1. Multiple Tobacco Product Use in WV - 2009 What Do We Know? What Are We Missing? Presented by Richard Meckstroth, Chairman Dept. of Dental Practice and Rural Health West Virginia University School of Dentistry National Smokeless & Spit Tobacco Summit Madison Wisconsin Sept. 21 - 23, 2009

2. © 2006 WV DHHR / DTP

3. Smokeless Tobacco Use … The tobacco industry has increasingly shifted its interests recently… (e.g. financial, marketing, acquisition of new products) … to smokeless and spitless tobacco markets (e.g. chew, snuff, dip, spit, … and recently SNUS) We know this to be true for WV! © 2008 WV DHHR / DTP

4. Tobacco Use in WV West Virginia has the United States highest rate of: smokeless tobacco use among adult males (16%) … and adult cigarette smoking prevalence (26.5%)

5. Poly-Tobacco Users Present a Unique, Newly-Identified Problem Poly-Tobacco Users – Those who use both smoking and smokeless tobacco products. Why is this happening? - Stricter Clean Indoor Air Regulations - Stricter workplace smoking policies - Marketing by industry - Other factors? © 2008 WV DHHR / DTP

6. “Unique” WV Adult Tobacco Survey Question in 2005 and 2007 & 2008 Do you use smokeless tobacco in situations where you can’t smoke, or, where you would prefer not to smoke? Please note: All current smokers were asked this question, whether or not they answered yes when asked if they currently used Smokeless Tobacco. © 2008 WV DHHR / DTP

7. Poly-Tobacco Use in WV, 2008 16% of smokers report that they do “Use Smokeless Tobacco In Certain Situations”: 16% of smokers report that they do “Use Smokeless Tobacco In Certain Situations”: 5.6% responded they “Often” used smokeless 6.9% responded they “Sometimes” used smokeless 3.6% responded they “Occasionally” used smokeless Indeed, WV has a high percentage of poly-tobacco users! © 2009 WV DHHR / DTP

8. SNUS is … A new smokeless, spitless tobacco product in small tea bag-like pouches in a variety of flavors (e.g. Camel Snus, Marlboro Snus, Tourney Snus) … Marketed as an attractive alternative to smoking for young adults, women, OR current smokers to use in smoke- free environments … Promotes dual tobacco use … Discourages quitting … © 2009 WV DHHR / DTP

9. RJ Reynolds spokesperson David Howard: "All indications point to Camel Snus being a viable product for adult tobacco consumers.“ RJ Reynolds has primarily focused on smokers with Camel Snus marketing …”in hopes of adding the product to their repertoire of tobacco choices.” “…there has been a learning curve for us in how to market Camel Snus, and a learning curve for adult tobacco consumers on how to use it." (Winston-Salem Journal, Jan 28, 2009)

10. Laboratory Analyses of Camel Snus, by Flavor, 2008 Tobacco Constituent UnitOriginalFrostSpice Nicotinemg/g13.5614.4413.10 Free Nicotinemg/g5.075.395.07 Nitrosonornicotine (NNN)ng/g120512141140 Nitrosoanatabine (NAT)ng/g807833819 Nitrosoanabasine (NAB)ng/gBDLNQ 4-(N- nitrosomethylamino)-1 (3-pyridyl)-1-butanone (NNK) ng/g416NQ pH7.80 7.82 Dry Matter%68.168.769.8 Moisture%31.931.330.2

11. Laboratory Analyses of Camel Snus ®, by Flavor, 2008 Contained more nicotine than most other snuff products sold in the US. The free nicotine content for all flavors of Camel Snus® was greater than >5mg/g.* *This was double in free nicotine content of the earlier test marketed versions (sold in Austin & Portland). © 2008 WV DHHR / DTP

12. Laboratory Analyses of Tourney ®, by Flavor, 2008 Tobacco Constituent UnitOriginalSpearmintWintergreen Nicotinemg/g20.588.709.13 Free Nicotinemg/g2.170.320.48 Nitrosonornicotine (NNN)ng/g1088374348 Nitrosoanatabine (NAT)ng/g685NQ331 Nitrosoanabasine (NAB)ng/gNQ 4-(N- nitrosomethylamino)-1 (3-pyridyl)-1-butanone (NNK) ng/gNQ pH7.096.606.76 Dry Matter%71.573.876.5 Moisture%28.526.223.5

13. Laboratory Analyses of Tourney Snus, by Flavor, 2008 The free nicotine for the Tourney® “Original” flavor was much lower at 2.17 mg/g (than Camel’s brands). * Other 2 flavors of Tourney <0.5 mg/g free nicotine © 2008 WV DHHR / DTP

14. “…no tobacco product has been shown to be safe and without risks…” “Despite the reductions in smoking that have been achieved, millions of adult Americans continue to smoke.” “…tobacco products are likely to continue to be legal for adults to use…” Excerpts from December 2008 Letter from James Swauger, PhD Vice President - Corporate Social Responsibility at Reynolds American 401 North Main Street Winston Salem, NC 27101-3804

15. Findings of the International Agency for Research on Cancer (IARC) and the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) … “Smokeless tobacco is addictive and withdrawal symptoms are broadly similar to smoking.” … (SCENIHR, 2008) “There is sufficient evidence in humans for the carcinogenicity of smokeless tobacco. Smokeless tobacco causes cancer of the oral cavity and pancreas.” … (IARC, Vol. 89, 1/2008; SCENIHR, 2008) “The effectiveness of smokeless tobacco products as a smoking cessation aid is insufficient.” … (SCENIHR, 2008) © 2008 WV DHHR / DTP

16. “Tobacco Harm Reduction” A “strategy” that encourages tobacco users who cannot or will not quit to switch to an alternative nicotine- delivery product that is “potentially less harmful” than the other tobacco product they already use. © 2008 WV DHHR / DTP

17. “Tobacco Harm Reduction” DHHR finds that advocating “tobacco harm reduction” is neither an acceptable nor ethical public health practice. The tobacco industry wants to enlist the support of public health practitioners in this strategy, and want help to increase their tobacco sales by endorsing these new forms of tobacco. © 2008 WV DHHR / DTP

18. Primary arguments against “HR” Smokeless, spitless tobacco is definitely not harmless *associated with a number of health problems including oral, esophageal, and pancreatic cancers, other oral diseases, increased risk factors for cardiovascular disease, and risk for fetal toxicity. Better, toxin-free and regulated products currently offered having exceptional quitting success.

19. Conclusion: It is undeniable that tobacco use is habituating, addictive, and causes disease, therefore all tobacco products should be avoided.The best advice for concerned tobacco users is to quit. It is undeniable that tobacco use is habituating, addictive, and causes disease, therefore all tobacco products should be avoided. © 2008 WV DHHR / DTP There is no safe or harmless use for any tobacco product!

20. Contact Information: Bruce Adkins, M.S., PA - Director Division of Tobacco Prevention West Virginia Bureau for Public health 350 Capitol Street, Room 206 Charleston, WV 25301-3715 304-558-1743 Bruce.W.Adkins @wv.gov © 2008 WV DHHR / DTP www.wvdtp.org