• Snus and the risk of cancer of the mouth, lung and pancreas.
• Systematic review of the health effects of modified smokeless tobacco products.  New Zealand Health Technology Assessment
• Snus – what should the public-health response be?
• Should the health community promote smokeless tobacco (snus) as a harm reduction measure?  Smokers who switch to snus reduce their health risks.
• Assessment of Swedish snus for tobacco harm reduction: an epidemiological modeling study.
• Tobacco smoking, harm reduction, and nicotine product regulation.
• Royal College of Physicians (UK).  Harm reduction in nicotine addiction: helping people who can’t quit.
• Tobacco harm reduction: how rational public policy could transform a pandemic.

Rodu B.  Snus and the risk of cancer of the mouth, lung and pancreas.  Lancet 370: 1207-1208, 2007.

“…the study by Luo and colleagues has implications for cancer mortality patterns not only in Sweden, but in smoking-dominated societies…No tobacco product is demonstrably safe, but these data show that snus use is 97% less harmful than smoking with respect to cancers of the oral cavity, lung, and pancreas.”

“The evidence from this review suggests that the harm of using snus, relative to non tobacco use, is significantly less than found for smoking with respect to cancers of the head, neck and gastro-intestinal region, and cardiovascular disease events.”

Foulds J, Kozlowski L.  Snus – what should the public-health response be?  Lancet 369: 1976-1978, 2007.

“Around a billion people are addicted to nicotine in deadly cigarettes and many have no immediate plans to quit. Young people will also continue to try dangerous and addictive products. We believe it is preferable that, if people become addicted to cigarettes or decide to try tobacco, they can use a product that is markedly less harmful than cigarettes. In Sweden, primary use of snus is associated with reduced risk of cigarette smoking in adulthood. The Lancet papers published today, when added to mounting epidemiological evidence, indicate that we should not delay in allowing snus to compete with cigarettes for market share, and we should be prepared to accurately inform smokers about the relative risks of cigarettes, snus, and approved smoking-cessation medications.  In light of all the available evidence, the banning or exaggerated opposition to snus in cigarette-rife environments is not sound public-health policy.”

Gartner CE, Hall WD.  Should the health community promote smokeless tobacco (snus) as a harm reduction measure?  Smokers who switch to snus reduce their health risks.  PLoS Medicine 4, July 2007.

“Similar to other types of smokeless tobacco products, snus may increase the risk of some cancers, and there may be some risk of cardiovascular disease caused by nicotine. But its cardiovascular risks are certainly lower than those of smoking, it has no respiratory risks, and its oral cancer risk is probably much lower than that of conventional chewed tobacco because snus has a much lower nitrosamine content. Studies in Sweden, where men have used snus for 20 years, have so far failed to detect any increase in oral cancer or cardiovascular disease rates. On current evidence the health risks of snus are comparable to those of regular alcohol use rather than cigarette smoking.”

“If the goal of tobacco control is to reduce tobacco-related disease, rather than tobacco use per se, then the promotion of snus use by inveterate smokers is a promising public health policy.”

“Tobacco smokers who switch to snus will reduce the risks of their tobacco use. Based on the Swedish experience, there is a strong prima facie case on public health and ethical grounds for recommending snus to inveterate smokers who want to reduce their health risks and for considering public policies (such as lower taxes for snus and public information campaigns) to promote its use by smokers.”

Gartner CE, Hall WD, Vos T, Bertram MY, Wallace AL, Lim SS.  Assessment of Swedish snus for tobacco harm reduction: an epidemiological modeling study.  Lancet 369: 2010-2114, 2007.

“Individual smokers who switched to snus instead of continuing to smoke and new tobacco users who only used snus rather than smoking would achieve large health gains compared with smokers.”

“Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.”

Britton J, Edwards R.  Tobacco smoking, harm reduction, and nicotine product regulation.  Lancet, October 5, 2007 (online).

“The risk of adverse effects associated with snus use is lower than that associated with smoking, overall by an estimated 90%.  Whatever the true overall hazard, use of low nitrosamine smokeless products is clearly substantially less harmful than tobacco smoking.”

“A logical harm reduction approach for the millions of smokers who are unlikely to achieve complete abstinence in the short-term or medium-term future is to promote the substitution of tobacco smoking with an alternative, less hazardous means of obtaining nicotine.”

“We believe that the absence of effective harm reduction options for smokers is perverse, unjust, and acts against the rights and best interests of smokers and the public health.  Addicted smokers have a right to choose from a range of safer nicotine products, as well as accurate and unbiased information to guide that choice.”

“The regulatory framework should therefore apply the levers of affordability, promotion, and availability in direct inverse relation to the hazard of the product, thus creating the most favourable market environment for the least hazardous products while also strongly discouraging the use of smoked tobacco.”

Royal College of Physicians (UK).  Harm reduction in nicotine addiction: helping people who can’t quit. Full report available here.

From the Executive Summary:

“In this report we make the case for harm reduction strategies to protect smokers. We demonstrate that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved. We also argue that the regulatory systems that currently govern nicotine products in most countries, including the UK, actively discourage the development, marketing and promotion of significantly safer nicotine products to smokers.”

“Harm reduction is a fundamental component of many aspects of medicine and, indeed, everyday life, yet for some reason effective harm reduction principles have not been applied to tobacco smoking. This report makes the case for radical reform of the way that nicotine products are regulated and used in society. The ideas we present are controversial, and challenge many current and entrenched views in medicine and public health. They also have the potential to save millions of lives. They deserve serious consideration.”

Sweanor D, Alcabes P, Drucker E.  Tobacco harm reduction: how rational public policy could transform a pandemic.  International Journal of Drug Policy 18: 70-74, 2007.

“Smokeless tobacco products do cause disease – but at very low rates compared to cigarettes. The disease risk of smokeless tobacco can be made lower still through changes in manufacturing techniques that reduce toxins such as tobacco-specific nitrosamines. It has been estimated that modern smokeless tobacco products are least 90%, and perhaps closer to 99%, less deadly than smoking cigarettes.”

“The relative safety of smokeless tobacco and other smokefree systems for delivering nicotine demolishes the claim that abstinence-only approaches to tobacco are rational public health campaigns. This is not to say that all smokers would or should necessarily switch to snus or current forms of medicinal nicotine. But it does mean that cigarettes need not be seen as the only way consumers can obtain their nicotine.  This also means that it need not be that the only alternative to continued cigarette smoking must be complete cessation of nicotine in any form.”

“The consumer who rejects (or cannot achieve) abstinence but will use a product that reduces risk by 90% should not be prevented from making that preferred choice. Indeed, it is exactly the forced choice between smoking and abstinence that reinforces the current dominance of cigarettes.”

“The paradoxical, and lamentable, outcome of the public health profession’s anti-industry stance is that government and non-profit public-health agencies will generally not fund the research that would define the continuum of risk for nicotine delivery devices, and thereby allow for rational and evidence-based decision making on behalf of the public’s health. Instead, in the U.S. (whose research budget dwarfs other countries’), virtually the only substantive research on alternative delivery systems now being carried out is
funded by industry: research on smokeless tobacco products is financed by the tobacco companies, and research on nicotine replacement is financed by the pharmaceutical industry.  To public-health advocates whose idée fixe is that industry is singularly self-interested, venal, and treacherous, these funding streams serve to discredit the researchers who are doing what would, otherwise, be the essential work of determining how best to serve the public’s health. The consequent situation is this tautology: the only nicotine- or tobacco-related research that is recognized as valid is research funded by the government or non-profits; the government and non-profits will fund only research on smoking cessation; only smoking cessation is a valid public-health intervention.”

“Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century.”