Soldiers: Let Them Have (Alternative) Tobacco Products
Published: Jul 10, 2014
By Elbert Chu, Associate Producer, MedPage Today
Note that this opinion piece suggests that alternative nicotine products may be a reasonable “middle-ground” should the U.S. government bar smokers from military service.
Be aware that large, dedicated longitudinal studies of users of these alternative products do not yet exist; it remains unclear what health risks they may pose.
Sally Satel, MD is a psychiatrist who specializes in addiction treatment and is a resident scholar at the American Enterprise Institute. Here, Satel responds to a New England Journal of Medicine Perspectives piece calling for the U.S. military to reject smokers from service. Parts of this article appeared previously in The New Republic.
The NEJM writers offer a reasonable health rationale for eliminating cigarettes from the U.S. Military. If Congress approves this move, then the service branches should permit the use of snus and electronic cigarettes by smoking recruits who want to serve their country.
To be sure, some smoking recruits, perhaps most, will simply stop on their own. And there are patches and gum which, by themselves, are of marginal help, but when paired with relapse prevention strategies are useful. The military could offer this intervention to would-be soldiers who want to be nicotine-free. But the military could be a bastion of enlightened harm reduction by offering snus, a tiny pouch of tobacco that sits between a person’s cheek and gum. The user does not spit.
Most important, the levels of nitrosamine are vanishingly small, so tobacco-related cancer rates are no higher than in non-snus users, adjusting for prior smoking in the snus population. Snus originated in Sweden, the only EU country, incredibly, where snus is legal. For 50 years, snus use by Swedish men has been associated with world-record low rates of smoking and smoking-attributable deaths, including lung, oral, and throat cancers as well as cardiovascular events.
Another boon to the smoker who wants to quit or find an alternative nicotine device is electronic cigarettes. They do not burn tobacco, the source of the carcinogenic tar and disease-producing gases and particulates, and thus are far safer for smokers than cigarettes. The risk, if any, of long-term inhalation of propylene glycol, the common substrate used for the nicotine solution, is not known — the devices have simply not been around long enough.
In limited exposure, however, the U.S. Food and Drug Administration generally regards propylene glycol as safe; it is used in toothpaste, asthma inhalers, and many other foods and cosmetics.
And while there are also traces of nitrosamines, which are known carcinogens, they are present at levels comparable to medicinal products, such as nicotine gum and patch and at concentrations 500 to 1,400 times lower than in regular cigarettes.
Cadmium, lead, and nickel may be there, too, but in amounts and forms considered nontoxic. Also, e-cigarettes do provide nicotine, which can be addictive, but the health effects of nicotine are generally benign.
Electronic cigarettes might well be a good way, perhaps a great way, to quit but good epidemiologic data do not yet exist. Yet the study in JAMA Internal Medicine, which purported to show the ineffectiveness of e-cigarettes in quitting, did not evaluate the products in a meaningful way.
Researchers from the University of California San Francisco looked at 949 smokers who were surveyed online in 2011 and 2012. Only 88 smokers used e-cigarettes in 2011; 1 year later nine had quit, which was not statistically different from the smokers who had not vaped.
First, quitting is not the only measure of success: merely switching to e-cigarettes spares them the carcinogenic tar, not a trivial health advantage. Moreover, only 8% of the 88 vapers expressed an intention to quit. If they had no desire to quit, there is no reason to think that use of e-cigs would make it more likely. In fact, the authors reported that “intention” to quit did predict quitting while electronic cigarette use, per se, did not.
Another important facet of the debate is the worry that vaping will serve as a gateway function to actual smoking. Many critics of e-cigs, consider this prospect ample reason to curtail marketing and availability to adults. Much alarm has surrounded the notion of a “gateway-to-cigarettes” but if these products are sold to smokers (former smokers who want to maintain nicotine use and those who are weaning off of it), then that concern is moot.
But how realistic is the gateway phenomenon? The National Youth Tobacco Survey reveals that e-cigarette use (as little as a single puff within the last month) among high school students almost doubled from 2011 to 2012, from 1.5 percent to 2.8 percent. However, the same survey showed that cigarette use declined from 14.6 percent to 11.8 percent at the same time.
The central question is whether the small group of teens who reported trying e-cigarettes move on to smoking conventional ones. At this time, there are no reliable signs of this.
To date, then, data suggest that increased exposure to e-cigarettes isn’t encouraging more teens to smoke. Yet the numbers of youthful vapers are still so small that it’s too early to make definitive claims about the relationship between teen vaping and smoking.
Epidemiologists and researchers must continue to collect data on patterns and long-term outcomes of vaping and smoking among teens and adults. And, in the meantime, the FDA moved to ban e-cig sales to minors in the same way as cigarettes. But epidemiologists will be following the advantages of e-cigs as well. After all, people switch to e-cigs because they are less hazardous than conventional ones. They don’t combust tobacco leaves, so “vapers” are not exposed to carcinogenic tars and harmful gases that cigarettes produce.
What’s more, e-cigarettes have advantages over nicotine patches and gums: they provide a quicker fix because the pulmonary route is the fastest practical way to deliver nicotine to the brain, and they offer appealing visual, tactile, and gestural similarities to traditional cigarettes.
This is why so many public health experts are enthusiastic about harm reduction properties of e-cigarettes. Harm reduction is an approach to risky behavior (smoking, in this case) that prioritizes minimizing damage (by cutting out tobacco combustion) rather than eliminating the behavior (by tolerating, even encouraging vaping).
“For the first time in a century, we have an appealing alternative way to give addicted current smokers a satisfying way to give up their combusted products,” said David J. Abrams, Professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health.
Finally, the dangers of nicotine, though it is an addictive substance, are trivial to nonexistent in healthy, military-eligible young men and women. If anything, the drug might help focus and concentration.
Our military needs all the brave young men and women it can get. If these individuals are qualified in every other way — save their Marlboro habits — then there are sound methods (via quit counseling, snus, and e-cigarettes) to accommodate them.
Satel reported no relevant financial disclosures. She served as an expert witness in tobacco litigation.