• The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimates of a Panel of Experts.
• The antioxidant properties of tobacco.
• Smokeless tobacco, smoking cessation and harm reduction: an economic analysis.
• Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study.
• ABC of smoking cessation: harm reduction.
• The burden of mortality from smoking: Comparing Sweden with other countries in the European Union.
• Smokeless tobacco and oral cancer: a review of the risks and determinants.
• Oral cancer after using Swedish snus (smokeless tobacco) for 70 years – a case report.

Levy DT, Mumford EA, Cummings KM, et al. The Relative Risks of a Low-Nitrosamine Smokeless Tobacco Product Compared with Smoking Cigarettes: Estimates of a Panel of Experts. Cancer Epidemiology, Biomarkers and Prevention 2004; 13: 2035-2042.

“For total mortality, the estimated median relative risks for individual users of LN-SLT [low-nitrosamine smokeless tobacco] were 9% and 5% of the risk associated with smoking for those ages 35 to 49 and ≥50 years, respectively. Median mortality risks relative to smoking were estimated to be 2% to 3% for lung cancer, 10% for heart disease, and 15% to 30% for oral cancer.   “In comparison with smoking, experts perceive at least a 90% reduction in the relative risk of LN-SLT use. The risks of using LN-SLT products therefore should not be portrayed as comparable with those of smoking cigarettes as has been the practice of some governmental and public health authorities in the past.” (p. 2035).”

“On the narrow question of the relative health risk of LN-SLT products, these results clearly indicate that experts perceive these products to be far less dangerous than conventional cigarettes. Based on the available published scientific literature as of 2003, there seems to be consensus that LN-SLT products pose a substantially lower risk to the user than do conventional cigarettes. This finding raises ethical questions concerning whether it is inappropriate and misleading for government officials or public health experts to characterize smokeless tobacco products as comparably dangerous with cigarette smoking.” (p. 2039).

  Rodu B, Ou B.  The antioxidant properties of tobacco.  Tobacco Science 2000 (published in 2004; 44: 71-73.

“The tobacco products tested had a range of antioxidant activity from modest to high… The high antioxidant activity in smokeless tobacco may partially explain the low cancer risk associated with long-term use of these products.” (p. 71)

“Two categories of antioxidants present in tobacco may serve as inhibitors of carcinogenesis.  The first is carotenoids…The second category is the phenolic compounds, which are responsible for most of the antioxicant activity in fruits and vegetables.” (p. 72)

Ault RW, Ekelund RB, Jr., Jackson JD, Saba RP. Smokeless tobacco, smoking cessation and harm reduction: an economic analysis. Applied Economics 2004; 36: 17-29.

“We find that if all current male smokers begin using smokeless tobacco, life years for the current population of adult males in the United States could be extended by approximately 18 million years. It is, of course, unrealistic to assume that all current smokers would try smokeless products. However, if we could reach an attainable goal of bringing smokeless use rate up to Sweden’s, approximately 9.4 million smokers would begin using smokeless tobacco. The number of life years saved would be about 2.16 million. We also estimate, from recent health cost data, that the potential health care cost savings due to the use of smokeless tobacco with corresponding reduction in smoking would amount to 4.3% of the total smoking-related health care costs or about $3 billion per year. . . We conclude that the potential health and economic impact of harm reduction from the use of smokeless tobacco suggests strongly that public policy and institutions regarding smokeless tobacco be re-examined.” (pp. 17 – 18).

  Eliasson M, Asplund K, Nasic S, Rodu B.  Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study.  Journal of Internal Medicine 2004; 256: 101-110.

“We confirm previous reports that smoking, current or former, is a risk factor for type 2 diabetes in men…but cannot find any substantial increase of risk in users of Swedish snus.” (p. 109)

McNeill A. ABC of smoking cessation: harm reduction. British Medical Journal 2004; 328: 885-887.

“In Sweden the use of oral moist snuff (known as snus) has been common among men for several decades. The health risks of this product seem to be extremely low, in absolute terms as well as in relation to cigarette smoking. Snus seems to be widely used by smokers as an alternative to cigarettes, contributing to the low overall prevalence of smoking and smoking related disease in Sweden.

Snus and other smokeless oral tobacco products currently being developed by some tobacco companies could therefore provide a viable alternative to smoking for many smokers in other countries, and thus deliver substantial health gains. However, these products are currently prohibited throughout the European Union (except in Sweden) on the grounds that they are unsafe.” (p. 886)

Rodu B, Cole P. The burden of mortality from smoking: Comparing Sweden with other countries in the European Union. European Journal of Epidemiology 2004; 19: 129-131.

“The low smoking-related mortality among Swedish men is probably due to their use of snus (Swedish smokeless tobacco). A recent study from northern Sweden showed that high prevalence of snus use is strongly associated with low smoking prevalence, the latter a result of both reduced smoking initiation and increased cessation. The prevalence of tobacco use among Swedish men (snus use 20%, smoking 19%) is the same as the prevalence of smoking among men throughout the EU (40%). But, because snus use produces a very low risk for cardiovascular diseases and no risk for pulmonary diseases and for oral or other cancers, there is no demonstrable incremental burden of mortality among Swedish men who use snus.

The likely beneficial effect of snus use by men in Sweden raises policy questions, because the sale of snus is prohibited in all other EU countries. In 2002 Britain’s Royal College of Physicians described the harm reduction potential of Swedish snus, and in 2003 the Action on Smoking and Health (UK) issued a policy paper stating, with reference to snus, that ‘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’.”

“Our study shows that the low prevalence of smoking among men in Sweden, if adopted throughout the EU, would result in a 40% reduction in smoking-related mortality.” (p. 131).

Rodu B, Jansson C. Smokeless tobacco and oral cancer: a review of the risks and determinants.  Critical Reviews in Oral Biology and Medicine 2004; 15: 252-263.

“The available epidemiologic studies indicate that the use of chewing tobacco and American moist snuff is associated with minimal risk for oral cancer, while the use of Swedish moist snuff is associated with no demonstrable risk. In comparison, some studies have reported elevated risks for dry snuff use, and these studies may have influenced the perception of the entire SLT [smokeless tobacco] category in past evaluations. For example, in 1986 the US Congress passed the Comprehensive Smokeless Tobacco Education Act, which mandated placement of an oral cancer warning on all SLT products. One year later, IARC classified SLT products as carcinogenic to humans, based almost entirely on epidemiologic studies. In the 17 years since these two actions occurred, the number of relevant epidemiologic studies has nearly doubled. The new body of epidemiologic evidence suggests that these actions may now be seen as too broad. It may be time for these agencies to re-examine the issue of the risks of specific forms of SLT use.” (p. 260).

Zatterstrom UK, Svensson M, Sand L, Nordgren H, Hirsch JM. Oral cancer after using Swedish snus (smokeless tobacco) for 70 years – a case report. Oral Diseases 2004; 10: 50-53.

“The prevalence of moist snuff consumption in Sweden is high. Approximately 900,000 of a population of 8.9 million are daily users of snuff and the number of ‘snuff dippers’ has been increasing steadily since the 1970s. The high prevalence is due primarily to the growing popularity of this habit among young and middle-aged men. More recently, the trend has been boosted by the marketing of snuff as a harmless alternative to smoking cigarettes. From epidemiological studies it is clear that the risk of cancer to snuff dippers is nothing like as great as that in cigarette smokers.” (p. 50).