Journal of the National Cancer Institute Advance Access originally published online on September 11, 2007
JNCI Journal of the National Cancer Institute 2007 99(18):1358-1365; doi:10.1093/jnci/djm165
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© Oxford University Press 2007.
NEWS |
Experts Fear Swedish Snus Sales in the U.S. Could Thwart Anti-Tobacco Measures
A new product on the market in a handful of U.S. cities has stirred up mixed feelings in the public-health community. Known as snus (rhymes with "goose"), it is a smokeless tobacco product that has been used in Sweden for nearly a century. Because it has lower levels of cancer-causing toxins than cigarettes or other smokeless tobacco products that are currently sold in the U.S. (such as chewing or dipping tobacco) some public-health experts are wondering whether snus could be a less dangerous substitute for smoking.
Within the public-health community, there are two camps on this issue. Most believe that no tobacco product should ever be promoted because even a "safer" product is still not safe. But the other side, an outspoken minority, thinks it is better to be realistic about tobacco use and provide consumers with honest information about less harmful alternatives to cigarettes. This debate, which includes other harm-reduction strategies like long-term nicotine replacement, might have remained in the realm of the theoretical. but two tobacco companies, Philip Morris and R.J. Reynolds, have been test-marketing their own snus products (named after their best-selling cigarettes Marlboro and Camel, respectively) in cities around the country.
The new snus products come in small teabag-like pouches that are about the size of a paperclip. While Swedish snus has nicotine levels comparable to those of cigarettes, these new snus products deliver much less nicotine. That's the tradeoff for creating a more socially acceptable, spit-free product, said Gregory Connolly, D.M.D., director of the tobacco control research program at Harvard School of Public Health.
There is no debate that snus is less harmful than cigarettes. The tobacco in snus is steam pasteurized, not fermented like other spit tobacco products, including chewing tobacco. This process, developed in Sweden, kills the microbes that create some of the cancer-causing toxins found in other smokeless tobacco products. Snus also doesn’t have the dangerous combustion products that cigarettes do, and there is little to no risk of lung cancer. But this is not to say that snus is completely safe. The most common health effects of snus are white patches in the mouth, called leukoplakia, and gum recession. There are cancer risks as well. A recent study in The Lancet showed that long-term snus users in Sweden had twice the risk of pancreatic cancer of people who never used any tobacco product (smokers had the highest risk of all). The researchers did not find an increase in oral cancer among snus users, but many experts contend that it is nevertheless a risk. "The evidence [from our study] was clearly reassuring with regard to oral cancer, which was perhaps contrary to our prior expectations," said Hans-Olov Adami, M.D., Ph.D., professor of epidemiology at the Harvard School of Public Health.
Despite some of the dangers associated with snus, proponents point to the so-called Swedish experience as proof of snus's benefits. Sweden has one of the lowest smoking rates in the world. Does snus deserve some credit? Absolutely, said Jonathan Foulds, Ph.D., director of the tobacco dependence program at the University of Medicine and Dentistry of New Jersey. "In the one country where it's widely used [Sweden], it's had a beneficial effect by reducing smoking and its health effects," he said. In a study published last year in Tobacco Control, Foulds presented data suggesting that smoking rates have fallen because many Swedish smokers have switched to snus instead. Snus has been less popular with women in Sweden—one of the few countries where women smoke more than men—which is why female smoking rates have not fallen as far, he said. And he found that smokers were much more successful at quitting smoking if they used snus, though he notes that this may not be a causal effect.
One reason that snus might be an effective smoking cessation aid is that people can use it long term, unlike other clean nicotine replacements, which are supposed to be used for only a few months. But, he said, this doesn’t mean doctors should tell their patients to use snus to quit smoking because safer methods of quitting are available. "All I’m saying is that this product is less harmful (than smoking cigarettes). We should allow the product on the market and give people accurate information because some people are going to use tobacco no matter what. ... And for some people who aren’t ready to quit, they may be more open to using smokeless tobacco."
But many public-health experts are skeptical that the Swedish experience even exists. "I think we should give the Swedish public-health community some credit ... not the Swedish tobacco industry," Connolly said. Sweden has implemented many strategies to decrease smoking rates, such as bans on advertising tobacco products, clean indoor air laws, increasing the price of cigarettes—all strategies that have been effective in countries that don’t have snus. Over the last hundred years, snus's popularity has waxed and waned, but only in the last few decades has snus been associated with a decrease in smoking rates. "So looking at this from a more historical perspective, it is not clear at all that the use of snus has always been accompanied by the decrease in smoking," said Olof Nyrén, M.D., Ph.D., professor of clinical epidemiology of Karolinska Institutet in Stockholm.
In Australia and most of Europe, the sale of snus is banned. A group of Australian researchers wanted to find out what the public-health outcome would be if snus were allowed. Their findings, which were also published in the June 16 issue of The Lancet, suggested that there were health benefits for individuals who would have otherwise kept smoking but instead switched to snus. On a population level, permitting snus would most likely produce a net benefit for society if smokers switched to snus instead of smoking. It is unclear how likely this is, and it would depend heavily on how snus is marketed and whether it is regulated. But it would be possible to cause more harm than good if smokers use snus in addition to, not instead of, cigarettes or if people who would have never otherwise used tobacco took up snus, according to Wayne Hall, one of the Australian researchers from the University of Queensland.
These two scenarios are exactly what snus opponents are worried about. public-health professionals, skeptical of the tobacco industry's motives, don’t see a safer product—they see a way to keep smokers from quitting altogether. As more and more cities and states pass clean indoor air laws, it's becoming harder to be a smoker. But snus is "pleasure for wherever," according to marketing statements on the Camel snus box, even restaurants, bars, or the office. Snus could keep people addicted to nicotine and hold them over until they can have another cigarette. "Dual use is clearly the intention of tobacco companies," Scott Tomar, Dr.P.H., D.M.D., professor in the division of public-health services and research at the University of Florida College of Dentistry. "Until we’ve maximized our efforts to promote evidence-based approaches to cessation and reducing the use of tobacco in society, I think it's a sellout to get in bed with the tobacco companies."
But is this just a philosophical debate for academics? The U.S. doesn’t have the tradition of snus use as Sweden does, and smokeless tobacco, which makes up only a small fraction of the tobacco market, has never gained much popularity in the U.S. It's unclear whether snus would be any different. Nonetheless, deep-rooted distrust of the tobacco industry pervades the public-health community. "If the history of tobacco use tells us anything," Adami said, "it really tells us that it's a habit that is enormously manipulable."
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