US legislation requiring warnings for smokeless tobacco products failed to make Americans aware that smokeless tobacco is much less harmful than cigarettes, reveals leading tobacco policy expert Lynn Kozlowski in the Harm Reduction Journal.
In 1986, the US government passed legislation requiring a series of warnings for smokeless tobacco products, one of which advised “This product is not a safe alternative to cigarettes”, writesDavid J Hill for the University at Buffalo.
That warning, however, obscured an important distinction – that cigarettes are much more harmful to health than smokeless tobacco products – and over the 30-plus years since, the American public has mostly been unaware that smokeless tobacco is much less harmful than cigarettes, one of the nation’s leading tobacco policy experts writes in a paper published recently in Harm Reduction Journal.
“It is important to distinguish between evidence that a product is ‘not safe’ and evidence that a product is ‘not safer’ than cigarettes or ‘just as harmful’ as cigarettes,” says paper author Lynn Kozlowski, professor of community health and health behavior in the University at Buffalo’s School of Public Health and Health Professions.
“The process at the time of the establishment of official smokeless tobacco warnings in the 1980s paid no attention to this distinction,” Kozlowski adds. “The American public has become mostly unaware that smokeless tobacco is much less harmful than cigarettes.”
Kozlowski notes that as long as cigarettes remain legal in the US, American consumers should be provided with proper information on the relative risks of tobacco and nicotine products that are less lethal or otherwise less harmful than cigarettes. In addition, consumers should receive information on the ways in which a product causes harm, he says, adding that none should be viewed as harmless.
In his paper, Kozlowski examines the origins of the 1980s warning labels and the war that was brewing between the smokeless tobacco industry and US cigarette companies – separate at the time – which contributed to the “not a safe alternative to cigarettes” labeling for smokeless tobacco products.
Neither liked the warning labels that many states were in the process of requiring, which referenced the addictive nature of smokeless tobacco. The concern was that cigarettes would be next on the list to be declared addictive.
In addition, US cigarette companies and health authorities balked at a successful advertising campaign for Skoal’s wintergreen flavored moist snuff. The campaign encouraged consumers to “Take a pouch instead of a puff” which, to some groups, implied the Skoal product was a safe choice compared to smoking cigarettes.
With smokeless tobacco gaining in popularity, many states began to take action, and by January 1986 more than two dozen states had passed legislation requiring warning labels for smokeless tobacco products. Many labels noted the products contained nicotine and were addictive, and some warned that smokeless tobacco could cause mouth cancer. None, however, included the “not a safe alternative to cigarettes” message.
That came at the urging of the cigarette industry, Kozlowski says. There were fears the tough labels states were requiring for smokeless tobacco products could also affect cigarette package warnings.
Kozlowski reviewed more than 400 documents distributed or published between 1964 and 1990 to gain a better understanding of the historical context of the warning labels. The review included internal industry documents, legislative materials and media reports, among others.
One thing in particular stood out, Kozlowski says: “The evidence that the cigarette industry was concerned about smokeless tobacco being marketed in a way that seemed to promote smokeless as less harmful than cigarettes.”
Understanding the origins of the warning labels remains relevant today with emerging products such as e-cigarettes, which Kozlowski says also should not be labeled with the misleading ‘not a safe alternative to cigarettes’ designation.
Ultimately, the US Food and Drug Administration can help clear up any confusion among users of tobacco and nicotine products, Kozlowski says.
“The FDA Tobacco Law could help improve the warning labels, stop using the ‘not a safe alternative’ warning and mount public education efforts about the harms and differential harms of tobacco/nicotine products,” he says. “Focusing on the ‘no safe product’ message disserves the actual consumers of multiple products who should be aware of differential product risks.”
Before the 1980s in the US, smokeless tobacco carried no health warnings, was not judged to cause disease, and was a declining practice. In 1986, the federal government passed legislation requiring rotating warnings on “mouth cancer,” “gum disease and tooth loss,” and “This product is not a safe alternative to cigarettes.”
This paper explores the history of the establishment of these warnings with emphasis on the ‘not a safe alternative’ warning and the bases for claiming that smokeless was ‘not safe’ (absolute harm) versus ‘not safer than cigarettes’ (relative harm).
Results of searches of Truth Tobacco Industry Document archives and transcripts of legislative hearings were analysed. Critical assessments were made of the evidence-base.
New evidence of oral cancer causation emerged along with a much-publicized case of a teenager dying of oral cancer. Public health concerns also arose over a widespread, successful marketing campaign implying smokeless was a safe alternative to cigarettes. Industry wanted pre-emptive federal warnings, to prevent a diversity of pending state warnings.
To avoid an addiction warning, the industry accepted a compromise ‘not a safe alternative’ warning, which had not been initially proposed and which the cigarette industry may have sought in order to constrain the smokeless tobacco industry. The evidence presented supported smokeless only as ‘not safe’ and not ‘as harmful as cigarette smoking.’
The comparative warning was a compromise to prevent an addiction warning and consistent with the preferences of cigarette companies. Prior surveys indicated that the public generally did not view smokeless tobacco as harmless, but they did generally report smokeless as less harmful than cigarettes despite expert interpretations to the contrary.
As would not have been appreciated by public health supporters at the outset, subsequent research has shown that the ‘not a safe alternative’ message is misinterpreted by consumers to indicate that smokeless is ‘not safer’ than cigarettes – which was not established and has been disconfirmed by subsequent assessments of that question.
Though many countries have banned smokeless tobacco (but not cigarettes), where smokeless is legally available accurate information on the nature of harms and differential harms needs to be developed.
[link url="http://www.buffalo.edu/news/releases/2018/07/021.html"]University at Bufallo release[/link]
[link url="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0228-8"]Harm Reduction Journal article[/link]