Snus

Portioned snus of the Swedish label General.

Snus (Template:Pron-en) is a type of moist powder tobacco that is consumed by placing it under the lip for extended periods of time. Snus is steam- rather than fire-cured, is not fermented, and contains no added sugar. It is manufactured and consumed primarily in Sweden and Norway. Its sale within the rest of the European Union is not allowed.

Health consequences

Since snus is not intended nor recommended for inhalation, it does not affect the lungs as cigarettes do. Because it is steam-cured, rather than fire-cured like smoking tobacco or other chewing tobacco, it contains lower concentrations of nitrosamines and other carcinogens that form from the partially anaerobic heating of proteins; 2.8 parts per mil for Ettan brand compared to as high as 127.9 parts per mil in American brands, according to a study by the Commonwealth of Massachusetts Department of Health. The World Health Organization (WHO) acknowledges that Swedish men have the lowest rate of lung cancer in Europe, partly due to the low tobacco smoking rate, but does not argue for substituting snus for smoking, citing that the effects of snus still remain unclear. Around 2005 several reports pointed to the fact that no carcinogenic effects could be attributed to Nordic snus and this resulted in the warning label that snus could cause cancer could be removed. It was replaced with the more neutral label "Can affect your health negatively". Research is still going on but at the moment no conclusive reports have been made regarding the health effects of snus.

The European Union banned the sale of snus in 1992, after a 1985 WHO study concluded that "oral use of snuffs of the types used in North America and western Europe is carcinogenic to humans", but a WHO committee on tobacco has also acknowledged that evidence is inconclusive regarding health consequences for snus consumers.[1]. Only Sweden and EFTA-member Norway are exempt from this ban. A popular movement during the run-up to the 1994 referendum for Sweden's EU membership made exemption from the EU sale ban of snus a condition of the membership treaty.

Recent actions by many European governments to limit the use of cigarettes has led to calls to lift the ban on snus, as it is generally considered to be much less harmful than cigarette smoke, both to the user and especially to others, as the effects of passive smoking are abolished.

Debate among public health researchers

There is some debate among public health researchers over the use of safer tobacco or nicotine delivery systems, generally dividing along two lines of thought. Most researchers are currently of the "abstinence" belief, believing that no form of tobacco or nicotine use is acceptable or safe, and should be minimized among the population. A minority (primarily in the European Union and Canada) believes in "harm reduction," where the belief is generally that, while it should remain a goal to reduce addiction to nicotine in the population as a whole, the reduction of harm to the health of those who choose to use nicotine should override the need to reduce overall nicotine addiction. For example, some research[2] available today shows that snus use reduces or eliminates the risk of cancers that afflict other users of tobacco products such as "chewing tobacco" (the type primarily used in the United States and Canada, created in a process similar to cigarette tobacco) and cigarettes. It is hypothesized that the widespread use of snus by Swedish men (estimated at 30% of Swedish male ex-smokers), displacing tobacco smoking and other varieties of snuff, is responsible for the incidence of tobacco-related mortality in men being significantly lower in Sweden than any other European country; in contrast, since women traditionally are less likely to use snus, their rate of tobacco-related deaths in Sweden can be compared to that of other European countries.

Snus is considered much less harmful than other tobacco products; according to Kenneth Warner, director of the University of Michigan Tobacco Research Network,

"The Swedish government has studied this stuff to death, and to date, there is no compelling evidence that it has any adverse health consequences. ... Whatever they eventually find out, it is dramatically less dangerous than smoking." [3]

Ongoing discussion and debates among primary scientific researchers of the effects of snus use on life expectancy appears to indicate that there is a significant increase in life expectancy among persons who previously smoked tobacco and switch to Swedish snus, depending on the age of the persons who switch, even when it is assumed that 100% of the risk of cardiovascular diseases among smokers transfers to snus users. It is also noted, in the correspondence seen in the previous citation that concerns about the effect of marketing by the tobacco industry, as influenced by the results of these scientific studies, is of primary concern to many researchers in the field, including the risk of emboldening the industry to attempt to increase snus sales among young people and promote dual-use of snus and smoked tobacco, and that the use of medical nicotine, rather than snus, can better target at-risk populations, given better access and pricing.

Opponents of snus sales maintain that, nevertheless, even the low nitrosamine levels in snus cannot be completely risk free, but snus proponents point out that inasmuch as snus is used as a substitute for smoking or a means to quit smoking, the net overall effect is positive, similar to the effect of nicotine patches, for instance.

In addition, rather obviously, this eliminates any exposure to second-hand smoke, further reducing possible harm to other non-tobacco users. This is seen by public health advocates who believe in "harm reduction" as a reason for recommending snus in addition to other nicotine replacement therapies rather than continued use of cancer-causing nicotine delivery systems.

This does not however, eliminate any harm to health caused by the nicotine itself. Current research focuses on possible long-term effects on blood pressure, hypertension and possible risk of pancreatic cancer due to tobacco-specific nitrosamines (TSNAs). TSNAs are the only component of tobacco shown to induce pancreatic cancer in laboratory animals. Nicotine may also exacerbate pancreatic illness, because nicotine stimulates the gastrointestinal tract's production of cholecystokinin, which stimulates pancreatic growth and may be implicated in pancreatic cancer. Thus far the evidence specifically implicating snus in pancreatic cancer is only suggestive. It should also be noted that the probability of developing pancreatic cancer from cigarettes is higher than the suggested chance of developing pancreatic cancer from snus. The effects of Swedish snus on blood pressure has been studied at Umeå University in a randomly selected population sample of 4,305 Swedish men between 25 and 74 years of age. In the study, published in November 2008, the researchers found no elevation of blood pressure in snus users who had never been smokers compared to non tobacco users. In fact, snus users had lower systolic blood pressure than non tobacco users in the unadjusted data.

Published peer-reviewed studies

• Effect of smokeless tobacco (snus) on smoking and public health in Sweden, October, 2003 (full text)
• Broadstock M. Systematic review of the health effects of modified smokeless tobacco products, N Zealand Health Technol Assessment Rep, February 2007 (full text)

Cardiovascular diseases

• Hergens MP, Ahlbom A, Andersson T, Pershagen G (2005). "Swedish moist snuff and myocardial infarction among men". Epidemiology. 16 (1): 12–6. doi:10.1097/01.ede.0000147108.92895.ba. PMID 15613940. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
• Broadstock M. Systematic review of the health effects of modified smokeless tobacco products, N Zealand Health Technol Assessment Rep, February 2007, p37-56 (full text)

Diabetes

• Eliasson M, Asplund K, Nasic S, Rodu B (2004). "Influence of smoking and snus on the prevalence and incidence of type 2 diabetes amongst men: the northern Sweden MONICA study". J. Intern. Med. 256 (2): 101–10. doi:10.1111/j.1365-2796.2004.01344.x. PMID 15257722. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Cancer

• Juhua Luo MSc, Weimin Ye MD, Kazem Zendehdel MD, Johanna Adami MD, Prof Hans-Olov Adami MD, Prof Paolo Boffetta MD and Prof Olof Nyrén MD 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 The Lancet, Volume 369, Issue 9578, Pages 2015-2020 (abstract - full text by subscription only)

• Roosaar A, Johansson AL, Sandborgh-Englund G, Axéll T, Nyrén O (2008). "Cancer and mortality among users and nonusers of snus". Int. J. Cancer. 123 (1): 168–73. doi:10.1002/ijc.23469. PMID 18412245. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Smoking cessation

• Gilljam H, Galanti MR (2003). "Role of snus (oral moist snuff ) in smoking cessation and smoking reduction in Sweden". Addiction. 98 (9): 1183–9. doi:10.1046/j.1360-0443.2003.00379.x. PMID 12930201. {{cite journal}}: Unknown parameter |month= ignored (help)
• Rodu B, Godshall WT (2006). "Tobacco harm reduction: an alternative cessation strategy for inveterate smokers". Harm Reduct J. 3: 37. doi:10.1186/1477-7517-3-37. PMC 1779270. PMID 17184539. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: unflagged free DOI (link)

Medical community discussions and reports

• Kjell Asplund. Snuffing, Smoking and the risk for heart disease and other vascular diseases. 3rd revised version. ASH Britain; 2002 (full text)
• The 3rd (2002) International Conference on Smokeless Tobacco - Daily Media Summaries from the U.S. National Cancer Institute
• Discussion of Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control’s efforts?; Tobacco control (BMJ). 2003.
• Some practical points on harm reduction: what to tell your lawmaker and what to tell your brother about Swedish snus, Tobacco Control Online, December, 2003

General media articles

• A Smokeless Alternative To Quitting (Unabridged Version), The New York Times, April 6, 2004
• Should Snuff Be Used as a Tool To Quit Smoking?, The Wall Street Journal, September 16, 2006; Page A1.
• Doctors: Swedish snus cut risk of cancer, Associated Press via USA Today, May 10, 2007
• Swedish Smokeless Tobacco Aims at U.S. Market New York Times, October 3, 2007
• Doctors call for new nicotine products Reuters (UK) Oct 5, 2007 12:48pm BST

Herbal snus

Main article: Herbal snus

External links

Tobacco Industry-sponsored discussion forums

• The harm reduction Bulletin Board The Eudoxa think tank's Bulletin Board for discussing snus and harm reduction, funded by the U.S. Smokeless Tobacco Company

Articles

• "Use of Swedish 'snus' is linked to a doubled risk of pancreatic cancer". EurekAlert. May 11, 2007. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
• "Use Of Swedish 'Snus' Is Linked To A Doubled Risk Of Pancreatic Cancer", Science Daily, May 11, 2007
• Snus - a safer option for smokers Slate, July 10, 2007
• Dr. Gunilla Bolinder talked about snus (video, in Swedish)
• The Snus Experience - Lessons from Norway Sweden and Canada on the public health consequences of widespread oral tobacco use (PDF) Physicians for a Smoke-Free Canada, October, 2007 - PSC's response to claims made by Imperial Tobacco Canada that snus is linked to reduction of smoking rates and tobacco-related deaths using statistics from snus and non-snus countries

Non-medical blogs and commentary

• Hit and Run article on Snus
• Snus article that compares a few online sellers