Kozlowski and Sweanor (K&S) convincingly argue that consumers should be provided with the best information about the risks of different tobacco products to make informed choices. While the discussion is directed at smokeless tobacco (ST) use, recent evidence suggests that ST, and more specifically snus, has not gained much ground and that e-cigarette use may be more relevant.
K&S also argue that concerns about the “gateway effect” are often exaggerated. Although the evidence of gateway effects from ST use to cigarette smoking is weak, gateway effects may be more plausible for e-cigarettes due to the greater similarity of e-cigarettes to cigarettes. However, a recent analysis1 suggests, over a wide range of plausible parameters, population harms are likely to be reduced rather than increased as a result of e-cigarette use. Nevertheless, messaging about the use of ST or other alternative nicotine delivery products, such as e-cigarettes, needs to inform youth and young adults about the risks of addiction as well as any potential reduced health risks compared with combustible cigarettes.
K&S also argue that accurate information about relative risks can facilitate smoking cessation, since ST can provide a less harmful nicotine delivery alternative. However, evidence indicates that ST is not viewed as a viable substitute to cigarettes by most smokers.2–4 Nevertheless, better information could encourage e-cigarette use among cigarette smokers, which appears to provide a more desirable alternative to cigarette smoking than ST due to more rapid nicotine delivery and similar sensorimotor and throat-hit experiences.5
A concern raised by tobacco control advocates, but not adequately addressed by K&S, is that, instead of smokers switching completely to ST, they may use ST in combination with cigarettes as a way to circumvent smoke-free restrictions or higher taxes on cigarettes.6 Thereby, dual use may enable smokers to avoid quitting smoking and thereby hamper efforts to encourage smoking cessation. While the evidence for this possibility is scant,6 further study is warranted that carefully distinguishes long-term dual use from temporary dual use that leads to exclusive ST or no tobacco use.7
Dual use is an important concern because, while the relative mortality risk is substantially lower for exclusive ST use than exclusive cigarette use, the risk differential is likely to be far less between dual use and exclusive cigarette use.6,7 Hence, smokers need to be informed that complete substitution of ST for cigarette use is required for there to be a substantial reduction in health risks. It is important that smokers do not think that substituting a few cigarettes per day instead of switching completely to a lower risk alterative will result in reduced harms. Communicating the risks of dual vs exclusive use is more subtle and likely more difficult to communicate than just indicating that ST use is safer than cigarette use.8 Unfortunately, studies of the effect of these types of message are sparse.6
Better information is needed about effectively communicating relative as well as absolute risks and how those risks depend on specific behaviors.6 In particular, studies are needed on communicating the risks of dual use. This type of study will require extended follow up and will need to capture a complex range of tobacco use outcomes: cigarette smoking, ST use, dual smoking & ST use in order to know if it is leading to informed consumer choices and changes in behaviors that would ultimately reduce population-level harms from tobacco. Nevertheless, accurate and up-to-date information must be communicated. Not only is accurate information needed for tobacco users to make informed decisions, but misinformation can lead to unintended consequences, such as distrust, which can ultimately lead to behaviors inconsistent with the intended goals of tobacco control policy.
Highlights.
Kozlowski and Sweanor (K&S) convincingly argue that consumers should be provided with the best information about the risks of different tobacco products to make informed choices. However, better information is needed about effectively communicating relative as well as absolute risks. In particular, studies are needed on communicating the risks of dual use.
Footnotes
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References
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