Nice find. I've got access to The Lancet (which did the original article), here it is :
Mixed feelings on snus
Nigel Graya
Tobacco Unit
International Agency for Research on Cancer
69008
Lyon, France
Available online 15 September 2005.
Public health often requires balancing risks and benefits and this can be complex, especially with tobacco. Some recent manoeuvres by the tobacco industry exemplify a topical dilemma, typical of what can be done, and can be claimed, by an industry whose product contents are almost completely unregulated. The European Union mandates levels of tar, nicotine, and carbon monoxide, but smoke constituents and additives are not controlled in any way in any part of the world.
First, British American Tobacco (BAT) has test-marketed in South Africa its version of Swedish snus1 under the names of two of its major brands, Lucky Strike and Peter Stuyvesant. The product is a finely ground snuff that is pasteurised during production to diminish the carcinogenic nitrosamines found, sometimes in very high levels, in cigarettes and some other forms of smokeless tobacco.1 BAT is trying to “extend the appeal of snus to more adult smokers and encourage smokers who have not heard of snus to try it”.1
At the same time,2 the Swedish Match Company is preparing to take advantage of the forthcoming ban on smoking in restaurants and bars in Sweden by presenting snus as a smokeless alternative where smoking is forbidden. They are providing custom-made refrigerators and vending machines to night clubs together with “sleek black snus trays” to replace ashtrays. The sale of snus is illegal in the European Union, except in Sweden. The companies are working to reverse this,2 and, in so doing, have the philosophical support of some senior public-health workers, subject to appropriate regulation of snus.3
BAT claims that the move is part of their “continuing efforts in harm reduction” towards products which they hope will be recognised by scientific and regulatory authorities as posing “substantially reduced health risks”.1 Swedish Match claims that the biggest group of quitters in Sweden used snus as “the main aid in quitting”.2
Is it true that snus is a harm-reduction product and an aid to quitting? Compared with cigarettes, snus is certainly much less harmful, having, so far, not been inculpated as actually causing any increase in lung cancer.4 However, smokeless tobacco is classified as a carcinogen by the International Agency for Research on Cancer (IARC).5 And Paolo Boffeta and colleagues, from IARC, recently reported an increase in pancreatic cancer in snus users.6 So, snus is not harmless.
Is snus an effective aid to quitting? The evidence is inadequate but suggestive that it may be for some smokers.4 However, the experience in Sweden does show the important fact that a large number of nicotine users favour it over tobacco smoke, suggesting that it is an acceptable alternative. The fact that more Swedes choose snus rather than therapeutic nicotine-replacement therapy for routine use also suggests it offers a better “fix” than such replacement therapy.
The question of the “addictiveness” of alternatives to cigarettes is important and controversial. Nicotine-replacement therapy is relatively non-addictive,7 but there is a view that, if such therapy is to replace cigarettes, it needs to be more competitive … and this means more addictive.8
Does this mean that public-health workers should join the manufacturers' lobby to have the sale of snus made legal in the European Union and Australia? There are dilemmas here too. It is unlikely that any public-health worker would wish for legalisation of snus without regulatory control on its toxicant levels, which means legislation would be necessary. If legislation were desirable to control snus, surely it could not be introduced in isolation, ignoring the much greater need to regulate tobacco smoke.
Many public-health workers are opposed to the concept of harm reduction, and particularly one that introduces another tobacco product to be aligned with nicotine-replacement therapy. Even those calling for more competitive (and hence addictive) nicotine-replacement therapy should hesitate over a tobacco-containing cigarette-smoke substitute, on the grounds that tobacco contains carcinogens other than nitrosamines9 and long-term use of snus has now been associated with pancreatic cancer.6
So it is possible (however, reluctantly) to agree with BAT and Swedish Match that snus is a harm-reduction product, but only when compared with the cigarette. However, the proponents of harm reduction (including myself) also need to recognise another, almost certain downside to the mass marketing of snus—the probability that it will lead to reduced quitting, as occurred with the low-tar cigarette,10 due to similar perceptions of reduced harm. Whilst Swedish Match suggests snus is an aid to quitting, it is also expecting sales to rise as a result of smoking bans, from which I imply that there is an expectation it might be used to sustain nicotine dose when smoking is not possible.
On balance, for snus to be legally available, it must be regulated; any new regulation must be comprehensive and also cover toxicant levels in other forms of tobacco, especially cigarettes. So snus is quite a long way from the market in Europe.
2 I Ekman, Fight? Swedes would rather switch, International Herald Tribune (May 27, 2005), p. 1 7..
3 C Bates, K Fagerstrom, MJ Jarvis, M Kunze, A McNeill and L Ramstrom, European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health, Tob Control 12 (2003), pp. 360–367. Full Text via CrossRef
4 J Foulds, L Ramstrom, M Burke and K Fagerstrom, Effect of smokeless tobacco (snus) on smoking and public health in Sweden, Tob Control 12 (2003), pp. 349–359. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
5 V Cogliano, K Straif, R Baan, Y Grosse, B Secretan and F El Ghissassi, Smokeless tobacco and tobacco-related nitrosamines, Lancet Oncol 5 (2004), p. 708. SummaryPlus | Full Text + Links | PDF (68 K) | View Record in Scopus | Cited By in Scopus
6 P Boffetta, B Aagnes, E Weiderpass and A Andersen, Smokeless tobacco use and risk of cancer of the pancreas and other organs, Int J Cancer 114 (2005), pp. 992–995. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
7 JR Hughes, EH Adams, MA Franzon, MK Maguire and J Guary, A prospective study of off-label use of, abuse of, and dependence on nicotine inhaler, Tob Control 14 (2005), pp. 49–54. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
8 N Gray and P Boyle, The future of the nicotine-addiction market, Lancet 362 (2003), pp. 845–846. SummaryPlus | Full Text + Links | PDF (61 K) | View Record in Scopus | Cited By in Scopus
9 International Agency for Research on Cancer, Tobacco smoke and involuntary smoking, International Agency for Research on Cancer, Lyon (2004).
10 ND Weinstein, Public understanding of risk and reasons for smoking a low yield product: risks associated with smoking cigarettes with low machine-measured yields of tar and nicotine, US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Bethesda (2001), pp. 193–235.
On balance, for snus to be legally available, it must be regulated; any new regulation must be comprehensive and also cover toxicant levels in other forms of tobacco, especially cigarettes. So snus is quite a long way from the market in Europe.
Isn't that crazy? Snus is less harmful than cigarettes. Cigarettes are currently not regulated (the producers can virtually use any ingredient) and freely available througout the EU, while snus is regulated in Sweden as if it were food, but yes, of course, snus is far away from the market. :roll: Greetings to Brussels!
On balance, for snus to be legally available, it must be regulated; any new regulation must be comprehensive and also cover toxicant levels in other forms of tobacco, especially cigarettes. So snus is quite a long way from the market in Europe.
Isn't that crazy? Snus is less harmful than cigarettes. Cigarettes are currently not regulated (the producers can virtually use any ingredient) and freely available througout the EU, while snus is regulated in Sweden as if it were food, but yes, of course, snus is far away from the market. :roll: Greetings to Brussels!
There has to be some economic purpose to why as there are a HEFTY amount of studies showing how much more beneficial it is than smoking. I could see if there was an ambiguity in the air, if like 3/4 of the studies were showing how it was terrible but that is certainly not the case.
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