by Catherine M Nissen
[Editor’s Note: This is a guest post by CASAA Research Associate, Catherine Nissen. –CVP]
As most readers of this blog know, the gateway effect argument has been used aggressively by anti-THR advocates against smokeless tobacco and electronic cigarettes. They claim that using the low-risk alternatives will cause people to start smoking. Recently I have been working with Carl V Phillips on his paper about detecting gateway effects. He explains the logic of the claim and why it would be unlikely to occur in natural circumstances. But, as he explains, policy actions could manage to create gateway effects, either intentionally or inadvertently. Even then, he was able to offer only a few examples of where it might have happened. I am living in the middle of one of those examples, in western Canada.
As Carl has noted a few times (example), several nonsmoker experts on low-risk tobacco products have started using snus as adults because they learned about the minimal health risk and wanted to reap the benefits of the cognitive enhancement and risk reduction in neurodegenerative diseases that tobacco offers. While I may not be among the esteemed senior scientists he is referring to, and I admit I use snus a bit more for the pure pleasure of it rather than the cognitive enhancement, I am among those who took up snus use after learning about the low costs and substantial benefits. My grandmother suffers from Parkinson’s, and the risk reduction from it that tobacco offers is definitely among my motivations for continued use. I am also among the unfortunate few who have been pushed from low-risk product use into smoking some of the time. I am not sure whether this counts as a gateway case. It certainly is not an example of what the tobacco controllers have in mind when they make the gateway claim, since they are the ones responsible for it.
I have only smoked very occasionally throughout my life, yet I enjoy using snus (smokeless tobacco). I have a firmly established preference for nicotine, but I also have firmly established boundaries on how much I am willing to pay to enjoy it. I am a nonsmoker because the cost of smoking, health-wise, was always too much for me.
After Carl established the tobacco harm reduction research and education efforts at the University of Alberta School of Public Health in the 2000s (a group that would later include me, Karyn Heavner, and several others who have contributed to the field, along with Igor Burstyn sitting in), he, Paul Bergen, and some of Carl’s students launched the first concerted attempt to widely popularize the THR message. In response to this, the anti-tobacco people in Alberta shifted their effort away from trying to discourage smoking to trying to discourage THR. It worked. Today the taxes here on smokeless tobacco are exorbitant. I pay almost $25 for a tin of snus. A pack of cigarettes is about $12, less than half the cost. The price of a tin of snus in the U.S. or overseas is about $4. Under those economic circumstances, only people who are both wealthy enough and highly motivated would choose smokeless tobacco it in lieu of cigarettes. For a person of average means, this price difference is a strong incentive not to try THR, even if they are aware of its benefits.
I have a friend who was a very avid smoker, but armed with the knowledge of THR (simply because he knew me, and despite “public health” efforts to sow disinformation) and the desire to quit smoking, he switched successfully to snus. It wasn’t easy at first, but he became a regular user. As the prices kept rising, though, he moved back to cigarettes. The balance of cost and benefit in his case gave the edge to cigarettes. Eventually, however, he moved back to snus, despite the cost, because of his desire to be smoke-free. He is being punished for that choice, at a rate of about almost $5000 per year more than he would pay for smoking. The difference is because the government is charging him over $7000 per year in taxes on snus, a price he pays for not smoking.
It was much the same with me. I found myself strapped for cash and not willing to pay the cost of snus. My initial brief thoughts on buying cigarettes instead (as I talked about here) became much more prevalent. I caved to them and did buy cigarettes for a time. However, I found I could not smoke more than a pack a week because the health effects from them were so immediate and unpleasant. At the end of a week I would cough throughout my day and my taste and smell were affected. I ended up giving up on cigarettes and now just use snus infrequently. This lowers my welfare substantially from what it would be, and provides no benefit for me or anyone else.
Still, I am luckier than many others. There are countless stories around here of people who prefer smokeless tobacco and have a history of using it instead of smoking sometimes, and being tempted to switch because of the absurd anti-THR price differential. Many of them are also victims of the disinformation about smokeless tobacco and so think there is little or no health difference between the products. For me, the punitive tax on snus made smoking a more attractive option in the short-term, but near-abstinence was more attractive because I understand the huge increase in risk with smoking and because I don’t gain as much from tobacco use as some others do. But others will just choose to smoke. I don’t personally know any smokeless tobacco users who switched to being exclusive smokers because of this tax, but I’m sure there are some because there are many smokeless tobacco users in the region.
So we have a demonstration of policy actions causing a gateway effect from smokeless products to cigarettes (for both a nonsmoker and an ex-smoker). For people uninformed about the health benefits of THR, high taxes on smokeless products (and lower taxes on the more harmful alternative) discourage it. People respond to price in the near term, especially when they are strapped for cash. This is a clear argument for making sure that THR products remain at lower prices than cigarettes, not higher.
As far as I can tell, my story is the only published testimonial of someone who was never a smoker (and clearly never would have become a smoker) who started using smokeless tobacco, and as a result of that became a smoker (though only temporarily). The proponents of the gateway claim never give any examples of people who seem to be gateway cases, which is one of the many reasons that their theory does not hold up to scientific scrutiny. I doubt that my story is what they have in mind, however, since anti-THR efforts were the ultimate cause of this. Without those “public health” policies, I would not have become a smoker.
I am sure a much more common story is like that of my friend who was encouraged to return to smoking even though he wanted to switch, which you might or might not call a gateway effect. This same effect seems to have happened with electronic cigarettes in Spain. It may be happening with electronic cigarettes elsewhere (the UK, California), because disinformation about their risk is tricking many people into believing they might as well smoke. It could certainly happen if all or most e-cigarettes are banned, as the U.S. FDA has proposed.
There is a high prevalence of “natural” smokeless tobacco use in Alberta, probably more than anywhere else outside of Scandinavia and a few rural subpopulations in the USA, because so many people work in jobs where smoking would be difficult. Most likely they don’t know they are engaging in THR (thanks to the disinformation campaigns that are ongoing here). Some may simply enjoy the fact that they are coughing less and experiencing other health benefits from reducing or quitting their smoking. In any case, giving these people a good reason to smoke instead is potentially creating a gateway effect to smoking, and yet it is created by the very people who claim to be worried about gateway effects.