a thing as a safe cigarette. The example you provide is a low tar cigarette with a carbon monoxide yield of 10-6 mg. Unfortunately, carbon monoxide may be the component of smoke implicated in vascular diseaseIf cigarette companies were serious about a safer cigarette they should probably produce a low tar, high nicotine cigarette. This is unlikely to happen in a free-market economy because cigarette sales would plummet as nicotine-dependent smokers achieved their desired nicotine levels with fewer cigarettes (and therefore less harmful tar and carbon monoxide). Monash University Department of Social and Preventive Medicine, Alfred Hospital, Prahran, 3181 Melbourne, Australia
S. G. GOURLAY
1. Fiore MC, Novomy TE, Pierce JP, et al. Methods used to quit smoking m the United States. JAMA 1990; 263: 2760-65. 2. Department of Health and Human Services. The health consequences of smoking: nicotine addiction; a report of the US Surgeon General, 1988. 3. Gourlay SG, McNeil JJ. Antismoking Products 1990; 153: 699-707
Medicine and culture SiR,—As Levi-Strauss remarked,’ the microorganism is external the indios’ thinking, but the evil spirit is not. Dr Littlewood (April 27, p 1013) stresses the importance of our patients’ assumptions and expectations regarding their illnesses and
to
Tobacco smoking control SIR,- The arguments in
May 18 editorial (p 1191), in favour of the promotion of "safe" cigarettes and nicotine substitutes as long-term replacements for tobacco smoking, are fundamentally your
flawed. You state that considerable progress has been made in tobacco
smoking control in many countries but suggest that a different approach may be needed in developing countries, where the prevalence of smoking is rising. Why? The public health solutions of the past few centuries have usually been discovered and first applied in more economically advanced countries. Thus it is no surprise that the tobacco epidemic is persisting in less advantaged societies while being controlled elsewhere. Until the resources and political will to bring about change becomeareality the situation is unlikely to change. Successful control of tobacco smoking has not mainly resulted from the promotion of a treatment approach, such as nicotine therapies, because such strategies have reached only a small
strengthens my doubts whether inversion of Levi-Strauss’ dictum would hold in both its parts for westerners. Even in medical professionals, if ill, the "trains of scientific logic" may come to a grinding halt with the uncertainties and fears of disease. For most doctors, professional contacts with persons from the same cultural background far outnumber contacts with people with a different or even exotic upbringing. The seeming familiarity does hide difficulty in understanding the conceptual background a patient places his illness against. More research and teaching in this area are needed but interventions by anthropologists in a normal clinical setting may be a two-edged sword. I feel reluctant to involve a specialist to elucidate an everyday problem among the central responsibilities of medicine. Furthermore, the several hundred square miles without a medical anthropologist that stretch around most hospitals make the logistics awkward. For everyday use we must settle for something simpler. von Weizsäcker2 used to ask his patients what they thought the reason was for their pain, weakness, paraesthesiae, or other
Banning oral snuff SIR,- The European Commission (EC) has proposed a ban on oral snuffy a fmely ground tobacco that is placed between the cheek and gum. The proposal is based on the findings of the International Agency for Research on Cancer that oral snuff is a carcinogen and the recommendation of the World Health Organisation3 that nations ban oral snuff before use becomes widespread. Outside Denmark, oral snuff is not popular within the EC. The proposal has been criticised by the United States Tobacco Company and the Swedish Tobacco Company, manufacturers who hope to open a new market for oral snuff in the region. The Swedish company claims that their brands have not been shown to cause cancer in man and cites the low levels of cancer-causing nitrosamines in their brands in comparison to the high levels found in US snuff as a possible reason.4 Tests of three Swedish brands found total nitrosamine content to range from 9-3 to 95 )µg/g5, and the most popular US brands contain 20-6-22-3
µg/g. However, this claim may be just a smokescreen. Swedish Tobacco acquired the US based Pinkerton Tobacco Company in 1987 .6 Before that time, Pinkerton manufactured chewing tobacco with very low nitrosamine levels (0-6-8-9 µg/g) and it did not advertise its product widely. In 1990, the newly acquired Swedish subsidiary introduced its first oral snuff brand, ’Red Man Snuff, which has been heavily advertised in US sports magazines (a practice that is illegal in Sweden). The new brand contained nitrosamines in the range 48-280 µg/g;7 at those levels the product would probably not be sold in Sweden.8 Swedish Tobacco is part of the holding company, Procordia, which also owns the drug company AB Leo. Leo manufactures nicotine chewing gum to help people quit tobacco use and the tobacco company manufactures snuff to keep people in the hapit. EC officials should apply the non-discriminatory standard of the WHO and ban all oral snuff within the twelve EC countries. Office of Dental Health, 399 Common Street, Belmont, Massachusetts 02178, USA
GREGORY N. CONNOLLY
1. Commission of the European Economic Communities. Proposal for a Council directive amending directive 89/622/EEC. Brussells: EC Commission, 1991. 2. International Agency for Research on Cancer. Tobacco habits other than smoking: betel-quid, areca nut chewing, and some related nitrosamines IARC Monogr Eval Carc Risks Chem Hum 1985: vol XXXVII. Vol.37) and addendum to Vol.37 (1978). 3. World Health Organisation. Smokeless tobacco control: report of a WHO study group. WHO Tech Rep Ser 1988, no 773. 4. Koemer M. Swedish Tobacco: a former monopoly goes international. Tobacco Int
1991, no 191. Hjem L. Is it possible to clearly define "oral moist snuff". Stockholm: Procordia United Brands AB, 1991: 1-13. 6. Curvall M. Biological test of Swedish snuff. In: Sandlund M, ed. Snuffing a health hazard. Stockholm: Sodalstryelson, 1988: 37-50. 7. Hoffman D, Djordjevic MV, Brunneman KD. New brands of oral snuff. Food Chem Toxicol 1991; 29: 65-68. (Decoding of snuff samples provided by Freedom of Information Office, US National Cancer Institute, February, 1991). 8. National Swedish Board of Consumer Policies. Guidelines for marketing of tobacco products. Stockholm: NSBCP, 1987.
5.
proportion of the community.1 Rather, it has been associated with a mix of education, price increases, restrictions on the promotion of tobacco, and, lately, limitations on environmental tobacco smoke exposure. These measures are desirable because they help to prevent the uptake of smoking as well as motivate smokers to stop. In comparison nicotine therapies are expensive. Therefore the tried and true population approach, adapted for local conditions, should be the first priority for developing economies. Nicotine therapies could then be incorporated into the strategy if they can be afforded and are cost-effective. Global promotion of nicotine therapies or safe cigarettes seems to be an example of corporate opportunismnot unlike that shown by the aggressive marketing of American and European tobacco companies in Asia and Africa. Furthermore, tobacco addiction is not synonymous with nicotine addiction. Smokers vary in their level of physical dependence on nicotine and the degree to which their smoking behaviour is determined by habit. To suggest that nicotine use could be countenanced long-term rather than as a short-term aid to smoking cessation ignores the fact that many non-smokers and light smokers could then be encouraged to start a new form of drug addiction. Although evidence based on research in animals generally suggests that long-term use of pure nicotine is safe (and it is certainly safer than smoking) there are concerns about the potential of nicotine as a co-carcinogen, carcinogenic precursor, and activator of the adrenergic nervous system.2 Therefore, it is inappropriate to advise nicotine use unless it is in the context of harm reduction-ie, for tobacco cessation in nicotine-dependent smokers, for which nicotine gum and transdermal skin patches seem to be modestly effective.3 Finally, I dispute that there may be such a thing as a safe cigarette. The example you provide is a low tar cigarette with a carbon monoxide yield of 10-6 mg. Unfortunately, carbon monoxide may be the component of smoke implicated in vascular diseaseIf cigarette companies were serious about a safer cigarette they should probably produce a low tar, high nicotine cigarette. This is unlikely to happen in a free-market economy because cigarette sales would plummet as nicotine-dependent smokers achieved their desired nicotine levels with fewer cigarettes (and therefore less harmful tar and carbon monoxide). Monash University Department of Social and Preventive Medicine, Alfred Hospital, Prahran, 3181 Melbourne, Australia
S. G. GOURLAY
1. Fiore MC, Novomy TE, Pierce JP, et al. Methods used to quit smoking m the United States. JAMA 1990; 263: 2760-65. 2. Department of Health and Human Services. The health consequences of smoking: nicotine addiction; a report of the US Surgeon General, 1988. 3. Gourlay SG, McNeil JJ. Antismoking Products 1990; 153: 699-707
Medicine and culture SiR,—As Levi-Strauss remarked,’ the microorganism is external the indios’ thinking, but the evil spirit is not. Dr Littlewood (April 27, p 1013) stresses the importance of our patients’ assumptions and expectations regarding their illnesses and
to
Tobacco smoking control SIR,- The arguments in
May 18 editorial (p 1191), in favour of the promotion of "safe" cigarettes and nicotine substitutes as long-term replacements for tobacco smoking, are fundamentally your
flawed. You state that considerable progress has been made in tobacco
smoking control in many countries but suggest that a different approach may be needed in developing countries, where the prevalence of smoking is rising. Why? The public health solutions of the past few centuries have usually been discovered and first applied in more economically advanced countries. Thus it is no surprise that the tobacco epidemic is persisting in less advantaged societies while being controlled elsewhere. Until the resources and political will to bring about change becomeareality the situation is unlikely to change. Successful control of tobacco smoking has not mainly resulted from the promotion of a treatment approach, such as nicotine therapies, because such strategies have reached only a small
strengthens my doubts whether inversion of Levi-Strauss’ dictum would hold in both its parts for westerners. Even in medical professionals, if ill, the "trains of scientific logic" may come to a grinding halt with the uncertainties and fears of disease. For most doctors, professional contacts with persons from the same cultural background far outnumber contacts with people with a different or even exotic upbringing. The seeming familiarity does hide difficulty in understanding the conceptual background a patient places his illness against. More research and teaching in this area are needed but interventions by anthropologists in a normal clinical setting may be a two-edged sword. I feel reluctant to involve a specialist to elucidate an everyday problem among the central responsibilities of medicine. Furthermore, the several hundred square miles without a medical anthropologist that stretch around most hospitals make the logistics awkward. For everyday use we must settle for something simpler. von Weizsäcker2 used to ask his patients what they thought the reason was for their pain, weakness, paraesthesiae, or other
