Since moving to Norway in January, I've been fascinated by Snus. I had been meaning to read up and write something about it for ages but then managed to pursuade the folks over at
to let me writing something for them.
I've reproduced the article here for those that can't get hold of the print copy of magazine. Many thanks to Marion Pliebe for the wonderful, quirky illustration and all the editors at Argument for their useful feedback and their help in shaping my writing.
I gave a draft to a friend I met through Oslo SITP who works in drug harm reduction who recommended a whole bunch of articles on the subject that I just didn't have time to read and use before the publication deadline. Given the constraints of writing for a magazine instead of rambling on my blog, I ended up writing something quite different to what I had intended, but from what I've heard back from the people that have read it so far, the article has sparked the discussion that I had intended. I think this might just be the first of many times I write about snus, so there's plenty of time for me to add to my understanding of what is a complex and interesting issue.
Snus: What's the Harm?
The popularity of snus has sky-rocketed in Sweden and Norway in the last decade, and more recently in the US. The co-occurrence of high snus use, low smoking rates and relatively low rates of tobacco-related diseases in Sweden has been presented as a real-world uncontrolled experiment in tobacco harm reduction. Tobacco users substitute snus for cigarettes, either by initially taking up snus instead of smoking, using snus after quitting, or reducing smoking by using snus as a cessation tool.
If this is the case, why aren’t public health policy makers across Europe using snus as a means of reducing the harm of tobacco use? The answer depends on how deeply tobacco is ingrained in a country’s culture and whether you believe that health authorities should be promoting a non-medical tobacco product.
Banned across the EU
The commercial sale of snus has been banned across the EU since 1992, largely on the back of a World Health Organisation study that suggested that snus was carcinogenic. Sweden received exemption from the law in when it joined the EU in 1995 on the grounds of its widespread traditional use amongst Swedes, and as a member of the European Economic Area, but not the European Union, Norway is unaffected by the ban.
Because of the EU-wide ban, few outside Scandinavia have even heard of snus. It was certainly a strange experience when I moved to Norway earlier this year to see people discreetly stuffing little sachets in their mouths and walking around with strange bulging upper lips.
‘Safer’, but not safe
It was easy to ban snus across the EU, because, save for Sweden, there was no culture for it and therefore little public opposition. A ban on cigarettes, however more justified on the basis of actual harm, appears to be unthinkable. Smoking is associated with at least 16 types of cancer, five types of respiratory disease, five kinds of cardiovascular disease and a whole host of other health and reproductive problems. It’s responsible for one in seven deaths in Europe, with a further 13 million people suffering from a serious, chronic disease as a result of cigarettes.
Some research suggests that snus might be 90–95 per cent less harmful than smoking, but snus use is not entirely risk free. Snus does not have the dangerous combustion products that cigarettes do, which removes the increased risk of lung cancer and effects of secondary smoking. However, the use of snus is associated with an increased risk of developing a number of diseases, including reversible and irreversible oral damage, tooth decay and gum disease; cancer in the pancreas, throat and stomach; lethal heart attacks; lethal stroke; and heightened blood pressure. There’s also evidence that snus use increases the risk of diabetes and metabolic syndromes, and in pregnant users, the risk of premature births and low birth weight. With all of these, it’s important to stress that the evidence is less solid than for smoking-related diseases, and the increased risk is smaller, too.
Snus as a harm reduction tool
As more legislation is brought in across the EU to limit the use of cigarettes, researchers and public health officials have to consider the increasing importance of snus in tobacco control policies.
Advocates of snus as a harm reduction tool, such as Dr Karl Erik Lund at SIRUS, the Norwegian Institute for Alcohol and Drug Research, have long argued that harm reduction is the only realistic and pragmatic way forward. It’s not just a matter of being pro- or anti-snus, but a choice between focusing effort on restricting access to the most harmful products (cigarettes) or focusing time, energy and legislation on restricting access to the least harmful products (snus), that in some circumstances can produce a net health benefit to society. If snus stops people dying from lung cancer, it makes sense to use snus as a tool in public health policy.
Advocates of snus as a harm reduction tool further argue that this is a matter of human rights: that smokers have the right to a fully informed choice, and that those who oppose the harm reduction approach are guilty of exaggerating the harmful effects of snus by labelling all tobacco products ‘not safe’ or ‘not harmless’. This borne out in the way the public perceive snus: a 2008 study showed that around 40 per cent of nearly 2500 Norwegian 16 to 20-year-olds thought that snus was ‘equally or more harmful than cigarettes’, something which is not true based on the evidence and may be putting smokers off making an informed decision to switch to snus.
Current control strategies
Opponents of snus as a harm reduction tool, on the other hand, argue that a tobacco-free society should be the ultimate goal and that no form of tobacco should ever be promoted: “Snus does not save lives: quitting smoking does. Snus only saves the tobacco industry.” There is a real concern about the signals it would send to the public if health authorities were to be seen to be jumping into bed with tobacco companies and endorsing their products, rather than standing by existing nicotine replacement products, which are specifically intended as a medical therapy. The position of the Norwegian Directorate of Health is unequivocal, with Deputy Director Anne Hafstad stating: “Smokeless tobacco is an addictive drug and we know it increases the risk of certain cancers. It is therefore not applicable to the Directorate of Health to recommend smokeless tobacco as a method to quit smoking”.
In 2009, a joint paper co-authored by representatives from each of the National Boards of Health in Sweden, Norway, Finland, Iceland and Denmark called for a clear move away from promoting snus as a cessation aid. The paper instead called for more support for initiatives that (1) serve to reduce social acceptance of smoking, such as advertising bans and neutral tobacco packaging with new warning labels stating that snus increases cancer risk, and (2) decrease product availability, through the use of continual price hikes, the licensing of sales outlets, increased supervision of the enforcement of the age limit and greater opportunities for prosecution of control violations.
These are the kind of strategies that Sweden has been vigorously implementing since the 1970s and 80s, which complicates the picture, as figures showing that ‘snus use goes up while smoking and smoking-related diseases go down’ may not directly prove cause and effect. These statistics play into the snus manufacturers’ hands and undermines the efforts of effective public health programs.
Lifting the EU ban
Lifting a ban on a product is not the same as not banning it in the first place. There are concerns among public health officials and researchers that removing the ban on snus products across the EU could do more harm than good. Sales would increase and may lead to an increase in the acceptability of nicotine dependence, and smokers may use snus as well as, and not instead of, cigarettes. In the US, snus is marketed as an adjunct and not a replacement for cigarettes: “When you can’t smoke, snus”; “Pleasure, whenever”.
Opponents of snus argue not just that it could be “gateway drug” for cigarettes, but also a way for tobacco industries to promote nicotine use amongst teens and young adults, who may be put off by the stigma associated with smoking. With a sachet of snus delivering the same nicotine hit as a cigarette, snus is just as addictive as smoking, which means users suffer from the same kind of nicotine dependency and withdrawal problems. It’s not unreasonable to believe that those who are in the business of selling nicotine would do everything they can to keep people hooked on nicotine.
If you snus, you lose?
The following analogy has been used to describe the current situation: While smoking tobacco is the skyscraper in terms of health risks, the use of snus, although not risk-free, is a two-storey building and on a par with risks from many other unhealthy habits or products.
Snus may be safer than smoking, so it’s not quite the case that if you snus you lose, but compared to staying clear of tobacco in the first place, you don’t exactly win, either.
A few snus facts:
Snus is currently banned in Australia, Israel and all European Union countries except Sweden.
In Norway, around 11 per cent of men use snus daily, compared to just under one per cent of Norwegian women. The number of female users is rising rapidly, and much faster than use in men, something which is attributed to intensified marketing such as feminine (read: pink) packaging and smaller sachets.
Around 22 per cent of Swedish men use snus daily, compared to four per cent of Swedish women.
Swedish-style snus is becoming increasingly popular in the US, as tobacco companies introduce their own versions. Altria (formerly Philip Morris), the manufacturer of Marlboro products, spent more than $10 billion in 2008 to acquire the popular smokeless tobacco brands
Skoal and Copenhagen.
The average cost of a box of sacheted snus in Norway is 75 kroner, compared to around 90 kroner for a pack of 20 cigarettes, with around 40 per cent of the snus in Norway imported from Sweden.
- Bates, C., Fagerstrom, K., et al. (2003). European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control. 12, 4: 360-7.
- Bolinder, G. (2003). Swedish snuff: a hazardous experiment when interpreting scientific data into public health ethics. Addiction. 98, 9: 1201-4; discussion 1204-7.
- European Commission (2004). Tobacco or health in the European Union, past present and future. Directorate-General for Health and Consumer Protection. Luxembourg.
- Daniel Roth, H., Roth, A. B., et al. (2005). Health risks of smoking compared to Swedish snus. Inhal Toxicol. 17, 13: 741-8.
- Fagerstrom, K. O. and Schildt, E. B. (2003). Should the European Union lift the ban on snus? Evidence from the Swedish experience. Addiction. 98, 9: 1191-5.
- Foulds, J. and Kozlowski, L. (2007). Snus--what should the public-health response be? Lancet. 369, 9578: 1976-8.
- Foulds, J., Ramstrom, L., et al. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control. 12, 4: 349-59.
- Gartner, C. E., Hall, W. D., et al. (2007a). Should the health community promote smokeless tobacco (snus) as a harm reduction measure? PLoS Med. 4, 7: e185.
- Gartner, C. E., Hall, W. D., et al. (2007b). Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet. 369, 9578: 2010-4.
- Grøtvedt, L., Forsén, L., et al. (2012 ). Patterns of snus and cigarette use: a study of Norwegian men followed from age 16 to 19. Tob Control. Ahead of print.
- Holm, L. E., Fisker, J., et al. (2009). Snus does not save lives: quitting smoking does! Tob Control. 18, 4.
- Lee, P. N. (2011). Summary of the epidemiological evidence relating snus to health. Regul Toxicol Pharmacol. 59, 2: 197-214.
- Levy, D. T., Mumford, E. A., et al. (2004). The relative risks of a low-nitrosamine smokeless tobacco product compared with smoking cigarettes: estimates of a panel of experts. Cancer Epidemiol Biomarkers Prev. 13, 12: 2035-42.
- Lund, K. E. (2009), A tobacco-free society or tobacco harm reduction? from http://www.sirus.no/filestore/Import_vedlegg/sirusrap.6.09.eng.pdf.
- Lund, K. E., Scheffels, J., et al. (2011). The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction. 106, 1: 162-7.
- Luo, J., Ye, W., et al. (2007). Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. 369, 9578: 2015-20.
- Norsk Telegrambyrå (NTB). (2012, March 12). Forsker vil fortelle røykere at snus er fornuftig. Dagbladet. Retreived from http://www.dagbladet.no/2012/03/25/nyheter/snus/helse/20833849/ [Accessed 03.04.2012]
- Overland, S., Hetland, J., et al. (2008). Relative harm of snus and cigarettes: what do Norwegian adolescents say? Tob Control. 17, 6: 422-5.
- Ramstrom, L. M. and Foulds, J. (2006). Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob Control. 15, 3: 210-4.
- Schwarzfeld, M. (2012), How Snus Works. Retrieved from http://science.howstuffworks.com/snus.htm. [Accessed 07.09.2012]
- Tomar, S. L., Connolly, G. N., et al. (2003). Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control's efforts? Tob Control. 12, 4: 368-71.
- WHO International (2009), 10 facts on second-hand smoke. Retrieved from http://www.who.int/features/factfiles/tobacco/en/index.html. [Accessed 08.08.2012]