• Smokeless tobacco and cardiovascular disease.
• European Union policy on Smokeless tobacco. A statement in favour of evidence-based regulation for public health.
• Smokeless tobacco: friend or foe?
• Adverse pregnancy outcomes in snuff users.
• Should the European Union lift the ban on snus? Evidence from the Swedish experience.
• Effect of smokeless tobacco (snus) on smoking and public health in Sweden.
• Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden.
• Apply federal research rules on deception to misleading health information: an example on smokeless tobacco and cigarettes.
• Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus.
• Health communication ethics and CDC qualitycontrol guidelines for information.
• Implications of nicotine dependence: need for revision of tobacco product regulations.
• Snus: part of the problem or part of the solution?
• Evolving patterns of tobacco use in northern Sweden.
• Legal strategies to reduce tobacco-caused disease.

Asplund K. Smokeless tobacco and cardiovascular disease. Progress in Cardiovascular Diseases 2003 45: 383-394.

“[T]he use of smokeless tobacco (with snuff being the most studied variant) involves a much lower risk for adverse cardiovascular effects than smoking does.” (p. 383).

Bates C, Fagerström K, Jarvis M, et al. European Union policy on Smokeless tobacco. A statement in favour of evidence-based regulation for public health. Tobacco Control 2003; 12: 360-367.

“We believe that the partial ban applied to some forms of smokeless tobacco in the EU should be replaced by regulation of the toxicity of all smokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a ‘‘gateway’’ it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco—the alternative being to ‘‘quit or die’’… and many die.”(p. 360).”

“[F]or oral tobacco to play a role in harm reduction it is not necessary to show that it does not cause cancer – it just needs to be substantially less hazardous than smoking. Even allowing for cautious assumptions about the health impact, snus – and other oral tobaccos – are a very substantially less dangerous way to use tobacco than cigarettes. Smokeless tobaccos are not associated with major lung diseases, including chronic obstructive pulmonary disease (COPD) and lung cancer, which account for more than half of smoking related deaths in Europe. If there is a CVD [cardiovascular disease] risk, which is not yet clear, it appears to be a substantially lower CVD risk than for smoking. Smokeless tobacco also produces no environmental tobacco smoke (ETS) and therefore eliminates an important source of disease in non-smokers and children. These are very substantial benefits in reduced risk to anyone that switches from smoking to smokeless tobacco and we believe the public health community has a moral obligation to explore this strategy. It is likewise ethically wrong to actively deny users the option to reduce their risk in this way.”

“The risk to the user arising from use of a smokeless tobacco product varies by product and is to some extent uncertain – notably in the area of heart disease (though at worst the heart disease impact appears to be substantially less than smoking). However, we are confident that the evidence base described above and elsewhere suggests that it is reasonable to formulate the overall relative risk as follows: on average Scandinavian or some American smokeless tobaccos are at least 90% less hazardous than cigarette smoking. In a spectrum of risk, snus is much closer to NRT [nicotine replacement therapy] than it is to cigarette smoking.” (p. 361).

Britton J. Smokeless tobacco: friend or foe? Addiction 2003; 98: 1199-1201.

“Nicotine addiction is the underlying force that drives continued smoking, and the traditional medical approach to helping smokers to quit has been to use medicinal nicotine to ‘replace’ that obtained from cigarettes. Medicinal nicotine is generally safe, especially when compared with continued smoking, and increases the chance of success in any quit attempt by around 70%. At their best, interventions combining medicinal nicotine with intensive behavioural support can achieve 12 month sustained cessation rates of up to 20%, but the balance of this statistic is that 80% of smokers who make a serious quit attempt with the best medical support available relapse into regular smoking. . . .

An ideal pharmaceutical solution would be a medicinal device that delivers nicotine to the brain at a dose and rate similar to cigarettes, something that none of the currently available products achieves. . . .

An alternative approach, which has already proved acceptable to smokers and to be commercially viable, is smokeless tobacco. . . .

Studies of snus in particular have demonstrated relatively modest effects on oral cancer and cardiovascular disease, few of which are statistically significant. Whilst a lack of statistical significance clearly does not rule out important effects, it is also evident that the risks of snus are substantially less than those of smoked tobacco. Snus is available in Sweden by special exemption from European Union laws, which prohibit the sale of smokeless tobacco in other member states. Sweden also currently has the lowest smoking rate in the European Union, which may be due, in no small part, to the availability and acceptability of snus as an alternative product for smokers.” (p. 1200).

“The Royal College of Physicians in London has recently argued that the regulatory system in the UK, which currently grants the greatest commercial freedom to the most dangerous nicotine product, needs to be overhauled to apply controls on medicinal nicotine and smokeless and smoked tobacco in proportion to the harm they cause. A similar proposal has been made from Action on Smoking and Health in the UK to the European Union. If adopted, these proposals would allow medicinal nicotine, snus and potential new smokeless products to become commercially available in a suitable environment of control, monitoring and review. The Swedish experience suggests strongly that this would reduce the current burden of disease caused by smoking. To date, the UK Government has responded by saying that ‘the time is not right’. One wonders if it will ever be otherwise.” (p. 1201).

England LJ, Levine RJ, Mills JL, et al. Adverse pregnancy outcomes in snuff users. American Journal of Obstetrics and Gynecology 2003; 189: 939-943.

“Because the use of smokeless tobacco does not result in exposure to products of combustion, snuff is considered to be generally less harmful than cigarettes. Compared with cigarette smoking, snuff use appears to have less effect on atherosclerosis, risk of myocardial infarction, and risk of death from cardiovascular disease. The effects of smokeless tobacco on pregnancy outcomes, however, are unclear.” (p. 941).

Fagerström KO, Schildt E-B. Should the European Union lift the ban on snus? Evidence from the Swedish experience. Addiction 2003; 98: 1191-1195.

“In summary, it seems clear that while smoking tobacco is the skyscraper in terms of health risks the use of snus, although not risk-free, is a two-storey building and on a par with risks from many other unhealthy habits or products.” (p. 1192).”

Foulds J, Ramström L, Burke M, Fagerström K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco Control 2003; 12: 349-359.

“As of 2000, Sweden has a lower standardised rate of male lung cancer incidence than any comparable developed nation in the world. Sweden also has a low rate of oral cancer by international standards and this low rate has been falling over the past 20 years while snus use has increased. . . . Interestingly Swedish men have also had a significant improvement in cardiovascular health over the same period. . . . It is noteworthy that these improvements in tobacco caused illnesses have occurred primarily in men, despite a stable consumption of tobacco among men during that time period. The main factor that has changed is that many Swedish men have switched from smoked tobacco to snus.” (p. 355-356).

“This review suggests that snus is notably less harmful to health than cigarettes, and that in Sweden snus has served as a pathway from smoking, rather than a gateway to smoking among Swedish men. A proportion of the reduction in illness caused by tobacco among Swedish men may be attributable to their shift from smoking to snus use. Policy and regulations on nicotine delivery should be designed to effectively discourage use of the most harmful products (that is, cigarettes) rather than products that are much less harmful.”

“Snus is clearly less harmful to the individual user than smoked tobacco, and also less harmful than the types of smokeless tobacco used in some other parts of the world, notably Sudan and India.” (p. 358).”

Gilljam H, Galanti RM. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003; 98: 1183-1189.

“Because most tobacco-related harm is caused by inhaled components of tobacco smoke, unburned tobacco products are considered relatively safer. An intuitive approach to harm reduction would therefore be to substitute inhaled nicotine with nicotine from other sources. . . .

“A real-life long-term test of the concept of harm reduction has been ongoing in Sweden with little or no scientific monitoring. . . . Due to the lack of consistent associations with major diseases, snus is considered to be less harmful than cigarettes and few users seek help for their addiction.” (p. 1184).

“Our study suggests that by using snus, Swedish male smokers may have increased their overall chance of abstinence by 70–80%. However, smokers using snus in order to quit smoking are probably a minority, even disregarding the gender imbalance. In the present sample, three of four Swedish males who quit smoking in the 1980s and 1990s reported doing so without using snus. Also, the duration of abstinence did not increase by the use of snus. This suggests that snus, however appealing as a tool for risk reduction, is certainly not a necessary component of smoking cessation at the population level.” (p. 1188).

Kozlowski LT, O’Connor RJ. Apply federal research rules on deception to misleading health information: an example on smokeless tobacco and cigarettes. Public Health Reports 2003; 118: 187-92.

“Two respected agencies of the U.S. Department of Health and Human Services (DHHS) – the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) – have maintained websites which have erroneously reported that smokeless tobacco is not safer than cigarettes. This claim is not supported by science and acts unethically to mislead readers of these websites.” (p. 187).

“Wherein lies the error or possible deception in asserting that smokeless tobacco and cigarettes are equally dangerous? First, there is no scientific doubt that smokeless tobacco is substantially safer than cigarettes. (The Institute of Medicine [IOM] report provides a thorough review, indicating that smokeless tobacco is safer than cigarettes, particulary as used in Sweden and North America, rather than as used in India.) Smokeless tobacco does not cause respiratory disease or lung cancer; meaning that there would be at least 60% fewer deaths from smokeless than from cigarettes. In fact, epidemiological analyses estimate that smokeless tobacco has only 2% of the risk of cigarettes. . . . The predominant health risk linked to smokeless tobacco is oral cancer, but cigarettes seem to be even more strongly linked to oral cancer than is smokeless tobacco.” (p. 188).

Kozlowski LT, O'Connor RJ, Quinio Edwards B. Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus. Tobacco Control 2003; 12: 372-373.

“To provide the most useful information to consumers, information comparing the most dangerous products (cigarettes) to much less dangerous products (snus, medicinal nicotine) is an essential component of legislation. By limiting comparative claims only to like products (cigarettes to cigarettes, smokeless to smokeless), the consumer is prevented from understanding where maximal harm reduction lies.”

“Individuals who do use or who are thinking of using cigarettes have a right to know that smokeless products are safer than cigarettes. . . . Snus and medicinal nicotine are so much safer than cigarettes that net societal harm is very unlikely. Public health concerns should trump individual rights only when there is clear and convincing evidence of harm to society. Lacking that evidence, individual rights should prevail.” (pp. 372 – 373).

McKenna JW, Pechacek TF, Stroup DF. Health communication ethics and CDC qualitycontrol guidelines for information. Public Health Reports 2003; 118: 193-196.

“The CDC has issued no current public pronouncements about the relative dangers of SLT [smokeless tobacco] and cigarettes, given the lack of scientific consensus about this and other harm-reduction issues in tobacco control. In general, most public health authorities agree that SLT is less hazardous than cigarette use in terms of overall mortality when evaluated in the context of lifetime exclusive use.” (p. 194).

Ramström LM. Implications of nicotine dependence: need for revision of tobacco product regulations. Wiener Klinische Wochenschrift 2003; 11: 401– 402.

“[S]ome features of the current European Union regulation of tobacco products appear rather illogical and a revision should therefore be considered. As far as smokeless tobacco is concerned the EU rules put no restrictions on oral chewing tobacco but prescribes a total ban on sale of moist, oral snuff. . . . We then find that tobacco-related diseases among Swedish males have been decreasing for several decades to reach levels lower than those in other developed countries. A major reason for this seems to be the increasing rates of smoking cessation. This development should be attributed to a combination of factors, one of them being the use of snus as a cessation aid, a kind of nicotine replacement therapy. . . . There is also evidence to suggest that the availability of snus as an alternative to smoking helps keeping down initiation of smoking. . . . Like all smokeless tobacco products snus is free from the combustion products that are the main health damaging constituents of cigarette smoke. This makes it reasonable to expect a generally lower health risk associated with this product than with cigarettes. . .

Ramström L. Snus: part of the problem or part of the solution? Addiction 2003; 98: 1198-1199.

“The recognition of tobacco dependence as a disorder due to use of a psychoactive substance, nicotine, has led to a growing awareness that total eradication of nicotine use may not be a realistic goal. Therefore, reduction of tobacco-related ill health should not rely entirely on total abstinence from nicotine but also include options for nicotine delivery in a less harmful form than smoking. Since the major harmful exposure from cigarettes comes from combustion products, a great deal of interest has been given to non-combustible tobacco products, especially snus, a Sweden-specific kind of moist oral snuff. This is because Swedish men have been combining record high consumption of snus and record low levels of tobacco-related illness.” (p. 1198).

“If, in the fight against tobacco-related ill health, we adopt a puritanical view, rejecting all nicotine use, we shall see snus as part of the problem. But if we adopt a pragmatic view, seeking to exploit all means of possible reduction of these health risks, we might well see snus as part of the solution.” (p. 1199).

Rodu B, Stegmayr B, Nasic S, et al. Evolving patterns of tobacco use in northern Sweden. Journal of Internal Medicine 2003; 253: 660-665.

“In summary, this study shows the major role of snus use in lowering smoking rates amongst men in northern Sweden during the past decade. The availability of snus as an alternative source of nicotine that is far safer than cigarettes has permitted many men to avoid the adverse risks of long-term smoking without abstaining from tobacco altogether.” (p. 665).

Sweanor D. Legal strategies to reduce tobacco-caused disease. Respirology 2003; 8: 413-418.

“Smokers need to understand that some things, such as smoking cessation, massively reduce risk. Smokers who understand risks but do not believe they can reduce them (e.g. ‘I’ve been smoking for 20 years so I’ve already done all the harm’) are not fully informed. Smokers who believe that products that do not significantly reduce their risks (such as ‘light’ cigarettes) actually do so are similarly misled. In addition, smokers who underestimate the health benefits of greatly less hazardous alternatives, such as medicinal nicotine or at least some forms of smokeless tobacco, are inadequately informed. For example, recent US research showed that 50% of smokers erroneously believed that nicotine causes cancer and 80% believed that smokeless tobacco was just as likely as cigarettes to cause cancer.” (pp. 415 – 416).