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Social Report 2006/2007
Case Studies - Swedish Snus
Snus is a type of smokeless tobacco. Smokeless does not mean harmless. However, since the use of the product does not involve inhalation, it is associated with significantly less health risks than cigarettes. Due to the unique way it is manufactured, it is also recognised as posing a lower risk than most other smokeless tobacco products. Evidence from Sweden, where snus use is common, shows it can reduce smoking rates by both offering a real alternative to starting smoking and helping smokers quit. Consequently, snus use is considered by some members of the public health community as being one of the main contributory factors to the record low smoking related mortality seen in Sweden. Snus however is currently banned in the EU.
Smokeless tobacco
Snus is a form of smokeless tobacco used orally and the Swedish type of snus is used between the cheek and the gum of the upper lip. There are numerous types of smokeless tobacco products used worldwide, particularly in India, South East Asia, North America and Sweden. The ways in which these products are consumed and used do vary from product to product and depend on the geography. The table below tries to categorise the most common variants of smokeless tobacco by separating them into two main classes: through the oral cavity and through the nose.
Swedish snus
Snus has been used in Sweden since before the turn of the 20th century and is today used by nearly a quarter of the Swedish adult male population. It comes in two main forms, loose or portioned backed sachets similar to small tea bags. Unlike other forms of moist snuff, snus tobacco is not fermented and, as part of the manufacturing process, undergoes a unique heat-treatment or pasteurisation like process that kills the microbes that naturally occur on the tobacco. These microbes are responsible for producing what are considered by some scientific experts to be potentially the main cancer-causing chemicals in tobacco, known as tobacco specific nitrosamines (TSNAs). Eliminating the microbes ensures the levels of TSNAs in snus are kept extremely low and amongst the lowest of all smokeless tobacco products.
Until recently there was only one major manufacturer of snus in Sweden. In the early 80's, this manufacturer introduced an internal quality standard that set limits for TSNAs and other potentially harmful elements found naturally in tobacco such as heavy metals and pesticides to further improve the quality of their products. Today, all new snus manufacturers comply with this standard and some members of the public health community are suggesting those limits as a sensible element in the regulation of smokeless tobacco products.
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Oral Smokeless Tobacco Products
* banned in the European Union |
Health risks of smokeless tobacco compared with smoking
Smoking exposes the respiratory tract and lungs to smoke that contains a mixture of more than 4000 compounds, some of which have been identified as potential carcinogens under certain conditions. The most prevalent smoking related diseases are those affecting the respiratory system including lung cancer and chronic obstructive pulmonary disease (emphysema and chronic bronchitis). As smokeless tobacco use involves exposing the body to far fewer compounds via the mouth and digestive tract, it is understandable why the risk of respiratory and other diseases is so much less than for smoking.
Health risks of snus compared with other smokeless tobacco products
Due to their different chemical profiles, different types of smokeless tobacco products have been shown to have different levels of risk. The UK Royal College of Physicians has stated that dependent upon the product, smokeless tobacco is 10-1000 times less hazardous than smoking.
The effects of snus use in Sweden have been studied for over sixty years. Recent population-based studies did not show increased risks of oral or gastric cancer with snus use in Sweden. A number of reviews of the health effects of snus have concluded that snus may be associated with a slight increase in cardiovascular risk, and may pose some risks to the unborn foetus. Lately there has been a discussion regarding on the potential role of snus with regards to pancreatic cancer. Still the risks are in all these scenarios significantly smaller than those associated with smoking.
The "Swedish Experience"
The "Swedish Experience" is the term given to describe the unique phenomenon that has occurred in Sweden with regard to the country's tobacco consumption patterns and resultant observed benefits to public health (the trends described below apply mainly to male population).
The Swedish have been using smokeless tobacco for over two hundred years and in the form of snus since the turn of the 20th century. Snus use declined and smoking increased with the advent of the manufactured cigarette during World War I, the trend being reversed in the seventies (see chart) at the same time as the deleterious health effects of cigarettes were emphasised by government.
Sales of snus and cigarettes in Sweden
1916-2003 (source: Swedish Match 2005)
Though the prevalence of total tobacco use in Sweden remains similar to that of the rest of Europe, the trends of smoking decline and increased snus use are continuing such that today, Sweden has one of the lowest rates of smoking in the world. Only 15% of the Swedish adult population are smokers making it the only country in Europe to reach the WHO's goal of less than 20% daily smoking prevalence by the year 2000. In the rest of Europe average daily smoking incidence is double that of Sweden at around 30%. This has resulted in Sweden having the lowest levels of smoking-related mortality in the developed world by some distance and approximately half of that of the rest of Europe.
Cessation / Initiation
A concern expressed by those opposed to snus forming part of a tobacco harm reduction policy is that smokeless tobacco use by young people may increase the risk that they might take up smoking. This is often referred to as the “gateway to smoking” issue. Similarly there are concerns that snus use might delay smoking cessation (quitting) and thus contribute to increased health risks.
Recent evidence from Sweden indicates the opposite is true, with snus use significantly reducing the risk of a non-smoker becoming a daily smoker and increasing the likelihood of a smoker stopping smoking. Results from "Sweden's Living Conditions Survey" show that for every snus user who takes up smoking there are four smokers who switch to snus when they quit smoking. This would indicate that snus provides a gateway out of smoking rather than into it.
Data also shows that those smokers who use snus as a quitting aid are significantly more likely to succeed in quitting smoking completely than those smokers who use nicotine replacement therapies (NRT) such as nicotine gum or patches. In fact a recent report from the Swedish National Board of Health and Welfare showed that of those who had quit smoking, 4 out of 5 had used snus.
The EU ban (1992 to present)
In May 1992, the European Union (EU) prohibited the placing on the market of tobacco for oral use (including Swedish snus). The prohibition was introduced by Directive 92/41/EEC amending Directive 89/622/EEC.
The EU prohibited tobacco for oral use on the basis that "...products for oral use will be used above all by young people, thus leading to nicotine addiction..." and that "...in accordance with the conclusions of the studies conducted by the International Agency for Research on Cancer, tobacco for oral use contains particularly large quantities of carcinogenic substances; whereas these new products cause cancer of the mouth in particular."
Article 8 states that:
"Member States shall prohibit the placing on the market of tobacco for oral use as defined in Article 2(4)".
Article 2(4) defined "tobacco for oral use" as "all products for oral use, except those intended to be smoked or chewed, made wholly or partly of tobacco, in powder or
particulate form or in any combination of these forms – particularly those presented in sachet portions or porous sachets – or in a form resembling a food product".
However, there are some notable exemptions to the prohibition of tobacco for oral use within the EU. The use of snus in Sweden, for example, was considered to be significant enough to justify an exemption when it joined the EU in 1995, although there was a ban on placing snus on the market in other EU member states. Separately, in Denmark "loose" snus is exempt because the product is considered a "traditional tobacco product". The prohibition of tobacco for oral use in the EU is also covered by Article 8 of Directive 2001/37/EC.
The change came about in response to a number of scientific studies indicating that Swedish snus is not associated with an increased risk of cancer in the oral cavity, and on that basis "...scientific opinion no longer supports a strong warning as is currently set out in Directive 92/41/EEC ('Causes Cancer'). It is therefore proposed to replace this warning with a more general one. This will better reflect the established health risks for such products..." (Explanatory Memorandum COM/99/0594 final - COD 99/0244). However, despite the new scientific evidence, a review of the prohibition of Swedish snus in the EU was not undertaken.
Currently the European Commission, aided by the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR), is conducting a review of snus.
A preliminary SCENIHR report has been published in June 2007 and following consultation process the final report is expected by end of 2007.
One of the report conclusions is that "...overall, in relation to the risks of the above major smoking-related diseases, and with the exception of use in pregnancy, STP and particularly snus are clearly less hazardous, or substantially less hazardous, than cigarette smoking.[…] The magnitude of the overall reduction in hazard is difficult to estimate, but […] for lung cancer and chronic obstructive pulmonary disease is possibly 100%".
Since snus was banned by the EU in 1992, a strong and growing body of scientific evidence has been developed which indicates that snus use can significantly reduce smoking related mortality. In line with commitments made to stakeholders in the social reporting dialogue at the global level, British American Tobacco will be an active contributor to the snus debate by seeking to raise EU decision-makers' awareness of the potential health benefits of snus use when compared to smoking and of the product's legalisation under appropriate regulatory conditions.