• Tobacco policy, by the Royal Australasian College of Physicians
• Cancer incidence among a cohort of smokeless tobacco users (United States).
• International advances in nicotine and tobacco research.
• Is Swedish snus associated with smoking initiation or smoking cessation?
• Tobacco use among Swedish schoolchildren.
• The decline of smoking in northern Sweden.
• The prospects for tobacco harm reduction.
• “Not safe” is not enough: smokers have a right to know more than there is no safe tobacco product.
• Public health measures to reduce smoking prevalence in the UK: how many lives could be saved.
• Smoker awareness of and beliefs about supposedly less-harmful tobacco products.
• You might as well smoke; the misleading and harmful public message about smokeless tobacco.
• Seven year follow-up of smoking cessation with smokeless tobacco.
• Swedish moist snuff and myocardial infarction among men.

Royal Australasian College of Physicians. Tobacco Policy: Using Evidence for Better Outcomes, 2005. Available at http://www.racp.edu.au/hpu/policy/tobacco/index.htm

"Harm reduction aims to minimise the harmful effects of cigarette smoking among those unable yet to quit."

"Oral tobaccos mean no smoke toxicants and are seldom lethal."

"Oral tobacco is much less dangerous than cigarette smoking. When sourced from Sweden (snus), oral tobacco is less toxic than when sourced from South Asia. Currently, commercial import from any country is prohibited in both Australia and New Zealand. Both countries are well-placed to permit only the importation of snus. Oral tobacco carries a reduced mortality risk (10 per cent) compared with cigarette smoking."

Accortt NA , Waterbor JW, Beall C, Howard G. Cancer incidence among a cohort of smokeless tobacco users (United States). Cancer Causes and Control 2005; 16: 1107-15.

“In contrast to the well-known deleterious effects of cigarette smoking, [smokeless tobacco] use did not substantially increase the risk for cancer incidence above that of nontobacco users, particularly among males. Although the use of tobacco in any form is to be discouraged, our data suggests that cancer risks are much lower from [smokeless tobacco] use than from cigarette smoking.” (p. 1107).

“Rates for all cancers and lung cancer were increased among male cigarette smokers when compared with non-tobacco users. Males who used only [smokeless tobacco] had no increased risk for these outcomes when compared to non-users.” (p. 1110).

Colby SM, Drobes DJ, West R. International advances in nicotine and tobacco research. 11th Annual Meeting Society for Research on Nicotine and Tobacco, Prague, Czech Republic, 20 – 23 March 2005. Nicotine and Tobacco Research 2005; 7: 667-709.

“While complete abstinence from both tobacco and nicotine is the ideal, Dr. Fagerström urged SRNT researchers not to let that ideal stand in the way of the possible. He asserted that NR [nicotine replacement] and also low-nitrosamine smokeless tobacco is by several orders so much less harmful compared with smoking that such forms could be used to make cigarette smoking less prevalent in our societies.” (p. 668).

“However, Dr. McNeill cautioned that as we move forward we must not lose sight of the main goal – to reduce death and disease. Regulatory requirements should not be so onerous that they divert resources away from this goal nor appear so complex that countries do not take simple steps to bring products under regulatory oversight. She suggests that SRNT should be playing a prominent role in deliberations around these issues. We should be aiming to move smokers along the continuum of nicotine-delivery away from the most harmful delivery systems (cigarettes) primarily by encouraging as many smokers to quit, but failing that, then by encouraging them to use clean nicotine-delivery products, and failing that, regulated smokeless-tobacco products.” (p. 669).

Furberg H, Bulik CM, Lerman C, Lichtenstein P, Pedersen NL, Sullivan PF. Is Swedish snus associated with smoking initiation or smoking cessation? Tobacco Control 2005; 14: 422-424.

“Swedish snus is a moist smokeless tobacco product that contains lower concentrations of cancer-causing tobacco-specific nitrosamines than found in other smokeless tobacco products and cigarettes. While snus delivers similar concentrations of nicotine, it carries substantially lower risks of cancer than cigarettes.” (p. 422).

Rodu B, Nasic S, Cole P.  Tobacco use among Swedish schoolchildren.  Tobacco Control 2005; 14: 405-408. 

“During the period 1989 to 2003, the prevalence of tobacco use declined both among boys and girls [in Sweden].  For boys, regular smoking declined after 1992 from 10% to 4%.  Their snus use was about 10% in the 1990s, but increased to 13% by 2003.  Regular smoking among firls was 20% in early years and declined to 15%.  Smoking among girls was always double that among boys…The high prevalence of snus use in Sweden not only reduces smoking rates among Swedish men, but suppresses smoking among boys as well.” (p. 405)

Stegmayr B, Eliasson M, Rodu B.  The decline of smoking in northern Sweden.  Scandinavian Journal of Public Health 2005; 33: 321-324.

“The  prevalence of smoking among all men is now 9%...and only 3%...among men age 25-34 years;  the prevalence of exclusive snus us is 27%...and 34% respectively… For the first time snus use is also associated with a decrease in smoking prevalence among women.” (p. 321)

“Snus use accounts for 90% of all tobacco use among men aged 25-34 [years] and for 45% among women.” (p. 322)

Hall WD. The prospects for tobacco harm reduction. International Journal of Drug Policy 2005 16: 139-42.

“Opponents argue that any reduction in health risks from THR [tobacco harm reduction] will be outweighed by adverse effects on public health because these products will deter smokers from quitting, encourage former smokers to resume use, and increase rates of smoking among adolescents by serving as a “gateway” to smoking. . . .Again this argument is most convincing in the case of combustible THR products.  For the following reasons it is not a compelling objection to THR using pharmaceutical nicotine or snus. First, Kozlowski, Strasser, Giovino, Erickson, & Terza (2001) have shown that the[re] would still be a net population health gain from their adoption, even on the most pessimistic assumptions about their residual health risks and assuming that they were used by the whole adult population.

Second, pharmaceutical nicotine and snus are less likely to initiate new nicotine users than cigarettes because they deliver nicotine at a much slower rate, produce a steadier blood level of nicotine, and hence are less rewarding than tobacco smoking in nicotine-naive users. . . .

Third, Swedish experience with snus contradicts the pessimistic view about the population impact of THR . . . . The uptake of snus among Swedish men increased over the past 20 years, with as many Swedish men now using snus as smoking cigarettes . . . . The increase in snus use was accompanied by a decline in cigarette smoking (from 40% in 1976 to 15% in 2002) . . . . Contrary to the gateway hypothesis, there were no increases in rates of smoking among adolescent males who were the heaviest users of snus . . . . Most continuing snus users are ex-smokers who used it to quit smoking . . . . The same patterns have been found in smokeless tobacco use and cigarette smoking in American males . . . .

Most critically, the increase in snus use was accompanied by a decline in lung cancer mortality and the absence of an increase in either cardiovascular mortality or head and neck cancers . . . . The plausibility of a causal relationship between increased snus use and these good health outcomes was strengthened by . . . the absence of any similar changes in smoking prevalence or lung cancer mortality in Swedish women who did not adopt snus at the same rate as men.” (p. 140).

Kozlowski LT, Edwards BQ. “Not safe” is not enough: smokers have a right to know more than there is no safe tobacco product. Tobacco Control 2005; 14: ii3-7.

“Finally, the ‘not safe’ or ‘not harmless’ messages don’t address the reality that some tobacco products are substantially safer than others. Smokeless tobacco (SLT), for example, while not safe, is substantially safer than cigarettes.” (p. ii5).

Lewis S, Arnott D, Godfrey C, Britton J. Public health measures to reduce smoking prevalence in the UK: how many lives could be saved. Tobacco Control 2005; 14: 251-4.

“Consideration should also be given to allowing limited market freedoms to alternative tobacco based products, such as Swedish oral smokeless tobacco (snus), since this product has a strongly favourable profile of adverse effects relative to cigarettes and appears to be widely acceptable as an alternative to cigarettes, particularly to men. By 2002, 14% of Swedish male smokers had switched from smoking to using snus, and the prevalence of smoking in Swedish men had fallen to only 15%. This appears to have had a substantial beneficial impact on lung cancer rates in Sweden, which are now lower than in any comparable developed nation. Making safer nicotine sources available in the UK as part of a controlled harm reduction strategy, even if some of these products are not entirely risk-free, could therefore generate substantial further reductions in smoking prevalence and related harm.” (p. 253).

O’Connor RJ, Hyland A, Giovino GA, Fong GT, Cummings KM. Smoker awareness of and beliefs about supposedly less-harmful tobacco products. American Journal of Preventive Medicine 2005; 29: 85-90.

“A much greater proportion of smokers (82%) were aware of SLT [smokeless tobacco] products than were aware of modified cigarettes and cigarette-like products. However, only 10.7% of smokers believed that SLT is less harmful than smoking ordinary cigarettes. Here, smokers are misinformed in the opposite direction. Epidemiologic data suggest that SLT products sold in the United States are significantly less dangerous than cigarettes….In short, this U.S. national sample of adult smokers holds beliefs about the relative harm reduction potential of modified cigarettes and SLT that are contrary to the available scientific evidence.” (p. 89)

Phillips C, Wang C, Guenzel B. You might as well smoke; the misleading and harmful public message about smokeless tobacco. BMC Public Health 2005; 5: 31.

“The negative health consequences of smoking cigarettes are well known. What is less well known is that not all tobacco products create similar levels of risk. In particular, use of Western smokeless tobacco (ST) is substantially less harmful than smoking cigarettes. This should not be surprising, given that ST use does not expose the body to the harmful combustion products and assault on the lungs that result from smoking. But even many health experts do not realize there is a major difference, perhaps because of repeated messages about “tobacco” (usually referring just to cigarettes), which imply that all products made from this plant have the same health implications.”

“ST is usually only linked to one life-threatening disease, oral cancer (OC), and even that association may not apply to the types of products that increasingly dominate ST use in the West. . . . Claims are sometimes also made about links to cardiovascular disease and pancreatic cancer, though the evidence supporting these claims is even thinner and more equivocal. The lack of clear evidence of a strong association with any diseases is not due to lack of research; there have been extensive attempts to find health risks from ST, including in Swedish populations where prevalence of use is high. While it is impossible to ever rule out small associations between an exposure and a disease, there is ample evidence to rule out, with a very high degree of confidence, the possibility that the combined risk of life threatening diseases due to ST use is anything close to that from smoking.” (pp. 1 – 2).

“Health advocates, particularly those in public service, have an affirmative ethical duty to tell the truth. It is difficult to justify keeping the truth from people, even when knowing it might be harmful; it is clearly unjustified when it would be beneficial.” (p. 6).

Tilashalski K, Rodu B, Cole P. Seven year follow-up of smoking cessation with smokeless tobacco. Journal of Psychoactive Drugs 2005; 37: 105-8.

“In a previous study, the authors documented that long-term use of SLT [smokeless tobacco] is 98% safer than smoking. According to recent research, SLT causes neither lung cancer nor other diseases of the lung, and users have no excess risk for cardiovascular diseases. The only consequential adverse health effect of SLT use is oral cancer, but even this risk is minimal, and far lower than that from smoking.” (p. 107).

“Data from Sweden support the role of SLT in harm reduction at the population level. Men in Sweden have the lowest smoking rate and the highest SLT usage rate in Europe, and Swedish men have the lowest rates of lung cancer and all smoking-related deaths among 20 European countries.” (p. 107).

“The results of the present study show that SLT can serve as an effective, long-term substitute for inveterate smokers who choose to quit smoking without quitting nicotine altogether.” (p. 107).

Hergens MP, Ahlbom A, Andersson T, Pershagen G. Swedish moist snuff and myocardial infarction among men. Epidemiology 2005; 16: 12-16.

“The hypothesis that smokeless tobacco increases the risk for myocardial infarction is not supported in the present study.”

“Our data confirm that smokers who also use snuff tend to smoke less. The negative confounding would result in a lower observed excess risk from snuff among former smokers and current smokers because the effects from smoking on myocardial infarction are stronger. We found no clear evidence for an association of snuff use with fatal infarction.”

“The difference in risks for myocardial infarction between smokers and snuff users could suggest that it is probably not the long-term exposure to nicotine in the smoking tobacco that increases the risk for myocardial infarction, but rather other components in cigarette smoke. Carbon monoxide, oxidant gases, and polycyclic aromatic hydrocarbons are substances in cigarette smoke that have a potential cardiovascular effect. Another hypothesis would be that oral moist snuff contains substances such as fatty acids and flavonoids that could have a protective effect for myocardial infarction.”