An analysis of the large PATH survey reports that 26% of US adults are current tobacco users and 18% are cigarette smokers (NEJM 376:342, 2016). Thus, 1/3rd of tobacco use is from products other than cigarettes. The two most common non-cigarette tobacco products in the study were cigars (7%) and ecigs (5%).
A major question now becomes is what is our goal with treatment: abstinence from cigarettes (clearly the most harmful), abstinence from the more harmful combustible tobacco products (cigs and cigars), abstinence from all tobacco (cigs, cigars, smokeless), abstinence from nicotine (cigs, cigars, smokeless and e-cigs). This gets even more complicated because many cigarettes smokers also use a second product or use one of the less harmful products to reduce or quit cigarettes.
If someone comes in for treatment of cocaine dependence, they are often told they most stop using other stimulants, opioids, sedatives and alcohol to really be cured. Does this translate well to the smoking situation?
I think the harm from cigarettes is so much greater than all other substances I that, if a cigarette smoker wants to stop cigarettes and continue or start another tobacco product because they think it will make stopping cigarettes easier, I am find with that I do think I should first make them aware that using NRT could be as effective and would be much safer and easier to eventually also quit. But I would also tell them that some evidence suggests e-cigs and snus can also help cigarette smokers stop. But, bottom line is,that if they still want to use a non-cigarette tobacco product, I am okay with that.
Looking forward to hearing what others think.