Lars Ramström | 25 November 2013
The revision of the EU Tobacco Products Directive raises some interesting issues regarding smokeless tobacco products (STP). In the Directive those oral STPs that are kept in the mouth (Swedish snus) are called ‘oral tobacco’, while those oral STPs that are chewed in the mouth are called ‘other STP’.
Some ‘other STP’ products are very harmful to health and are causing increasing concerns in the UK and elsewhere. These are allowed in the Directive. ‘Oral tobacco’ - snus - is not much more harmful than medicinal nicotine products, is substantially less harmful than most ‘other STP’ and dramatically less harmful than cigarettes. This product is banned in the EU outside Sweden.
To reach its goal of “a high level of health protection” the revised Directive should meet two objectives with respect to STP: it should protect citizens from products that entail severe health risks, and it should give citizens access to all products that can help minimise the worst risks, the cigarette-related ones, while entailing no or minimal risks by themselves.
Both these objectives can be met by a product regulation based on scientific evidence regarding levels of health risks as suggested by for example the WHO TobReg Committee and the Royal College of Physicians , London. This would remove some ‘other STP’ from the market while making Swedish snus available.
HEALTH RISKS OF SNUS
As a product used in the mouth snus cannot entail any risks for respiratory disease or lung cancer. Studies in Sweden indicate that there is no excess risk of oral cancer, and these findings are confirmed by the fact that Swedish men, with record high prevalence of snus use, have Europe’s lowest incidence of oral cancer. As far as cardiovascular disease is concerned studies in Sweden have compared risks between current snus users and never snus users finding an overall risk ratio of 1.08 which does not prove either increased or decreased risk in snus users.
The lower morbidity and mortality of snus users is not only a benefit for individual health. It also means that snus users cause substantially less social costs for health care and loss of productivity than smokers.
IMPACT OF SNUS USE ON INITIATION AND CESSATION OF SMOKING
Concerns have been raised that the introduction of snus on the market might have negative effects on public health despite the well recognized benefits for individual health. These concerns are based on more or less plausible assumptions rather than actual evidence However, solid scientific evidence exists from research in Sweden and Norway, but many snus opponents have avoided taking notice of that. The research findings indicate that contrary to recurring concerns:
- young people who start using snus are less likely than others ever to start smoking (and the few snus starters who do start smoking are more likely than average to eventually quit smoking)
- daily smokers who take up snus become substantially more likely to quit daily smoking (86% vs 60%, men and women alike)
- almost half of those who have switched from cigarettes to snus eventually quit snus as well
- very few people (1.7% of the male, 0.2% of the female population) pursue daily dual use, which further demonstrates that smokers’ uptake of snus does not interfere with their incentives to quit smoking
- uptake of nicotine by snus users is similar to that of smokers, while their nicotine dependence is deemed to be weaker than smoker’s dependence due to slower nicotine delivery from snus.
- among men, snus is the most commonly used smoking cessation aid (used in 51% of all “self-help quit attempts” compared to 16% for nicotine chewing gum and 12% for the nicotine patch)
- both men and women who use snus as a smoking cessation aid have almost double as high success rates as those using medicinal nicotine aids.
Some details of the scientific evidence are available at:
- http://www.tobaccofindings.org/publications/articles-in-scientific-journals/ and
The scientific findings indicate that snus use in Sweden has contributed to beneficial effects on public health as recognized by for example the EU SCENIHR Committee.
In Sweden in the last 50 years the increasing initiation of snus use among young men has been accompanied by an increase of the proportion of young men who do not initiate any tobacco use. This, in combination with the predominantly male use of snus as an effective cessation aid, appears to explain why Swedish men have lower tobacco‑related mortality than men in any other EU Member State, while Swedish women, with less snus use, do not have a similar position.
The development of snus use in Norway in recent decades and its development in the US in recent years suggests that widespread use of snus is possible in countries other than Sweden. In the long term a favourable development like the one in Sweden could therefore be possible in other EU Member states provided that the revised Directive secures availability and that truthful public information is carried out on large scale. Public health experts have called for the ban on snus to be lifted. Unfortunately – given the preoccupation with other issues in the TPD – lifting the snus ban does not seem a likely prospect at this time.
Lars Ramström. Institute for Tobacco Studies, Stockholm, Sweden
A version of this article was first published in "Making the case" a special supplement of The Parliament Magazine, February 2013