“Alternatives” for Cigarettes – What Do Smokers Tell Us? Joe Gitchell PinneyAssociates for Katie Kemper Campaign for Tobacco-Free Kids

Disclosures I provide consulting services on an exclusive basis to GlaxoSmithKline, marketer of stop-smoking products I provide consulting services on an exclusive basis to GlaxoSmithKline, marketer of stop-smoking products I also have an interest in a venture to develop a new stop-smoking product I also have an interest in a venture to develop a new stop-smoking product

Spectrum of Products

Tobacco companies believe Smokeless is a growth opportunity Launch of new products Launch of new products USA: Camel Snus, Marlboro Snus, Marlboro SLT USA: Camel Snus, Marlboro Snus, Marlboro SLT Lucky Strike and Peter Stuyvesant in Sweden and South Africa Lucky Strike and Peter Stuyvesant in Sweden and South Africa Challenge to snus ban in Europe Challenge to snus ban in Europe SCENIHR, RCP Report SCENIHR, RCP Report Acquisitions of new divisions Acquisitions of new divisions Conwood by RAI Conwood by RAI Statements to analysts Statements to analysts Smoke-free policies drive urgency Smoke-free policies drive urgency

Some experts think Smokeless is a public health opportunity A panel of medical experts funded by the National Cancer Institute studied low-nitrosamine smokeless tobacco and concluded that it posed at least a 90% reduction in health risks compared with smoking, according to a 2004 report in the journal Cancer Epidemiology, Biomarkers & Prevention. A panel of medical experts funded by the National Cancer Institute studied low-nitrosamine smokeless tobacco and concluded that it posed at least a 90% reduction in health risks compared with smoking, according to a 2004 report in the journal Cancer Epidemiology, Biomarkers & Prevention. "Smokers have a right to be informed of significant harm reduction options," Lynn T. Kozlowski, chairman of behavioral health at State University of New York at Buffalo "Smokers have a right to be informed of significant harm reduction options," Lynn T. Kozlowski, chairman of behavioral health at State University of New York at Buffalo “Should snuff be used as a tool to quit smoking? Smokeless tobacco is safer than cigarettes…” – WSJ, 16 September 2006 “Should snuff be used as a tool to quit smoking? Smokeless tobacco is safer than cigarettes…” – WSJ, 16 September 2006 October 2007 RCP Report October 2007 RCP Report “Low nitrosamine smokeless tobacco products may have a positive role to play in a coordinated and regulated harm reduction strategy which maximises public health benefit and protects against commercial market exploitation.” “Low nitrosamine smokeless tobacco products may have a positive role to play in a coordinated and regulated harm reduction strategy which maximises public health benefit and protects against commercial market exploitation.” This issue continues to be divisive!

…what do SMOKERS think? Research commissioned by GSK Research commissioned by GSK Quantitative Quantitative Phone survey of 501 respondents Phone survey of 501 respondents completed Jan’05 completed Jan’05 In Press: Am J Health Behavior In Press: Am J Health Behavior Qualitative Qualitative Focus groups, 3 US cities, videotaped Focus groups, 3 US cities, videotaped Completed June 2006 Completed June 2006

Quant Research Findings In concept, “Tobacco-free nicotine” is preferred to “smoke- free tobacco” In concept, “Tobacco-free nicotine” is preferred to “smoke- free tobacco” See chart, next page See chart, next page In reality, current NRT products don’t always deliver In reality, current NRT products don’t always deliver VERY low awareness of Commit lozenge VERY low awareness of Commit lozenge Ariva preferred to Commit in separate, small scale actual-usage study (Hatsukami) Ariva preferred to Commit in separate, small scale actual-usage study (Hatsukami) And smoker misperceptions of NRT safety persist And smoker misperceptions of NRT safety persist 2007 Survey reported that only 7% of smokers could correctly answer the True/False question of “Smoking while wearing the nicotine patch can cause heart attacks” 2007 Survey reported that only 7% of smokers could correctly answer the True/False question of “Smoking while wearing the nicotine patch can cause heart attacks” Same survey had only 31% of smokers able to correctly answer False to “Stop-smoking products with nicotine are just as harmful as cigarettes” Same survey had only 31% of smokers able to correctly answer False to “Stop-smoking products with nicotine are just as harmful as cigarettes”

Study II Nicotine Tobacco-free Nicotine As a smoker, you find there are times when smoking is not permitted, and there may be other times when you choose to smoke less, even when you are not quitting. You know less is better for you, but find it hard. Now there is a way to relieve the discomfort when you can’t or don’t want to smoke. R6 lozenges provide pure nicotine in a pleasant- tasting form. R6 lozenges dissolve in your mouth and reduce cravings and discomfort without the smoke and other harmful elements of tobacco. Almost all the harm smoking does is caused by the smoke and other chemicals in tobacco, not the nicotine. It would be great to get relief and satisfaction without smoking. R6 is better and safer than tobacco, and it works, because it is real nicotine. Remember, when you want relief and satisfaction without harmful smoke and tobacco, use R6.

Study II Tobacco Smoke-free Tobacco As a smoker, you find there are times when smoking is not permitted, and there may be other times when you choose to smoke less, even when you are not quitting. You know less is better for you, but find it hard. Now there is a way to relieve the discomfort when you can’t or don’t want to smoke. L2 lozenges provide tobacco in a pleasant-tasting form. L2 lozenges dissolve in your mouth and reduce cravings and discomfort without the smoke of cigarettes. Almost all the harm smoking does is caused by the smoke, not the tobacco itself. It would be great to get tobacco satisfaction without smoking. L2 is better and safer than smoking, and it works, because it contains tobacco. Remember, when you want tobacco satisfaction without harmful smoke, use L2.

TFN Preferred N=283 p< for binomial test of p Sft =0.51 N=238 p< for binomial test of p SFT =0.51 Study I v. Study II Comparisons SFT – p= TFN – p= No Pref – p =

Other Results Held for both gender, though women more likely to prefer TFN Held for both gender, though women more likely to prefer TFN Prior history of NRT use increased TFN preference Prior history of NRT use increased TFN preference Considerable interest in this more flexible expression of use for TFN Considerable interest in this more flexible expression of use for TFN 32% of smokers were interested in TFN and had never used NRT in the past, and these smokers were more likely to be men, non-white, less educated, lower income – groups that have been difficult to reach with quitting and treatment 32% of smokers were interested in TFN and had never used NRT in the past, and these smokers were more likely to be men, non-white, less educated, lower income – groups that have been difficult to reach with quitting and treatment

A series of six focus groups were conducted between June 15-21, 2006 in selected markets: Charleston, West VirginiaAdults Indianapolis, IndianaAdults Columbus, OhioYoung adults (18-25) Qual Research - Overview

Camel Snus is not a satisfactory substitute for smoking, although it is perceived by some to be safer, and might be seen as a quitting product.

Consumer Quotes “I look at chewing or dipping or whatever this would be considered as an alternative to smoking. To me smoking is the act of smoking. It’s not necessarily for the tobacco or the nicotine. It’s the actual act of smoking. “ “I wouldn’t use it day to day. I wouldn’t exchange it for my cigarettes.” “I’d try it, but I wouldn’t try it thinking I was going to be switching that out for smoking.” “I feel like it’s exactly the same thing as spit tobacco, except you don’t spit it out. Just another product for a new generation.”

Novel NRT can be more appealing to smokers than novel tobacco products. The opportunity to quit is seen as a positive aspect.

Consumer Quotes “You feel safe about it because it’s been through tests to be able to be in these stores.” “I’m attracted just because it’s by Nicorette, so I feel safer because it’s been through testing.” “It says it doesn’t have the harmful effects of tobacco.” “This seems like it’s actually going to further your effect of quitting smoking. The other one [Camel Snus] seems just like another tobacco product.”

The Reduce to Quit concept is perceived positively and considered supportive of smokers’ cessation efforts. Smokers seem to prefer a gradual reduction of smoking to a cold turkey approach.

Consumer Quotes “I like it because when you try to quit you start really having those cravings and you start to really get grouchy…it’s not like quitting all at once, because quitting all at once makes me feel panicked and it makes me feel ten times worse. And when I start back I’m smoking more than I was when I tried to quit.” “It kind of tells you that just because you don’t succeed the first time that you are not a failure.” “I just think that if I could gradually cut down from a pack and then in six months a half a pack I think I could do that by the end of a year.”

Qual Research: Summary Initially, new smokeless products have low inherent appeal Initially, new smokeless products have low inherent appeal -but tobacco companies are good marketers! -but tobacco companies are good marketers! Look at experience with filters and LTN Look at experience with filters and LTN Smokeless tobacco lacks the most satisfactory properties of combustible tobacco Smokeless tobacco lacks the most satisfactory properties of combustible tobacco Smokers are seeking inhalation effect, hand-to- mouth benefits Smokers are seeking inhalation effect, hand-to- mouth benefits “If I’m going to make this drastic a change, I might as well quit” - respondent “If I’m going to make this drastic a change, I might as well quit” - respondent

Conclusions Smoker intentions and attitudes are important – too few study this Smoker intentions and attitudes are important – too few study this Pushing smokeless for situational substitution may squander the opportunity to encourage smokers to QUIT as smokefree laws come into effect…but hard to know without surveillance Pushing smokeless for situational substitution may squander the opportunity to encourage smokers to QUIT as smokefree laws come into effect…but hard to know without surveillance A variety of quitting options are needed A variety of quitting options are needed More flexible approaches seem to have incremental appeal More flexible approaches seem to have incremental appeal Regulation of tobacco according to the continuum of risk is needed Regulation of tobacco according to the continuum of risk is needed More flexible quitting paths using NRT have considerable promise More flexible quitting paths using NRT have considerable promise