A practical guide to help people reduce the health burdens of cigarette addiction (March, 2006)

Table of Contents

Overview - Brain Disorders, Smoking and Nicotine Addiction

Possible Positives Effects of Nicotine for Schizophrenia

The Many Negative Effects of Smoking Cigarettes

The Least Harmful Alternatives to Smoking, for People who have Schizophrenia

• Resources for Quitting Smoking
• Medicinal Nicotine (Cost: approximately $3 to $14 per day)
• Low Nitrosamine Swedish Snus (Cost: approximately 40 cents to 80 cents per day)
• Tobacco Mints (Cost: Approximately $1.20 to $3.00 per day)

The Highest Risk Tobacco Products

• Cigarettes
• High Nitrosamine Dry Chewing Tobacco/Snuff

Appendix: Resources and more reading on schizophrenia and nicotine/smoking

Overview - Brain Disorders and Smoking & Nicotine Addiction

While the prevalence of smoking in the total U.S. population is about 25 to 30 percent, the prevalence among people with schizophrenia is approximately three times as high - or almost 90%, and approximately 60% to 70% for people who have bipolar disorder.

(Source: Psychiatic Times: Nicotine and Schizophrenia, February 2001)

Related to this issue of very high smoking rates, recent research out of Harvard University has even suggested that approximately 44%% of all cigarettes sold in the United States, are consumed by the mentally ill (who represent perhaps 4% to 8% of the population). The physical and financial costs of smoking are, therefore, heavily weighted towards the groups that can least afford them. (source: CNN News, 2000, original study: JAMA, 2000)

Given the well known cancer, and other health hazards of smoking, it’s not surprising researchers have suggested that smoking is one of the top causes of premature death of people with schizophrenia, and the likely reason why cancer is more common in people who have schizophrenia. Moreover, there is also the indirect problem of tobacco use affecting health via the high proportion of total income that people with schizophrenia spend on tobacco (research suggests that the typical person who has schizophrenia spends 27% of their total income on tobacco products). This high percentage of income spent on tobacco further harms the people who have schizophrenia because it redirects funds away from health promoting foods (such as more fresh vegetables and fruits), or better accommodations. (for more on this topic see: brain disorders and demand for alcohol, cigarettes and cocaine)

However research has shown that the relationship between smoking and schizophrenia is complex - it appears that there are both positive and negative effects of nicotine on a person who has schizophrenia and on the development of schizophrenia. The research is not entirely conclusive on this topic, but generally the research supports the idea that seem to be some psychological benefits that people with schizophrenia sometimes gain by smoking (or more specifically from nicotine)- and that is why the smoking rate is much higher than in normal populations.

An article in The Washington Post in 1998 highlighted the complex effects of nicotine:

"Nicotine .. is not selective. It has many different, often contradictory, effects on the body -- for example, it simultaneously calms smokers and speeds up their heartbeat.

"It's just what we would call a 'dirty drug,' " said Phyllis C. Pugh, a nicotine researcher at the Medical College of Ohio. "It has too many effects.""

Possible Positive Effects of Nicotine for Schizophrenia

A 2004 German scientific article specifically looked at studies that discuss why individuals with schizophrenia smoke chronically. Certain thinking patterns are affected in schizophrenia including sustained attention, focused attention, working memory, short-term memory, recognition memory and even processes that are preattentive (eg reflexes). Some studies have suggested that there may be improvements in these areas after treatment with nicotine. So, it maybe that nicotine is used as a "self-medication" strategy by those with schizophrenia to improve these difficulties with attention, cognition, and information processing as well as the side effects of antipsychotic medications (eg extrapyramidal effects). (Cattapan-Ludewig)

The Baltimore Sun (October, 2004) reported that "researchers have made progress in understanding tobacco's hold on the mentally ill. Dr. Gunvant Thaker, chief of the schizophrenia-related disorders program at the Maryland Psychiatric Research Center, said studies have shown that nicotine helps to mitigate two problems associated with schizophrenia.

The first is faulty sensory "gating," the ability to make sense of stimuli in the environment. People startle the first time they hear a loud noise such as a car alarm - but they're able to ignore it, or at least mute their reaction, when they hear it again and again.

Schizophrenics lack this "gating" capacity, which may explain some of the confusion and fear they feel in seemingly harmless situations.

As it turns out, the deficit is associated with a faulty gene that also happens to be a nicotine receptor gene. "When schizophrenia patients smoke, or are given nicotine gum, this deficit of sensory gating is reduced or normalized," Thaker said.

Nicotine also helps with other cognitive problems related to schizophrenia Thaker said, including difficulty tracking a moving object and remembering things. With these problems, however, a genetic link is less clear."

Looking at the specific research, one study done by Yale University “found that when study subjects with schizophrenia stopped smoking, attention and short-term memory were more impaired, but, when they started smoking again, their cognitive function improved. No effects from stopping or resuming smoking were observed in smokers without mental illness” (Yale University, 2005). Another report from Columbia University further supports the idea the smoking (or, specifically, nicotine) helps in concentration. 

Other research suggests that nicotine helps people who have schizophrenia in their auditory processing (i.e. processing of audible information, such as sounds or spoken words, etc.).  For more information on this see Transdermal nicotine treatment enhances automatic auditory processing. Research done by Dr. Robert Freedman, Dr. Sheri Leonard and co-workers at the University of Colorado has shown that schizophrenics process sensory information differently to 'normal' people. Unlike a person who has schizophrenia, if a person that doesn't have schizophrenia is startled by an auditory or visual stimulus, they quickly become accustomed to it if it is repeated. Research has found that when people that suffer from schizophrenics are given nicotine, via a patch or gum, they can cope with auditory or visual stimuli in much the same way as 'normal' people. This supports the theory that nicotine is acting in a therapeutic manner via receptors associated with the sensory habituation.

In addition, schizophrenic patients have fewer nicotine receptors in their brains than normal people, and the expression of one of the nicotine receptor subunits is also reduced in these subjects. These studies may have provided us with some important clues about the central workings of schizophrenia. First, the findings indicate that a nicotinic receptor may be at fault in at least one aspect of this behavioral syndrome - the inability of the schizophrenic to process certain kinds of sensory information. Second, the work also indicates that there may be a genetic link involving the inheritance of the alpha-7 nicotinic receptor gene from one generation to another.All of this provides important clues as to why schizophrenics smoke, and may be a rationale for using nicotine (nicotine patch or gum) in non-smokers with these abnormal behavioural symptoms. Again, much more careful research is needed before we can make the jump to using nicotine in the clinic.

There is another research report is one of several that provide evidence that nicotine may have a positive impact on people predisposed towards schizophrenia.  In 2004 research came out on a long term study of 50,000 Swedish military recruits which suggested that early cigarette smoking may provide a shield against schizophrenia. After a variety of other possible influences were accounted for, men who smoked cigarettes at the time of conscription (ages 18-20) were less likely to be diagnosed with schizophrenia during the following 27 years.  The more they smoked, the lower the chance of developing schizophrenia. Each increase of one half pack per day reduced the risk by about 10%, up to 11/2 packs per day. ( learn more about schizophrenia prevention and nicotine).

Some studies have found that the cognitive benefits elicited by nicotine are relative to how much nicotine is taken in by the individual. One example of such a study was done in Spain and published in the British Journal of Psychiatry in 2005 . They found that "for mildly dependent smokers nicotine could have a beneficial effect on their symptoms. But they also found that people with a high nicotine dependence were more likely to be readmitted to [a] hospital and have a poor outcome".

It is therefore apparent that nicotine can have both positive and negative effects. The high use of nicotine in patients with schizophrenia has also been attributed to nicotine lessening the side effects of some antipsychotic medications. One article noted that “there have been indications that nicotine can reverse the memory problems and slowness of thought induced by a commonly used medicine, haloperidol” (Watts, 2003). There has been some evidence that this is the case, but it seems that the major reason for nicotine use in those with schizophrenia is due to the benefits it can have relating to the disease specifically. One of the reasons that nicotine is thought to have the effect that it does is that it mimics the neurotransmitter acetylcholine. The nicotine does this by attaching to receptors (receptors are specific areas on the surfaces of cells that “act as molecular switches”), and therefore increases the activity of acetylcholine receptors. This gives one the feelings that they have after they have smoked a cigarette or had any other form of nicotine.

As we suggested above, however, the studies are far from conclusive. A 2005 study in the British Journal of Psychiatry (mentioned above) noted "Smoking may have a beneficial effect on either schizophrenic symptoms or antipsychotic side-effects, but studies are hampered by the lack of control of confounding factors". and then concluded that "The data do not generally support the self-medication hypothesis but rather suggest a complex interaction between nicotine dependence and nicotine dependence and schizophrenic symptoms".

In May, 2005, the Harvard Health Letter noted "researchers at Stanford and elsewhere have conducted experiments that show nicotine may stimulate angiogenesis, or the formation of new blood vessels. Tumors release angiogenic chemicals that create blood vessels so they have more blood to fuel their growth. A number of cancer treatment drugs are angiogenesis inhibitors, designed to block those chemicals. Moreover, angiogenesis may play a role in the formation of the plaques inside arteries that lead to heart attacks. If nicotine is angiogenic, then it may play a more direct role in causing, or perhaps accelerating, cancer and heart disease than previously thought."

Nicotine Medications?

Scientists are doing research for new drugs that may be based on, or operate in a way that is similar to nicotine (but without the negative aspects), to help people with brain disorders such as schizophrenia.  For more information on this topic, see: Nicotine Studied as Treatment for Brain Disorders and Potential Nicotine Treatment. One such company is called "Targacept" - that is working on a nicotine-oriented drug to treat the cognitive impairment common with schizophrenia. (more information: Targacept ). The Harvard Health Letter (May, 2005) noted "Researchers have been talking about nicotine-related drugs for decades, but none are on the market yet. Part of the problem is reputation. One researcher has suggested that nicotinic drugs be termed "cholinergic-channel modulators" to avoid the stigma. And it isn't just image. Nicotine researchers have accepted money from tobacco companies. Targacept, a biopharmaceutical firm that focuses exclusively on this area of research, was part of R. J. Reynolds until 2000." and that "Even without these problems, designing nicotine-related drugs is tricky. Researchers must find compounds that are selective. "Nicotine is a pretty promiscuous drug," Dr. Newhouse explains. "It hits a lot of things at once. But for effective medications, we want to target specific receptor subtypes." "

In 1998 an article The Washington Post, noted:

Abbott Laboratories is working with researchers at the National Institutes of Health to study a nicotine-like drug from the skin of Amazonian frogs used for poison darts that is, in smaller doses, a highly effective painkiller. And Esther Sabban at New York University Medical College is exploring the role of nicotine in relieving the ill effects of stress on the body.

... Sanberg said he has given nicotine in patch form to children as young as 8 who suffer from Tourette's. "There were clearly people that didn't like the idea of giving their children nicotine and the thought that maybe they could get addicted or start smoking," he said. Nicotine in patch and gum form does not appear to carry the risk of addiction that smoking does, Sanberg said: In cigarettes, the first puff sends a potent jolt of the drug directly to the brain in about eight seconds, while patches and gum work far more slowly and consistently. "We haven't seen any addiction," Sanberg said.

Compared with the usual treatments for the disease, including potent antipsychotic drugs with side effects that can be severe, parents generally opt for the nicotine treatment, Sanberg said.

Scientists studying nicotine say that even if the drug can be addicting, that side effect is something that society will tolerate if the benefits outweigh the risks. Opiates, Levin noted, "can produce an awful addiction -- but if you're in severe pain, it's a godsend."

For More Information: News Stories and Research findings related to nicotine and schizophrenia

Smoking Negatives:

Some of the major negative aspects of cigarette smoking include:

The more cigarettes smoked per day, the higher the risk of lung Cancer

Given that the average person who has schizophrenia smokes approximately 24 cigarettes per day, they are more likely than not to develop lung cancer during their life. Following is a graph showing how the risk of cancer goes up as the number of cigarettes smoked per day goes up.

Source: OncoProf.net, by Caen University School of Medicine

• Smoking is a direct cause of cancer and has been hypothesized as one of the key reasons life expectancy for people with schizophrenia is about 20% shorter than for people who do not have schizophrenia. The British Journal of Medicine has reported that approxmiately 50% of average smokers die prematurely (and likely a much higher percentage of smokers who have schizophrenia because of higher smoking rates)
• Smoking just one to four cigarettes a day almost triples a person's risk of dying of heart disease, according to Norwegian researchers (BBC News)
• A billion people will die from tobacco-related diseases such as cancer this century unless more are encouraged to quit, a UK expert warns (BBC News)
• Smoking is a large financial burden for people who have schizophrenia
• Long-term Smoking Is Associated With Up To 40 Percent Increased Risk Of Breast Cancer
• Smoking has also been found to interfere with the response to antipsychotic drugs.
• Several studies have found that schizophrenia patients who smoke need higher doses of antipsychotic medication.
• Smoking significantly increases risk of emphysema (lung diseases)
• Smoking significantly increases risk of diabetes
• Smoking (via discarded or forgotten cigarettes) can cause house fires
• Smoking is an important cause of cancer in other people close to the smoker (via "second hand smoke")

Smoking Statistics from TobaccoFreeKids.org :
• People who die each year from their own cigarette smoking: 400,000 (some people estimate that half of these people, or 200,000 a year, are mentally ill). (see presentation by Dr. Stephen Shroeder on smoking and schizophrenia) Powerpoint File
• People who die each year from others' smoking (secondhand smoke & pregnancy smoking): 38,000 to 67,500
• Kids under 18 alive today who will ultimately die from smoking (unless smoking rates decline): 6,000,000+
• People in the USA who currently suffer from smoking-caused illness: 8.6 million Smoking kills more people than alcohol, AIDS, car accidents, illegal drugs, murders, and suicides combined -- and thousands more die from spit tobacco use. Of the roughly 750,000 kids who become new regular, daily smokers each year, almost a third will ultimately die from it. In addition, smokers lose an average of 13 to 14 years of life because of their smoking.
• Tobacco-Related Monetary Costs in the USAHealthcare Costs. Total annual public and private health care expenditures caused by smoking: $89.0 billion − Annual Federal and state government smoking-caused Medicaid payments: $28.4 billion [Federal share: $16.2 billion per year. States share: $12.2 billion] − Federal government smoking-caused Medicare expenditures each year: $24.9 billion − Other federal government tobacco-caused healthcare costs (e.g. through VA health care): $8.7 billion
• Additional smoking-caused health costs caused by tobacco use include annual expenditures for health and developmental problems of infants and children caused by mothers smoking or being exposed to second-hand smoke during pregnancy or bykids being exposed to parents smoking after birth (at least $1.4 to $4.0 billion). Also not included above are costs from smokeless or spit tobacco use, adult secondhand smoke exposure, or pipe/cigar smoking.
• Non-Healthcare Costs: Productivity losses caused by smoking each year: $93.6 billion [Only includes costs from productive work lives shortened by smoking-caused death. Not included: costs from smoking-causeddisability during work lives, smoking-caused sick days, or smoking-caused productivity declines when on the job.
• For more information on the Health Effects of Cigarettes - Click here

A sample of the research on the negatives of smoking on people who have schizophrenia:

• Drug and alcohol use among patients with schizophrenia and related psychoses: levels and consequences (2004)
• Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study (2004)
• Treating the mind and body in schizophrenia: risks and prevention (2004)
• A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors (2005)
• The Lifestyle of People with Schizophrenia (Powerpoint Presentation from Crichton Royal Hospital, UK)

Quitting smoking may be especially difficult for people with schizophrenia, because the symptoms of nicotine withdrawal may cause a temporary worsening of schizophrenia symptoms. However, smoking cessation strategies that include nicotine replacement methods may be effective. Doctors should carefully monitor medication dosage and response when patients with schizophrenia either start or stop smoking. A study by Crichton Royal hospital suggested that 21% of people who had schizophrenia were ultimately able to quit smoking after they started.

The least harmful alternatives to smoking

There is no such thing as a completely "safe" or "harmless" level of tobacco or nicotine consumption. More importantly, of all the possible ways to consume tobacco to obtain nicotine, smoking cigarettes is generally seen as the most harmful to a person's health. Experts recommend that everyone who does smoke cigarettes, or who is addicted to nicotine - attempt to quit using the medicinal nicotine options listed below, and by working in concert with their doctor so as to minimize any negative issues.

Using data from a national mental health survey, researchers at Cambridge Hospital in Massachusetts found that people with mental illness were twice as likely to smoke. In that study, however, the authors defined mental illness more broadly, including addictions and milder afflictions. So defined, the mentally ill accounted for almost half of tobacco sales in the United States. But in a hopeful sign, they also found that "a third of patients with mental illness had quit smoking by the time of the survey."

Western State Hospital, one of the largest psychiatric hospitals in the western United States, banned smoking in 2003 on its entire 540-acre campus in the interest of patient health. Previously, only indoor areas had been smoke-free at the hospital south of Tacoma.

A report by Associated press quoted hospital Chief Executive Officer Jan Gregg "I have a 24-year history in psychiatric hospitals, and I've seen a tradition of giving out cigarettes as rewards," ... "We've gotten away from that, but this totally closes the loop. ... this hospital is a health care facility, and we need to promote healthy habits."

The story continued "Gregg said a year of research found rising costs to treat smoking-related heart problems. The hospital now offers nicotine gum, patches and smoking-cessation classes instead of cigarettes to its 794 patients.

But critics say the ban is a bad move, as research indicates that people with schizophrenia can benefit from nicotine.

Schizophrenics' "nicotine receptors" seem to be chemically different, said Dr. Robert Smith, a psychiatry researcher at New York University's Medical School.

Nicotine appears to help lessen the cognitive deficits that plague people with schizophrenia, including problems with attention span, memory and organization of their thoughts, he said.

Other medical researchers say nicotine reduces the potency of mental-health medications, which in turn reduces side effects like sexual impotency.

The hospital banned outdoor smoking a year ago for its criminal commitments unit. Administrators wanted to extend the ban to those patients who are civilly committed, as they are given more freedom to walk around the grounds.

Once-smokey entryways have cleared and there has been no rise in confrontations, said Gregg and her staff members."

People who, for any reason,do not want to break the nicotine addiction, would (experts suggest) likely be be able to minimize the negative impact on their health by adopting one of the alternatives identified below:

A typical American cigarette contains approximately 10mg of nicotine (there are higher levels - typically twice as much - in many foreign cigarettes) and the average mentally ill smoker may smoke between 20 and 40 cigarettes per day, if not more. The amount of nicotine that actually enters a persons body seems to vary by the by the way the nicotine is taken in (e.g. cigarette, pipe, gum, etc.) and there is also a personal variances in terms of nicotine absorption. On average, research indicates that the typical smoker who has schizophrenia may absorb approximately 2mg to 3mg of nicotine per cigarette, and therefore between 40 mg and 120 mg of nicotine per day.

More Information: A Complete List of Web Resources for stopping smoking, for People with Schizophrenia

Following are some product categories that may assist in a person's quitting smoking, or lowering the health risks associated with nicotine addiction and tobacco use.

Medicinal Nicotine, (also called Nicotine Replacement Products)

Nicotine replacement products are sometimes valuable for people trying to quit smoking. There are many products available, including: the patch, gum, lozenges, nasal spray, and the inhaler. All of these products have nicotine in them and are used as a substitution for the nicotine that a smoker is used to getting. They each have certain benefits involved and which one you choose to use is dependent on how much you smoke, whether you can physically use the product (e.g. those with dentures will not be able to use the gum), and what you personally prefer and find most helpful. They are used for a limited amount of time to quit smoking although using them for a long term period may be possible. You should talk to your doctor before deciding to start a long term nicotine replacement plan.

Some studies using nicotine patches have found that they help improve memory for those with mental disorders or age-related memory loss. One study using seniors “found that four weeks of nicotine treatment halved decision times on a standardized test of memory and increased participants' ability to focus their attention” (United Press International, 2003). This study suggests that nicotine may be of help with mild memory loss for several populations. It is another one of the reasons that people with schizophrenia may use nicotine to self-medicate for their symptoms. However, other studies have suggested that smoking actually harms the memories of normal teens (Yale, 2005) – so it seems that the impact of cigarette smoking and nicotine is likely to depend upon the person’s genetics and brain chemistry.

Nicotine replacement products seem to be a preferred way to intake nicotine considering how the many more unhealthy substances and chemicals created due to the burning of tobacco included in such products such as cigarettes, and also included in chewing tobacco, and snuff. Some studies have looked at the potential for nicotine replacement products to wean those with schizophrenia off of cigarettes. In one study nicotine nasal spray was administered to 12 people who had either schizophrenia or schizoaffective disorder and had not been successful in prior attempts to quit smoking. Of those 12, “After treatment five patients (42%) were abstinent from smoking for more than 90 days, and four patients (33%) substantially reduced the amount that they smoked” (see Nicotine Spray Reduces Smoking). Such studies demonstrate that a less harmful nicotine relief plan is a valid possibility for those with schizophrenia.

The Harvard Health Letter (May, 2005) noted that "Investigators are seeing if the nicotine patch might have other uses besides helping smokers quit. In 2004, one trial found that the patch improved cognitive performance in patients with schizophrenia. A 2003 study investigated the effectiveness of nicotine patch therapy in nonsmoking patients diagnosed with depression. And a 2001 study reported promising results for treatment of Tourette's disorder with a combination of the nicotine patch and the antipsychotic drug haloperidol (Haldol)."

Pros of nicotine replacement products:

• FDA Approved and regulated
• The product category with the lowest possible health risk option for nicotine addicts (and smokers)
• User has the option of gradually decreasing nicotine level, and eventually stopping nicotine addiction
• User has the option of continuing on with nicotine products, at a controlled nicotine level that works for him or her.
• Produced and controlled by the FDA (Food and Drug Administration) - and therefore of high quality and product consistency.
• Easily obtained from a wide variety of stores, and internet web sites.
• Eases long term decrease in nicotine consumption - as person gets better with proper medications, etc.

Cons of nicotine replacement products:

• Price/Cost - Typically significantly more expensive than cigarettes and other tobacco products (see below)
• Not as easy to obtain, in terms of where they are sold. Cigarettes are sold almost everywhere, but you are not going to usually find nicotine replacement products at your local gas station. They are, however available over the Internet (see links below)
• May increase insulin resistance (related to diabetes)

Long term use not recommended by the FDA or manufacturers - but experts say that there is no question there is much lower harm from these medicinal nicotine products (compared to cigarettes) and they seem to be the least harmful of commonly available nicotine tobacco products - so while long term use is not recommended by the FDA, they may still be much safer than smoking and a better alternative in terms of cancer risk than any other tobacco product on the market today. Discuss them with your doctor before long-term use.

More Information: A Good List of Additional Reading and Scientific Information on Nicotine Replacement Products

Comparison Table of Nicotine Replacement Products

Nicotine Patch

Note: All prices were as of September, 2005 and may have changed now)

Nicotine Gum

Full List of Discount Nicotine Gum Resellers on the Internet

Nicotine lozenges

Nicotine Nasal Spray

Recent research has highlighted a new type of nicotine nasal spray. See Nicotine spray for nose, reduces smoking for the full story.

 Nicotine Inhaler

Low Nitrosamine Swedish SNUS

Snus is a special type of "chewing tobacco" (or more accurately described as a "sucking tobacco") product that originates from Sweden. It exists in two forms: loose snus, and portion packaged snus (a small tea bag that a person can put between their upper gum and lip) . It is basically a ground tobacco mixed with water, salt, and flavoring additives and was first used in Sweden in the 1700’s. Sweden is where it is most commonly used, not coincidentally the nation that also happens to have the lowest level of tobacco related diseases in Europe. Snus is placed behind the upper lip and the nicotine is absorbed through one’s skin. Snus comes in an array of flavor varieties, some of the most common flavors are licorice, lemon, mint, and coffee; it also comes with just the tobacco taste if you prefer. Snus is pasteurized through a heat treatment and is under the same food regulations that foods in Sweden are held to. This means that the “production and additive standards are the same as those for food products”.  Snus (in the “portion”, or small packet design) is also spit-free which is an obvious advantage over products such as chewing tobacco.

In snus, many of the cancer-causing chemicals are eliminated or decreased dramatically because the tobacco is not burned by the consumer, as well as by the fact that with snus the tobacco is cured with techniques that result in very low levels of nitrosamines (a type of cancer-linked toxin that is evident in high levels of most other types of tobacco products).

Cancer-causing compounds are also introduced into tobacco during the "curing" process when the tobacco is dried. For traditional tobacco products dry heat is used in the curing process and this results in a high level of what are know as Tobacco Specific Nitrosamines or TSNAs  - which are regarded as the most powerful and abundant cancer-causing compounds in tobacco and tobacco smoke.   Swedish SNUS is steam cured which, among other techniques, is estimated to be one of the reasons why snus is so low in TSNAs (typically 75% to 95% lower than other tobacco products in other countries).

Virtually all tobacco products have some level (even if very low) of these and other toxic compounds in them, and this is why no tobacco product can be considered "healthy" - but the amount of nitrosamines varies dramatically by tobacco product, and accordingly there are varying degrees of risks associated with the different type of tobacco products. Although there is no definitive proof that low TSNA tobacco will reduce the risk of cancer at this stage, many independent experts in tobacco suggest that low-nitrosamine snus delivers much smaller quantities of toxins than smoked tobacco and smaller quantities than most other types of smokeless tobacco. Snus is not harmless but is markedly less harmful to health than smoked tobacco” (Source: foulds).

The typical cigarette may have (in addition to many other cancer causing compounds) anywhere from 5 to 1,000 micrograms/gram of TSNAs (Nitrosamines) in them. The typical packet of snus has approximately 2 micrograms/gram, and as low as .3 micrograms/gram for the lowest nitrosamine snus - so cigarettes can provide anywhere from 10 times, to 3,000 times, more cancer associated compounds than low nitrosamine Swedish snus. (and furthermore - cancer-causing toxins delivered by smoke are the most harmful).

While the long term research that is required to prove that these lower levels of cancer causing compounds translate directly into lower cancer rates in people, has not been done. Independent Experts are now suggesting that it is likely that the relative risk of premature death for users of low TSNA snus is probably 90% or lower than with cigarettes. In other words, the panel concluded that modern (low TSNA) snus tobacco products have only 5-10% of the health risks of smoking. There is still harm being caused to the snus user's body, but the risk of premature death from Swedish snus use seems to be much lower than for cigarette users.

Sweden has the lowest rate of lung cancer in the European Union, and the lowest risk of dying from a smoking related disease - just 11 per cent, as opposed to 25 per cent in Europe as a whole. It is the only country to meet the World Health Organization’s target of reducing smoking to just 20 per cent of its population by the year 2000. Many people believe that the snus products are responsible for this success - but definitive research on this point is difficult to complete and has not been done yet.

Women who are pregnant should not be encouraged to switch from cigarettes to snus as it is still dangerous to the child. Complete avoidance of tobacco is the only way to keep one’s baby safe from the dangers associated with nicotine and TSNA’s. One study done in Sweden looked at the birth weight, preterm delivery, and preeclampsia in women who used snuff compared to those who smoked cigarettes, or abstained from nicotine products. The study found that “both cigarette smoke and snus use [Swedish snus] were associated with restricted fetal growth and increased the risk of preterm delivery…snuff use was also associated with increased risk of preeclampsia” (England, et al., 2003. p.942). Although snus is not as damaging as smoking cigarettes, in terms of carcinogens and other health risks, snus can still have detrimental effects on the unborn child.

Smoking has been linked to an increased risk of Type II Diabetes and so the natural question is: does snus elicit the same risk? While there have been several studies that have confirmed the existence of a link between diabetes and smoking there have been fewer studies done on the link between snus and diabetes. One study in Sweden had 3,384 participants who were either smokers, ex-smokers, or snus users. Eliasson, Asplund, Nasic, and Rodu (2004) “found that being a smoker “current or former, is a risk factor for type 2 diabetes in men, especially clinically diagnosed, but cannot find any substantial increase of risk in users of Swedish snus” (p.109).

The impact of snus on one’s heart has also been taken into account. One such study looked for a link between Swedish snus and myocardial infarction (commonly known as a heart attack) in men. Hergens, Ahlbom, Andersson, and Pershagen (2005) found that their “results do not indicate an increase in risk of myocardial infarction among users of Swedish moist snuff.” They hypothesized that the reason for this might be because such a risk is not due to the nicotine in smoking tobacco, but rather some of the other components within the smoke. Some of the substances they named as potentially causing this risk where “Carbon monoxide, oxidant gases, and polycylic aromatic hydrocarbons.”

Another mentioned possibility by Hergens et al. (2005) was that Swedish moist snuff “contains substances such as fatty acids and flavinoids that could have a protective effect for myocardial infarction [heart attacks].” This study concluded that Swedish snus did not result in an increased risk in heart attacks which is one of the health claims that cigarettes and other tobacco products cannot make. Although all tobacco products have certain negative health risks associated with them, it appears (by looking at research available) that snus products have a relatively low amount of risks associated with them, especially in comparison to other tobacco products such as cigarettes or dry snuff.

• It causes nicotine dependence (similar to cigarettes), which he sees as a necessary characteristic of a nicotine maintenance product in order for it to be capable of helping significant numbers of people switch from cigarettes.

• It causes oral lesions/gum recession (most of which are reversible), but not oral, gastric, or head/neck cancer.

• It may increase cardiovascular risks but less than cigarettes. (Three studies find no increase; one finds increased myocardial infarction risk relative to non-tobacco users; all find a lower risk than cigarettes).

• It is certainly harmful to the unborn fetus (though less so than cigarettes).

• It does not cause respiratory disease or lung cancer.

Other Pros of Product

• Experts suggest that certain SNUS tobacco brands from Sweden are about 90% lower in terms of death risk than cigarettes and also much lower than US-produced "smokeless" tobacco brands such as snuff/chewing tobacco.
• Minimal or no increased risk of diabetes (as there is with cigarettes)
• No Increased Risk of Lung Cancer (compared to non-users, or non-smokers)
• No Increased Risk of Emphysema (compared to non-users, or non-smokers)
• Possible increased risk of heart disease (compared to proven and significant increased heart disease risk with cigarettes)
• Seems to be linked to much lower risk of death in Sweden for tobacco consumers
• Relatively inexpensive (compared to nicotine replacement products)
• Product has been sold for approximately 100 years in Sweden, and has been studied by scientific researchers to a relatively significant level. (Note: some of this research is funded by the tobacco companies, so should be considered as potentially biased).

Cons of Product:

• Tobacco-based product - means some potential increase risk of cancers is present when compared to not taking any tobacco product at all (no nicotine use is still the safest approach).
• Not as low a risk of cancer as nicotine replacement products (snus is not harmless). Medicinal Nicotine replacement products are likely to be the safest in terms of cancer risk.
• Possible (but unproven, and likely small) risk of oral cancer, and cancer to pancreas (but much lower than lung cancer risk in smoking). Note: It also seems reasonable that the lower TSNA (Tobacco specific Nitrosamines) level of the product, the lower the risk of the product to cause any type of cancer. In the US all “smokeless tobacco” (including Swedish Snus) is classified as one product class in the US and must be labeled with the warning, if sold in the USA “This product may cause mouth cancer”, but it seems likely that some products that lower in TSNAs have a significantly lower risk in this area, than products with high TSNAs.
• Different consumer experience than smoking (some people like the feel of smoking, for whatever reason, and these small pouches that you put in your mouth may not be liked by some people)
• Increased risk of dental cavities and mouth sores

Vendors and Product Information: Following are the vendors of what we believe are the products with the lowest levels of cancer-causing compounds.

Low Nitrosamine (TSNA) Brands of Swedish SNUS available (Lowest cancer causing agent brands at top of list)

Source: Table Information: All concentrations in parts per million based on dry weight. Note, because of the water content in most “moist” Snuff or Snus, the actual levels (due to water content) are typically lower than shown above (by up to 50%). (Information Source: Smokeless Tobacco and Oral Cancer: A Review of the Risks and Determinants, Crit Rev Oral Biol Med, 15(5):252-263, 2004). Rocker TSNA levels - from Rocker Lab results.

Additional Reading and Information on Snus

Tobacco Mints or Lozenges

Tobacco mints and lozenges taste sweet and contain compressed nicotine powder and are sugar free. Those made by Star Scientific (the product is called called Ariva) also contain eucalyptus. Ariva its “stated use” is as a substitution when one is incapable of smoking. Stonewall is dissolvable hard snuff and is marketed as a substitution for those who use snuff.

Pros of Product:

• Published research indicates that these tobacco mints are very low in cancer-associated TSNAs (Tobacco specific Nitrosamines) - so it has been suggested by researchers that it is likely (but not proven) that these products have relatively low cancer-causing properties. Therefore these types of products are highly likely to a much less harmful approach to satisfying a nicotine addiction than smoking cigarettes or higher nitroamine chewing tobacco.
• Relatively inexpensive (compared to nicotine replacement products)

Cons of Product:

• Tobacco-based product - means some potential increase risk of cancers is likely present when compared to not taking any tobacco product.
• Only available in some Southern states (difficult to find or purchase)
• Not readily available over the Internet, as the other products are. (Illegal to purchase over the Internet)
• Not as low a risk of cancer as nicotine replacement products (tobacco mints are not harmless). Nicotine replacement products are the safest in terms of cancer risk.
• A relatively new product - so no scientific research in the form of long terms studies, has been done on the product.
• Possible risk of cancer risks to mouth and pancreas
• High in nicotine - which it delivers very quickly into the blood stream, thus encouraging nicotine addiction (which we view as bad).
• Possible Increased risk of dental cavities and mouth sores

Vendors and Product Information: Following are the vendors of what we believe are the products with the lowest levels of cancer-causing Toxins.

Source: TSNA Information: All concentrations in parts per million Source: Smokeless Tobacco and Oral Cancer: A Review of the Risks and Determinants, Crit Rev Oral Biol Med, 15(5):252-263, 2004).

The Highest Risk Tobacco Products:

All tobacco products have certain levels of TSNA’s or tobacco specific nitrosamines which have been identified by some researchers as powerful carcinogens. The products with the highest levels of TSNA’s are therefore likely to be the most carcinogenic and experts have recommended that they avoided if at all possible. Dry snuff has the highest level of TSNA’s and should be avoided at all cost. The TSNA level in dry snuff can range from around 6 to 65ppm compared to the amount in Swedish snus which ranges from a low of around 2.0 to 2.2 parts per million (ppm).

US-produced Moist snuff is the second worse in terms of TSNA’s. They can deliver around 12 ppm depending on the brand. Cigarettes have about 6 to 7 ppm which although less than snuff (usually), it is still an exceptionally high level of carcinogens. Also it is important to remember that when you smoke cigarettes you are inhaling the product which means that your lungs get the full force of TSNA’s. This is what leads to the heightened levels of lung cancer in those who smoke cigarettes. About 90% of lung cancer cases are from smokers, sadly this is not surprising (Petrie, 2005).

Health Risks of Cigarettes:

Cigarettes contain around 4,000 chemical compounds and at least 400 of these are toxic. Tar, nicotine, and carbon monoxide are just three of the most well—known substances that are very bad for you. Tar is a carcinogen (in other words, a cancer causing agent). Nicotine has been known to increase cholesterol levels, and is well-known to be addictive. Carbon monoxide reduces the amount of oxygen in your body. TSNA’s are Tobacco Specific Nitrosamines, they are believed to be the most potent carcinogens in cigarettes. With these kinds of ingredients it is no wonder that smoking cigarettes amounts to a grocery list of diseases, cancers, and disorders; or that it shortens one’s life by seven to eight years (Petrie, 2005).

·        Lung Cancer: About 90% of those who get lung cancer develop it due to smoking.  One in 10 moderate smokers get lung cancer and nearly one out of five heavy smokers get lung cancer.

·        Cancers: Lung cancer is just one of the many cancers that smokers are at high risk for. Mouth and throat cancer are two forms of cancer that are much more common in smokers. Smokers are also more likely to develop bladder cancer, cancer of the oesophagus, kidney cancer, pancreas cancer, and cervical cancer.

·        Cardiovascular Disease: The main cause of death that can be attributed to smoking is cardiovascular disease which is disease of the heart and circulatory system. 9 out of 10 people who receive heart bypass surgery are smokers. Coronary thrombosis is when a blood clot within the arteries supplies the heart blood. This can often lead to a heart attack. Cerebral thrombosis is when the veins supplying the brain blood are blocked. This can cause paralysis, a stroke, or collapse. If the veins leading to the kidneys are blocked then one could have kidney failure. There are other cardiovascular conditions that can develop as a result of smoking.

·COPD (Chronic Obstructive Pulmonary Disease): is a phrase that stands for conditions that obstruct airflow and make it more difficult to breath. Two of the most common conditions are emphysema and chronic bronchitis. Emphysema results in having a hard time breathing and is caused by damage done to the air sacs within the lungs. Chronic bronchitis is when you have a cough plus a high amount of mucus (e.g. phlegm) for at least 3 months in a row.

High Nitrosamine Smokeless Tobacco (Chewing Tobacco and American Snuff)

Negative Aspects of Smokeless Tobacco

·        Gives a heightened risk of oral cancer, throat cancer, stomach cancer, cancer of the pancreas, as well as other bodily cancers.

• Increased risk of gum disease, cavities, and other dental problems.
• Leads to the development of precancerous sores such as the small white patches called leukoplakia which can become cancerous. You can also develop erythroleukoplaki which are red sores that are even more likely to be cancerous (more than half end up being cancerous).
• Possibly a slightly increased risk of developing diabetes.

TSNA Levels for US Smokeless Tobacco (Snuff)

Chewing tobacco has TSNA levels that vary from brand to brand. Beech Nut chewing tobacco has a TSNA level of 4.7 parts per million (ppm), Oliver Twist Senior has 3.4 ppm, and Red Man has 1. 8ppm. Moist snuff from the US has higher levels of TSNA’s, sometimes even higher levels than cigarettes have. Those with the highest TSNA levels are Kodiak Wintergreen with a TSNA level of 12.3ppm, Copenhagen with a TSNA level of 12.1ppm, and Skoal Straight L-Cut which has a level of 10.9ppm. These are all considered to be very high levels of nitrosamines, but what is even higher (by an alarming degree) is dry snuff. The brand Dental Sweet is a dry snuff that packs in an amazing 41ppm of TSNA’s, the brand Scotch has 65ppm of TSNA’s. These are both much higher than any other tobacco product. Dry snuff is the most carcinogenic product available on the market.

Smokeless tobacco products also have a strong correlation with pancreatic cancer. The link has been well documented by several studies, but whether the risk of pancreatic cancer is higher or lower in comparison to cigarette smokers has not been clarified. Despite that clarification, there is a 67% increased risk of pancreatic cancer for those who use smokeless tobacco products in comparison to non-tobacco users (Reuters Health, 2005). Using smokeless tobacco may lower one’s chances of getting lung cancer (compared to smokers), but it is still carcinogenic and can lead to the development of cancer in other areas of the body.

If one is addicted to nicotine there are products with lower TSNA levels than dry snuff and cigarettes. Obviously it is healthier to be nicotine free, but if that is not a viable option then it seems likely that a person would want to choose Swedish snus or nicotine replacement products (or low TSNA products like Ariva and Stonewall) as the research seems to indicate that these products result in a lower lung cancer and cardiovascular disease risk  (and ultimately premature death) compared to using cigarettes, chewing tobacco, moist snuff from the US, or dry snuff.

Table Information: All concentrations in parts per million based on dry weight. Note, because of the water content in most “moist” Snuff or Snus, the actual levels (due to water content) are typically lower than shown above (by up to 50%). (Information Source: Smokeless Tobacco and Oral Cancer: A Review of the Risks and Determinants, Crit Rev Oral Biol Med, 15(5):252-263, 2004

Appendix: Summary of Schizophrenia and Smoking Internet Resources