Gerry Stimson | 29 September 2013
What were they thinking of at the European Commission when they proposed continuing with the ban on snus? The ban, and the proposal to control e-cigarettes as medicines, ranks as public health folly of the highest order.
What is so dismal about the Tobacco Products Directive is that it is so unambitious. The European Commission’s own impact assessment is that the total TPD package will only reduce tobacco consumption by around 2% over a five year period (p113) – that’s a reduction of 2.4 million smokers – or a reduction in percent prevalence from the current 28% to around 27.5%. One half of one per cent! Is that all that the TPD can deliver? A prohibition mindset prevails, and opportunities to make big inroads into smoking in Europe are missed.
Snus is used as an alternative to smoking and as a means to quit. But is has been banned in the EU, other than in Sweden, since 1992. The new Tobacco products Directive (TPD), now going though the EU legislative process, provided an opportunity to reverse the ban: but those responsible for shaping public health in Europe can't see beyond the narrow tobacco control vision - that for snus, The Only Way is Prohibition (TOWIP).
TOWIP is based on the fear that snus could become a ‘gateway’ to smoking for young people and entice youngsters into a lifetime of nicotine addiction, could deter attempts to quit smoking, and allow smokers to continue dual use. However, the experience with snus in Sweden andNorway is the opposite: snus isa gateway out of smoking. According to the most recent Eurobarometer survey ( Special Eurobarometer 385), adult smoking prevalence in Sweden is just 13%, far lower than the EU average of 28%. Snus contributes to the extremely low rates of lung cancer in Sweden (Cancer mortality database). As Coral Gartner and colleagues have shown in their Lancet paper, switching to snus has a positive health impact equivalent to ceasing to smoke altogether.
Even the European Commission’s own impact assessment states that studies show that smokeless tobacco products (STP) are less hazardous to health than factory manufactured cigarettes (FMC) and that ‘for individuals who replace FMC entirely with STP the overall benefits would outweigh the risks although full abstention from tobacco use would be the most beneficial’ (p62-3).
Public health experts* have written to Martin Schulz, President of the European Parliament, ahead of the vote on the Tobacco Products Directive, asking for the ban on the sale of snus to be lifted. This follows a previous letter to then Commissioner Dalli in 2011. As they point out ‘It is primarily because of snus use that Sweden and Norway have the lowest rates of smoking in Europe, by far.’ Rather than being a threat to public health, snus is a benefit to public health.
What can be done to shift the tide of opinion away from prohibition? How can we change the mindset of European public health advisers and politicians? How can we persuade them that huge public health gains that will come by helping smokers switch to safer products?
Because of the ban on snus, most smokers in Europe are unaware of it and haven't tried it. There is a big gap in public health advocacy. A handful of public health experts has continued to argue the case for snus. But unlike e-cigarettes, there is no Europe wide consumer base from which to advocate for snus. The remarkable campaign to keep e-cigarettes out of the TPD, or keep them out of medicines regulations, has overshadowed the need to campaign to lift the ban on snus.
There are several policy possibilities and there is still time to amend the Tobacco Products Directive, including to (i) treat snus like any other smokeless tobacco, (ii) treat snus like a novel tobacco product or (iii) allow an exception to the general ban where snus has traditional use.
As argued in the letter to Martin Schulz ‘There is no credible explanation for why the safest known form of tobacco in the world, snus, is banned when the most dangerous, the manufactured cigarette, is widely available.’
This is a public health issue, and it is also a human rights issue - the right of smokers to protect themselves from the harmful effects of smoking by user safer products.
* The signatories are: Professor Martin Jarvis, Professor Riccardo Polosa, Professor Karl Olov Fagerström, Professor Michael Kunze, Dr Karl Erik Lund, Dr Jacques Le Houezec, Dr Tony Axell,
Dr Lars Ramström, Professor Gerry Stimson and Clive Bates