1. Department of Medicine

2. The Harm Reduction Debate Current context of the debate - Snus enthusiasts vs. pessimists Switching from cigarettes to snus alone will reduce individual risk But: What will happen on a population basis?

3. Department of Medicine Current Smokeless Advertising Cigarette-branded smokeless tobacco products Appear to promote dual use Free with purchase of cigarette pack Marketing messages – Convenient, discreet, for smokefree places – New demographic groups?

4. UST Conference for Investors December 19, 2007

5. Department of Medicine Data used in Modeling CDC MMWR reports National Health Interview Survey data U.S.T. marketing documents and shareholder presentations Phillip Morris documents IARC Monographs Peer Reviewed Literature Tobacco trade journals

6. Department of Medicine Modeling Assumptions Four mutually exclusive groups of smokers –Stable –Health concerned –Smoke-free environment –Price sensitive Non-users do not initiate tobacco use as dual users Snus use is not widely prevalent in the U.S. population Changes arise from the current pattern of use Smokeless not used as a cessation aid

7. Stable

8. Department of Medicine Health Effect: Base Case ConditionPrevalence Never User56% Quit19.8% Cigarettes21.6% Smokeless1% Dual1.6% Total

9. Department of Medicine Health Effect: Base Case ConditionPrevalenceRisk Never User56%0 Quit19.8%5 Cigarettes21.6%100 Smokeless1%10 Dual1.6%90 Total

10. Department of Medicine Health Effect: Base Case ConditionPrevalenceRiskEffect Never User56%00 Quit19.8%50.99 Cigarettes21.6%10021.6 Smokeless1%100.1 Dual1.6%901.44 Total24.1

11. Department of Medicine Results Health Effect: 24.2 (21.5, 27.2)

12. ScenarioTransition Probabilities Aggressive smokeless promotion Increase smokeless initiation x10 Health concerned: Increase smokeless use x 10 (half from cigarettes, half from quitters) Dual use among new users.25 Smoke-free environments: Quitting cut in half Cigarette users to smokeless.50 Dual use among new users.75 Price sensitive: Quitting cut in half Cigarette users to smokeless.50 Dual use among new users.25 USTIncrease smokeless initiation by 3.7 Aggressive promotion with most new users from smokers Increase smokeless initiation x 10 75% from smokers; 25% from never users No effect on initiationNo change in initiation patterns

13. Department of Medicine ScenarioTobacco-related health effect (95% CI) Base Case24.1 (21.5-27.1) Aggressive smokeless promotion 30.5 (25.8-35.6) UST24.8 (21.8-27.9) Aggressive promotion with most new users from smokers 25.9 (22.7-29.4) No effect on initiation22.3 (19.8-25.1)

14. Department of Medicine Conclusions Promotion of smokeless as a safer alternative to cigarettes unlikely to provide population health benefits Promotion of smokeless may actually lead to an increase in harm at the population level

15. Department of Medicine Public Health Implications Other risks of promotion of smokeless as less harmful than cigarettes include: –Undermining effective policies –Confusing public messages –Legitimizing tobacco companies Focus on proven harm reduction strategies that rapidly reduce tobacco use and disease Taxes, regulation, litigation

17. Department of Medicine

18. What would have to happen to cut health effects in half? Increase smokeless initiation by 5x, all from cigarettes Cut dual use in smokeless initiators from.40 to.15 Cut smokeless to cigarettes from.17 to.03 All smokers health concerned –Increase smokeless 15x –75% from cigarettes, rest from quitters –25% become dual users Reasonable assumptions?