On 2017 Oct 08, Clive Bates commented:

A further point to add to Rodu's and Sweanor's excellent critique above. The original authors inexplicably avoid exposing the quantified results in the abstract. Why? These are:

When asked whether some smokeless tobacco products “are less harmful to a person’s health than cigarettes,”the majority of respondents 66.8%, (95% CI=63.9, 69.6) said “no,” 22.2% (95% CI=20.0, 24.7) said “don’t know,” and 10.9% (95% CI=9.4, 12.8) said “yes.

So only 10.9% have the answer right - an astonishing misalignment of public perception and reality for which several federal agencies bear contributory responsibility. Given switching from smoking to smokeless radically reduces health risks, this is a very disturbing finding.

Yet the position is even more troubling than these data suggest. The most appropriate answer is that smokeless tobacco products "are much less harmful" than smoking. American smokeless tobacco is likely in the range 98-100% less harmful than smoking - but merely "less harmful" could mean 10%, 30%, 70% or 98% less harmful, and only the last of these is approximately correct.

The answer "much less harmful" is not allowed in the HINTS survey for smokeless. However, this response is allowed in the HINTS survey for e-cigarettes. In this survey, only 5.3% correctly say e-cigarettes are "much less harmful" and a further 20.6% say "less harmful" - indicating extensive misperceptions of the magnitude of the risk differential even among those who are not literally wrong in believing these products are less harmful than smoking.

On 2017 Oct 04, Brad Rodu commented:

The study by Feirman et al. (Feirman SP, 2018) described in detail the results from one question in the 2012, 2014, and 2015 Health Information National Trends Surveys: “Do you believe that some smokeless tobacco products, such as chewing tobacco and snuff, are less harmful than cigarettes?” The possible answers were “Yes,” “No,” and “Don’t Know.”

The article highlighted these findings:

• “A majority of adults do not think smokeless tobacco is less harmful than cigarettes.” (i.e., didn’t answer “yes.”) • “Believing smokeless tobacco is not less harmful than cigarettes declined from 2012–2015.” • “Perceptions about the harm of smokeless tobacco differed by demographic subgroup.”

The authors, from the U.S. FDA and National Cancer Institute, commented: “…our findings may help inform public health communications aimed at reducing tobacco-related harms. Additionally, understanding consumer perceptions of tobacco products plays an important role in FDA's regulatory work.”

This claim is not valid because of one glaring omission throughout the article, which contained 3,800 words, 3 large tables of numbers and 58 references. The article failed to specify that the correct answer is: “Yes, smokeless tobacco products are less harmful than cigarettes.” In fact, it focused almost entirely on the majority of participants who inaccurately answered “No” or “Don’t Know,” which reflects misperception fostered by an effective “quarantine” of truthful risk information by federal agencies (Kozlowski LT, 2016).

Decades of epidemiologic studies have documented that the health risks of smokeless tobacco use are, at most, 2% those of smoking (Rodu B, 2006; Rodu B, 2011; Fisher M 2017; Royal College of Physicians, 2002; Lee PN, 2009). Unlike cigarettes, smokeless tobacco does not cause lung cancer, heart and circulatory diseases or emphysema. In 2002 the Royal College of Physicians concluded: “As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10–1,000 times less hazardous than smoking, depending on the product.” (Royal College of Physicians, 2002)

The low risks from smokeless tobacco use even include mouth cancer. A 2002 review documented that men in the U.S. who use moist snuff and chewing tobacco have minimal to no risk for mouth cancer (Rodu B, 2002), and a recent federal study found no excess deaths from the disease among American men who use moist snuff or chewing tobacco (Wyss AB, 2016).

As one of us recently wrote, “Deception or evasion about major differences in product risks is not supported by public health ethics, health communication or consumer practices. Public health agencies have an obligation to correct the current dramatic level of consumer misinformation on relative risks that they have fostered.” (Kozlowski LT, 2018)

Brad Rodu Professor of Medicine University of Louisville

David Sweanor Adjunct Professor of Law Centre for Health Law, Policy and Ethics University of Ottawa

Brad Rodu is supported by unrestricted grants from tobacco manufacturers to the University of Louisville, and by the Kentucky Research Challenge Trust Fund.

On 2017 Oct 04, Brad Rodu commented:

The study by Feirman et al. (Feirman SP, 2018) described in detail the results from one question in the 2012, 2014, and 2015 Health Information National Trends Surveys: “Do you believe that some smokeless tobacco products, such as chewing tobacco and snuff, are less harmful than cigarettes?” The possible answers were “Yes,” “No,” and “Don’t Know.”

The article highlighted these findings:

• “A majority of adults do not think smokeless tobacco is less harmful than cigarettes.” (i.e., didn’t answer “yes.”) • “Believing smokeless tobacco is not less harmful than cigarettes declined from 2012–2015.” • “Perceptions about the harm of smokeless tobacco differed by demographic subgroup.”

The authors, from the U.S. FDA and National Cancer Institute, commented: “…our findings may help inform public health communications aimed at reducing tobacco-related harms. Additionally, understanding consumer perceptions of tobacco products plays an important role in FDA's regulatory work.”

This claim is not valid because of one glaring omission throughout the article, which contained 3,800 words, 3 large tables of numbers and 58 references. The article failed to specify that the correct answer is: “Yes, smokeless tobacco products are less harmful than cigarettes.” In fact, it focused almost entirely on the majority of participants who inaccurately answered “No” or “Don’t Know,” which reflects misperception fostered by an effective “quarantine” of truthful risk information by federal agencies (Kozlowski LT, 2016).

Decades of epidemiologic studies have documented that the health risks of smokeless tobacco use are, at most, 2% those of smoking (Rodu B, 2006; Rodu B, 2011; Fisher M 2017; Royal College of Physicians, 2002; Lee PN, 2009). Unlike cigarettes, smokeless tobacco does not cause lung cancer, heart and circulatory diseases or emphysema. In 2002 the Royal College of Physicians concluded: “As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10–1,000 times less hazardous than smoking, depending on the product.” (Royal College of Physicians, 2002)

The low risks from smokeless tobacco use even include mouth cancer. A 2002 review documented that men in the U.S. who use moist snuff and chewing tobacco have minimal to no risk for mouth cancer (Rodu B, 2002), and a recent federal study found no excess deaths from the disease among American men who use moist snuff or chewing tobacco (Wyss AB, 2016).

As one of us recently wrote, “Deception or evasion about major differences in product risks is not supported by public health ethics, health communication or consumer practices. Public health agencies have an obligation to correct the current dramatic level of consumer misinformation on relative risks that they have fostered.” (Kozlowski LT, 2018)

Brad Rodu Professor of Medicine University of Louisville

David Sweanor Adjunct Professor of Law Centre for Health Law, Policy and Ethics University of Ottawa

Brad Rodu is supported by unrestricted grants from tobacco manufacturers to the University of Louisville, and by the Kentucky Research Challenge Trust Fund.