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

Smokeless tobacco will not improve public health - quitting smoking will!

Editorial comment
For more than a century, Sweden has provided a culture of snus use, a domestic form of moist snuff or smokeless tobacco, especially in older working class men. However, finding the male market saturated tobacco manufacturers are in later years targeting girls and women. Sales of smokeless tobacco have been prohibited in the European Union since 1992. The snus culture and industrial pressure prompted the government to negotiate a permanent exception from EU regulation, when Sweden joined the European Union in 1995. Snus has been regarded as a harmless vector of nicotine, a view that is increasingly challenged by recent research data. Göran Boëthius and Maria Nilsson claim that smokeless tobacco will not cure smokers, not in Sweden, nor anywhere else. My working hypothesis is that they in 30-40 years will be considered as far-seeing as Åke Nordén in the case or health risks associated with alcohol. /Bo Norberg

Figure legend: Åke Nordén, 1915-2002, was the first professor of primary health care (family medicine) in Sweden, appointed 1972 in Dalby at the University of Lund. He was a pioneer in microbiology, diabetology, haematology, gastroenterology and in the research of alcohol-associated illnesses (cf A). Drawing about 1972 by his colleague professor Stig Radner.

Introduction 

In recent years, seductively simple messages are regularly repeated by the tobacco industry and supported by a small but loud-spoken minority:

  1. Smoking is the most dangerous way of using tobacco

  2. It is difficult for many smokers to quit

  3. Smokeless tobacco is much less dangerous to health

  4. Thus, it is better to satisfy the craving for nicotine with smokeless tobacco and

  5. It is unethical to deny citizens in other nation’s access to Swedish snus, as is the case in the European Union.

The active tobacco control community in Sweden strongly opposes the simplified “harm reduction” logic. There are three main questions discussed in order to elucidate the basic issue.

Has snus use helped Swedish smokers quit?

Firstly, to what extent has snus use had an impact on smoking in Sweden? There are several reasons to question the often repeated mantra of the tobacco manufacturers and some researchers, who claim that snus use reduces smoking in Sweden.

When compared to most European countries, Sweden has never had a high smoking prevalence in males and will therefore not reach a high lung cancer rate.

Smoking has continuously decreased in most western countries without the “help” of smokeless tobacco. Especially, substantial investments in tobacco control have had an impact on smoking habits in countries such as Canada and California.

Recent surveys in Sweden show that of regular snus users, 36% smoke daily or occasionally alongside with their snus use and 39% have never smoked. If all Swedish men are considered, at the most 5% may have had some help from snus in quitting smoking (1).

There is still no longitudinal data explaining to what extent snus, in the individual case, has played a major role in the quitting process or what the smoker would have done had snus not been available.

There is an important gender aspect to consider, as women in Sweden have diminished their smoking without more than a marginal increase in snus use. Notably, only 1% of women who use snus are former smokers (1). However, these low rates provide a potential market. Thus, snus manufacturers have declared women to be the main target today. Product development verifies this strategy, alerting concern over a recent rise in snus use among 15-year-old girls.

Harmful effects of snus use elucidated

The second issue to be elucidated is the harmful effect of snus to the user and the impact of “side effects” on public health. No one doubts that the use of smokeless tobacco is less harmful than smoking – everything is!

However, there is a tendency in the debate to underestimate how the evolution of knowledge again and again shows that all effects are not known in the beginning of an era of research. When smoking was acknowledged as a cause of lung cancer, the academic community was not aware of the cardiovascular risks of smoking.

Another lesson is provided by the introduction of “light” cigarettes 20-25 years ago. In the belief that they were less hazardous, millions of women have continued to smoke instead of quitting (2).

Converging scientific evidence suggests that snus use increases the risk for a number of conditions (3 - 7):

  1. reversible as well as irreversible oral lesions

  2. pancreatic and gastroesophageal cancer

  3. fatal myocardial infarction

  4. fatal stroke

  5. hypertensive disease.

Heavy snus use is independently associated with development of metabolic syndrome (8). Insufficient data or inconclusive results exist regarding diabetes and effects in pregnancy (9). Data are missing regarding effects of snus use on conditions that are observed in smokers such as disc degeneration (10), reduced sexual potency (11), impaired night vision (12) and neuropsychiatric effects in children (13). However, it is important to remember that even a small increase in risk is of concern from a population-based perspective.

Furthermore, there are other side effects of snus marketing seen in Sweden. Nicotine dependence in Sweden is substantial - every third man and every fifth woman is dependent on nicotine as shown by their daily need for cigarettes and/or snus (1). The snus use pattern reinforces the socioeconomic inequality pattern of smoking; one of the most challenging aspects in tobacco control.

The substantial snus use by adults increases the snuffing among children (14). The growing evidence for the interaction on the brain by nicotine and alcohol is also a cause for alarm – if we are concerned for our children’s drinking habits, we should not be liberal on nicotine use (15).

How to diminish smoking

Thirdly, what is a more effective strategy to diminish smoking in Sweden and elsewhere?

Political engagement, national co-ordination and financial investment in tobacco control are fundamental.

Today, more than 150 countries have ratified the WHO Framework Convention on Tobacco Control (16) in which all components of a successful program are spelled out. The strategy includes:

  1. legislation and regulation (i.e.: advertising bans, smoke-free environments, product regulation, tax policy)

  2. enforcement

  3. information, education, and opinion building

  4. primary prevention (support of minors by all adults)

  5. secondary prevention (increased and improved cessation support including pharmacological aid).

Discussion

We agree with harm reduction proponents that one of the basic problems in tobacco control is that public health policy makes an addictive drug widely available in its most harmful forms – cigarettes - while less hazardous forms are less available or more expensive. Regulation according to harmfulness would be rational - however, not so simply as the least hazardous forms meriting less restriction.

Obviously the biggest killer, the cigarette, should – finally - be appropriately regulated in an effort to limit a product that kills every other user when used according to manufacturer’s instruction. Yet, how do we handle a substance like nicotine with a dependence-producing capacity as great as that of many illegal drugs?

It is important to realise that today’s great interest in smokeless tobacco by the tobacco industry is not a wish to save lives – this industry has never cared for peoples’ health but of increasing shareholder’s wealth. Now smoking steadily decreases in the western world. The tobacco industry counteracts this development by product development and marketing of new products such as smokeless tobacco in order to maintain nicotine addiction in customers, both old and new.

It is naive to believe that smokeless tobacco could and would be marketed only for smokers with difficulties to quit smoking. The tobacco industry has repeatedly demonstrated their intention to target new groups.

Let us finally start doing our homework. Smokeless tobacco is not a prerequisite for diminishing smoking. Unfortunately, on account of society’s failure to tackle the tobacco industry and its deadly products, we will not be able to save all of today’s smokers – just as we cannot help many people who die from their alcoholism or drug addiction. But to cover our long time failure to help smokers under a thick layer of snus (or other forms of smokeless tobacco) would be a great mistake for which future generations will pay a prize.

Göran Boëthius MD, PhD
Chair Doctors Against Tobacco
Sweden
doctors@globalink.org 

Maria Nilsson, BA, PhD-student
Umeå International School of Public Health
Epidemiology and Public Health Sciences
Umeå University
SE-901 85 Umeå, Sweden
maria.nilsson@epiph.umu.se
www.umu.se/phmed/epidemi/
 

References

  1. National Institute of Public Health, Sweden. Hälsa på Lika Vilkor (Health on Equal Terms) Survey. Stockholm: 2006. Available from: http://www.fhi.se
  2. Weinstein ND. Public understanding of risk and reasons for smoking a low-yield product: risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine. Bethesda: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2001:193-235.
  3. Cnattingius S, Galanti R, Grafström R, Hergens MP, Lambe M, Nyrén O, Pershagen G, Wickholm S. Health Risks of Swedish Oral Smokeless Tobacco. National Institute of Public Health. Stockholm, November 2005.
  4. Health Effects of Smokeless Tobacco Products. Preliminary report. Scientific Committee on Emerging and Newly Identified Health Risks. European Commission 2007
  5. Luo J, Ye W, Zendehdel K et al. Oral use of Swedish moist snuff (snuff) and risk for cancer of the mouth, lung and pancreas in male construction workers: a retrospective cohort study. Lancet 2007; 369:2015-20.
  6. Zendehdel K, Nyrén O, Luo J, Dickman PW, Boffetta P, Englund A, Ye W. Risk of gastroesophageal cancer among smokers and users of Scandinavian moist snuff. Int J Cancer 2008 Mar 1; 122(5): 1095-9.
  7. Hergens M-P. Swedish moist snuff and the risk of cardiovascular diseases. Thesis. Karolinska Institutet 2007.
  8. Norberg M, Stenlund H, Lindahl B, Boman K, Weinehall L. Contribution of Swedish moist snuff to the metabolic syndrome: A wolf in sheep’s clothing? Scand J Public Health 2006; 34(6):576-83.
  9. England LJ, Levine RJ, Klebanoff MA, Yu KF, Cnattingius S. Adverse pregnancy outcomes in snuff users. Am J Obstet Gynecol 2003;189(4):939-43.
  10. Fogelholm RR, Alho AV. Smoking and intervertebral disc degeneration. Med Hypotheses. 2001 Apr;56(4):537-9
  11. Millett C, Wen LM, Rissel C, Smith A, Richters J, Grulich A, de Visser R. Smoking and erectile dysfunction: findings from a representative sample of Australian men. Tob Control. 2006 Apr;15(2):136-9.
  12. Havelius U, Hansen F. Ocular vasodynamic changes in light and darkness in smokers.
    Invest Ophthalmol Vis Sci. 2005 May;46(5):1698-705
  13. Wickström R. Effects of nicotine during pregnancy: human and experimental evidence. Current Neuropharmacology. 2007 September;5(3):213-222
  14. Rosendahl KI, Galanti MR, Gilljam H and Ahlbom A. Smoking mothers and snuffing fathers: behavioural influences on youth tobacco use in a Swedish cohort. Tobacco Control 2003; 12:74-78.
  15. Wickholm S, Galanti MR, Söder B, Gilljam H. Cigarette smoking, snuff use and alcohol drinking: coexisting risk behaviours for oral health in young males. Community Dent Oral Epidemiol. 2003 Aug;31(4):269-74.
  16. The World Health Organization. WHO-FCTC Secretariat webpage http://www.who.int/tobacco/framework/countrylist/en/index.html

Internal source

    A.        Brandt L. Vitamin B12 and phagocytosis [evaluation]. Rondel 2005; 25. URL: http://www.rondellen.net/evaluation25_eng.htm

Published december 31, 2007