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Frost-Pineda, Appleton, Fisher, Fox, and Gaworski (2010) from Altria Client Services reviewed the available literature on the health effects of “dual use” of smoked and smokeless tobacco and concluded that, “Overall, the concern about dual use appears to be contradicted by the evidence in the literature that dual use of smokeless tobacco and cigarettes may result in reduction in smoking-related harm as smoking intensity is decreased and smoking cessation increases.”
This conclusion is surprising, given that the confidence intervals for smokers and dual users overlap for all health endpoints (cancer, ischemic heart disease, stroke, and acute myocardial infarction) that they present. These results would include the effects of any reduction in cigarette consumption that might occur among dual users. They also represent the U.S. study by Zhu et al. (2009) as supporting the assertion that smokeless tobacco use promotes cessation despite the fact that Zhu et al. concluded, “Promoting smokeless tobacco for harm reduction in countries with ongoing tobacco control programmes may not result in any positive population effect on smoking cessation.”
We published an analysis (Mejia, Ling, & Glantz, 2010) of the effects of aggressive smokeless promotion in the United States that accounts for likely changes that will result from explicit tobacco industry promotion of dual use of cigarettes and smokeless tobacco (branded as cigarette line extensions). Altria and other companies are promoting dual use as a way to continue tobacco use despite expanding smoke-free environments. These promotional activities will encourage people who might simply quit smoking (i.e., stop all tobacco use) in response to smoke-free environments to remain tobacco users, an effect that Frost-Pineda et al. ignore. (Our analysis assumed that the health costs of dual use were lower than smoking. Based on the data Frost-Pineda et al. present, it is likely that we underestimated the population-level health effects of promoting smokeless tobacco.) Our analysis showed that promoting smokeless as a harm-reduction strategy was unlikely to have any net health benefits, a conclusion strengthened by the data Frost-Pineda et al. summarize.
Indeed, based on a careful review of the data in their paper, we are surprised that Frost-Pineda et al. did not reach the same conclusion that we did.