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Summary

Tobacco control programs introduced during recent decades in the EU as well as in many other countries are typically based on the hypothesis that all tobacco products are equally hazardous to public health. However, recent scientific documentation has convincingly demonstrated that smokeless tobacco products in general, and Swedish snus in particular, are associated with dramatically reduced health risks compared to cigarette smoking and has benefitted public health. This has prompted a growing number of tobacco researchers to suggest “tobacco harm reduction” as a supplement to current tobacco control measures. In this context a harm reduction approach would entail evidence-based information to smokers about the relative risks associated with different tobacco products and encouragement of current smokers who are unable to quit with conventional methods to switch to a smokeless tobacco product that has dramatically reduced health risks. However, as “harm reduction” is not part of the officially recognized measures to combat smoking, it remains a controversial concept within the tobacco control community.

The current scientific documentation about health effects of Swedish snus casts serious doubt on the evidence-base for the current EU ban on snus. It is now evident that the ban is a political – not a scientific - issue that concerns risk management and free trade since there are no valid scientific argument to support a continued ban. It is now up to the EU to decide on future tobacco control policies. Such decisions should take into account the enormity of the smoking problem within the EU today:  one third of the adult population is habitual smokers, and over 700,000 EU citizens die prematurely every year because of cigarette smoke.  These figures clearly illustrate the need for more pragmatism in European tobacco control including an evidence-based regulation of the market instead of the current, outdated snus ban. Cigarette smoking remains the single most important threat to public health. Therefore, since cigarettes remain legal, all evidence-based methods to combat them should be encouraged. 

Introduction                                   

In a ground-breaking work published during the early 1980s Doll & Peto established that smoking was the leading avoidable cause of cancer in the US. They estimated that about 30% of all cancer deaths could be prevented if smoking was abolished. That cigarettes were carcinogenic had been known for decades, but Doll & Peto’s quantitative estimates opened the eyes of many in the scientific and public health community as to the enormity of the problems associated with cigarette smoking. Cigarettes constitute 96% of the world market for tobacco.

These and other data on the health effects of smoking contributed to the introduction of tobacco control programs during the 1980s and 1990s at both national and international levels. The WHO’s FCTC (Framework Convention on Tobacco Control) epitomizes the efforts on the part of society to deal with the smoking pandemic and is also a cornerstone in the European Union’s current tobacco control program. The actions mentioned in the FCTC are based on the three so-called classical pillars of tobacco control: to prevent initiation of smoking, to promote cessation among current smokers, and to protect the public from environmental tobacco smoke. The FCTC mainly focus on efforts to control cigarette smoking. However, the convention implicitly considers all forms of tobacco equally hazardous.

The dominance of cigarettes as the preferred form of tobacco is a 20^th century phenomenon as is the pandemic of smoking related disease. During the 19^th century various form of smokeless products were much more used than today in both Europe and North America. The habit of using such products is still prevalent in the US, Scandinavia, East & North Africa, and on the Indian subcontinent. These products vary widely as to their production technique and, therefore, also as to their content of carcinogenic, non-tobacco ingredients (such as betel leaves and areca nuts) or other potentially toxic constituents. The levels of tobacco-specific nitrosamines (TSNA), for instance, in certain Indian and African products have been reported to exceed those of modern Scandinavian and North American products by about three orders of magnitude.

In the early to mid- 1980s it was commonly believed that both smoked and non-smoked forms of tobacco had roughly the same adverse health effects. This belief was reinforced by reports stating that smokeless tobacco products were carcinogenic although most of these studies concerned Indian and African smokeless products (1).

These circumstances help to explain why the EU: s current paradigm for tobacco control does not recognize any differences in health effects between different forms of tobacco use.

The Swedish Experience

During the past four decades Sweden has developed a tobacco consumption pattern that is distinctly different from all other countries. Since the late 1960s a traditional Swedish smokeless product (“snus”) has to a large extent replaced cigarettes. This trend has mainly occurred among men resulting in Swedish males exhibiting record low rates of smoking. Today, the smoking prevalence in Sweden is higher among females than males which is an internationally unique situation. In more recent years also Swedish females have started to quit cigarettes through the use of snus.

Population-based surveys have demonstrated that snus in both Sweden and Norway is the most commonly used smoking cessation aid, particularly among men (2, 3). In addition, it is also the smoking cessation aid that most frequently results in long term smoking cessation among both men and women. This observation helps to explain why Swedish women more often fail in their quit attempts as they more often use therapies (nicotine chewing gum, nicotine patches) which are associated with less favorable long-term cessation rates compared to snus.

As a consequence, Swedish males today exhibit record low rates of tobacco-related disease. They have, for instance, Europe’s lowest incidence of lung cancer whereas Swedish females exhibit rates comparable to many other European countries (4). Smoking is a major risk factor for a large number of different cancers, for instance, oral cancer and pancreatic cancer.  For these cancer types too, Swedish males have record low rates. Also, cardiovascular morbidity and mortality in Sweden has dropped dramatically during recent decades. This observation accords with the results of several studies, with both cohort and case-control design, demonstrating that snus use is not a risk factor for cardiovascular disease. Against this background, it is understandable that the Swedish National Board of Health recently concluded that the availability of snus as a substitute for cigarettes has had a positive impact on public health in Sweden.

Tobacco harm reduction

During the past 20-25 years more than 100 scientific studies have been published about potential health effects of long-term use of Swedish snus. The main research areas have been cancer, cardiovascular disease, and metabolic disease.

Several international scientists and scientific institutions, for instance, the Royal College of Physicians in London, have unanimously concluded that the health risks with snus are dramatically lower than those associated with cigarette smoking (5). The estimates of the level of risk reduction vary somewhat but in general the scientific community seems to agree that snus is in the order of 90-99% less hazardous than smoking. It is also generally agreed that the risk reductions cited for snus do not concern all types of smokeless tobacco products, particularly not those traditionally used in India or Africa.

Despite the dramatic risk difference between cigarettes and Swedish snus, it is important to remember that any nicotine-containing product can have adverse effects. Pregnant and lactating women should not use any form of nicotine as it is passed over to their fetus or child.  Age limits for nicotine products are necessary for several reasons including the fact that nicotine may affect brain development.

During past decades several changes have been made in the production of Swedish snus aiming at lowering the levels of potentially toxic substances. An industrial standard for snus has been introduced (GothiaTek) in which the guiding principle is the existing Swedish regulation for food stuffs. In terms of health risks many researchers agree that Swedish snus is the “golden standard” for all smokeless tobacco products.

The vastly reduced health risks with smokeless tobacco, particularly Swedish snus, and the ability of such products to replace cigarettes among smokers has led many tobacco researchers to propose a “harm reduction” strategy as a supplement to current tobacco control measures. “Tobacco harm reduction” implies that smokers who are unable to quit using standard methods should be encouraged to switch from their highly dangerous cigarettes to smokeless tobacco products with dramatically reduced health risks. The Swedish experience suggests that such a strategy may actually support the conventional three pillars of tobacco control: snus has decreased initiation of smoking, snus functions as a smoking cessation aid, and with snus there is no environmental tobacco smoke.

The growing acceptance within the scientific community of tobacco harm reduction as a potentially useful strategy was illustrated recently by an Editorial Comment in the Lancet written by two well-respected American tobacco researchers (6). They concluded that it was not sound public health policy to ban snus in a cigarette-rife setting (such as, the European Union where one third of the adult population are habitual cigarette smokers). This Editorial was a historic event. No medical journal had previously stated that a tobacco product could have a positive impact on public health.

Although harm reduction strategies are well accepted and implemented in many other areas of human life (for instance, in traffic safety), the concept remains highly controversial in the tobacco control community although the substantial risk difference between cigarettes and smokeless products now is almost universally accepted.

Swedish snus and the EU

Almost 20 years ago the UK introduced a ban on snus-type products, particularly those sold in pouches. The ban was a reaction to an American moist snuff product that was marketed  to adolescents. This unethical behavior created a motivated public outcry. When the UK entered the EU in 1992, the ban was accepted by the other member states. Since then, all oral tobacco products are banned in the EU except those “intended to be sucked or chewed”. This wording implies that, in practice, all smokeless products, irrespective of health effects are allowed. The only exception is American moist snuff and Swedish snus.  However, when Sweden entered the union in 1995, it was granted derogation from the ban.

With the increased scientific documentation about Swedish snus and the debate about the validity of “tobacco harm reduction” within the scientific community as a backdrop, a scientific committee within EU recently published a review of the health effects of smokeless tobacco products. The report concludes that snus is much less hazardous than smoking, that the data from Sweden clearly shows that it is not a gateway to smoking among young people, that observational data indicate that snus has helped Swedes to stop smoking and, therefore, that snus has had a positive impact on Swedish public health although controlled clinical trials of smoking cessation with snus have not been performed. Unfortunately, the Executive Summary of the report fails to mention all of these facts. Instead it is vague and provides little guidance to decision-makers about the options for tobacco control or if a more pragmatic approach including “tobacco harm reduction” may help to manage the risks posed by smoking.

It is interesting to note that those within the European tobacco control community who opposes a lifting of the snus ban find themselves concurring with the pharmaceutical industry and the big international cigarette companies. The pharmaceutical companies that produce nicotine replacement therapies typically view Swedish snus as potentially their main commercial competitor within the EU. The big cigarette companies also prefer not to have commercial competition from snus. The EU snus ban appears to have become a symbolic issue to some members of the public health community. A lifting of the ban is viewed as a backward step for tobacco control. But that argument  fail to focus on what is the ultimate goal of tobacco control, namely to prevent disease and premature death.

With the publication of the SCENIHR report it is now evident that the EU snus ban is no longer a scientific issue. It is a political issue that concerns risk management and free trade since the report provides no valid scientific argument to support a continued ban. However, the EU must now decide whether it is satisfied with the effect of current policies, or whether a more pragmatic approach is reasonable.  It seems inconceivable that anyone could  be content with current measures given that one third of the adult EU population still are habitual smokers. More than 700,000 EU citizens die prematurely every year because of cigarette smoke. This figure is not expected to drop substantially in the foreseeable future unless novel smoking cessation strategies are introduced.

Lars Erik Rutqvist, MD, PhD
lars-erik.rutqvist@swedishmatch.com

Rutqvist was born in Stockholm, Sweden, in 1952. He was promoted an MD in 1977 at Karolinska Institutet. His clinical training includes medical and radiation oncology, his scientific training clinical cancer epidemiology. He had leading positions in clinical oncology at Karolinska Sjukhuset, Stockholm,1985-2005. He is now Vice President, Scientific Affairs, at Swedish Match, producer of e.g. Swedish snus.

References

1. International Agency for Research on Cancer. Tobacco-habits other than smoking; Betel-Quid and Areca-Nut Chewing; and some related nitrosamines. Evaluation of the carcinogenic risk of chemicals to humans vol 37. WHO-IARC, 1985.

2. Ramström L, Foulds J. Role of snus in intitiation and cessation of tobacco smoking in Sweden. Tob Control 2006;15:210-214

3. Sosial- og helsedirektoratet. Tall om tobakk 1973-2006. Oslo 2007.

4. Rodu B, Cole P. The burden of mortality from smoking : comparing Sweden with other countries in the European Union. Eur J Epidemiol 2004;19:129-131

5. Harm reduction in nicotine addiction. Helping people who can’t quit. A report by the Tobacco Advisory Group of the Royal College of Physicians, October 2007

6. Foulds J, Kozlowski L. Snus—what should the public-health response be? (Editorial Comment). Lancet, published online May 10, 2007

The Rondel, the European Union and nicotine:

A. Nyberg H. Bible and Koran – tools of tolerance [culture]. Rondel 2005; 24. URL: http://www.rondellen.net/culture24_eng.htm

B. Boëthius G, Nilsson M. Smokeless tobacco will not improve public health - quitting smoking will [culture]! Rondel 2007; 27. URL: http://www.rondellen.net/culture27_eng.htm

Published March 11, 2009