November 25, 2014

Stanton A. Glantz, PhD

Swedish Match’s claim that perceptions of health risks of snus are exaggerated is likely incorrect

This comment was just submitted to FDA.  The tracking number is 1jy-8fp5-z353
Swedish Match’s claim that perceptions of health risks of snus are exaggerated
is likely incorrect
Docket ID: FDA-2014-N-1051
Lucy Popova, PhD & Pamela M. Ling, MD, MPH
Center for Tobacco Control Research and Education
University of California San Francisco
November 24, 2014
The petitioners claim that “adults generally, and smokers in particular, had an exaggerated perception of the health risks related to snus use” (p. 688). In support of this claim, they cite five studies with adults and one with youth that measured perceptions of relative risk, all done in Scandinavia.
Leaving aside the issue whether the Scandinavian data on harm perceptions are applicable to the US case, there is another serious problem with this claim. This issue is detailed in our attached paper, “Perceptions of Relative Risk of Snus and Cigarettes Among US Smokers” (American Journal of Public Health 2013;103:e21–e23. doi:10.2105/AJPH.2013.301547).
This demonstrates that the proportion of people saying that smokeless tobacco is less harmful than cigarettes depends on the way relative harm is described in the question.  One way is to measure the relative harm directly, by asking a single question, such as “Compared to cigarettes, is smokeless tobacco less harmful, as harmful as, or more harmful?” Another way is to ask about perceived harm of cigarettes and smokeless tobacco separately.  In our study, only 22.1% of the nationally representative sample of smokers said smokeless tobacco was less harmful than cigarettes when we used a single question, but 51.6% gave lower ratings of harm to smokeless tobacco when two separate questions were asked.  Thus, assessing perceived relative harm with a single question dramatically underestimates actual understanding of perceived risks.
Among the studies cited in the petition that measured relative risk to justify changing the warning label on snus, all but one used direct measurement of relative risk, asking the single question, and, so, likely underestimating the true proportion of participants who believe that smokeless tobacco or snus is less harmful than cigarettes.
The details of the studies are presented below:


Measure of relative harm

Borland R, Li L, Cummings KM, O'Connor R, Mortimer K, Wikmans T, Ramstrom L, King B, and McNeill A. 2012. Effects of a Fact Sheet on beliefs about the harmfulness of alternative nicotine delivery systems compared with cigarettes. Harm Reduct J 9:19.

Single question

Lund I and Scheffels J. 2012. Perceptions of the relative harmfulness of snus among Norwegian general practitioners and their effect on the tendency to recommend snus in smoking cessation. Nicotine Tob Res 14:169-175.

Single question

Lund I and Scheffels J. 2013. Perceptions of Relative Risk of Disease and Addiction From Cigarettes and Snus. Psychol Addict Behav Epub

Single question

Lund KE. 2012. Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes. Nicotine Tob Res 14:1221-1228.

Single question

Wikmans T and Ramstrom L. 2010. Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish Snus. Tob Induc Dis 8:9.

Single question

Overland S, Hetland J, and Aaro LE. 2008. Relative harm of snus and cigarettes: what do Norwegian adolescents say? Tob Control 17:422-425.

Multiple questions

In determining what portion of the population believes that smokeless tobacco is less harmful than cigarettes, FDA should recognize that data from studies, including those cited by Swedish Match, that use a single question to measure comparative harm are likely to underestimate the proportion of people who consider smokeless tobacco to be less harmful than cigarettes.
Based on the combination of the lack of US data and the fact that the evidence submitted to justify the claim that the public does not appreciate the likelihood that snus is less dangerous than cigarettes the FDA should deny the requested petition to change the warning labels on snus.
Attached: Popova, L, Ling, PM. "Perceptions of Relative Risk of Snus and Cigarettes Among US Smokers." Am J Public Health. 2013;103:e21–e23. doi:10.2105/AJPH.2013.301547

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