- Email: [email protected]
Mixed feelings on snus
Comment
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Human Rights Watch. The politics of food assistance in Zimbabwe. Aug 12, 2004: http://www.hrw.org/backgrounder/africa/zimbabwe/2004/zimbabwe 0804.pdf (accessed July 13, 2005). Amnesty International. Zimbabwe: unprecedented call for UN and AU action over evictions by 200 rights groups. June 23, 2005: http://news.amnesty. org/index/ENGAFR460172005 (accessed July 13, 2005). BBC. Africa rejects action on Zimbabwe. June 24, 2005: http://news.bbc. co.uk/2/hi/africa/4618341.stm (accessed July 13, 2005). Tibaijuka AK. Report of the fact-finding mission to Zimbabwe to assess the scope and impact of Operation Murambatsvina by the UN special envoy on human settlements issues in Zimbabwe. July 18, 2005: http:// www.un.org/ News/dh/infocus/zimbabwe/zimbabwe_rpt.pdf (accessed July 24, 2005). Hartnack M. IMF team arrives for Zimbabwe reassessment. August 22, 2005: http://www.businessweek.com/ap/financialnews/D8C4UEP80.htm?campai gn_id=apn_home_down&chan=db (accessed Aug 25, 2005). UNAIDS. Zimbabwe. 2005: http://www.unaids.org/en/geographical+area/ by+country/zimbabwe.asp (accessed July 13, 2005). UN Population Fund. State of the world population 2004—the Cairo consensus at ten: population, reproductive health and the global effort to end poverty. 2004: http://www.unfpa.org/swp/2004/pdf/en_swp04.pdf (accessed July 13, 2005). UN Office for the Coordination of Humanitarian Affairs. Doctors demand better pay as inflation bites. June 30, 2005: http://www.irinnews.org/ report.asp?ReportID=47896&SelectRegion=Southern_Africa&SelectCountry =ZIMBABWE (accessed Aug 1, 2005).
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Southern Africa Migration Resources. Zimbabwe coverage of brain drain. May 19, 2004: http://www.queensu.ca/samp/migrationresources/ braindrain/documents/zimbabwe.htm (accessed Aug 1, 2005). UN Office for the Coordination of Humanitarian Affairs. Zimbabwe: forced evictions could aggravate disease—health experts. July 6, 2005: http:// www.irinnews.org/print.asp?ReportID=48006 (accessed July 13, 2005). News 24.com. Zim doctors condemn clean-up. June 13, 2005: http://www. news24.com/News24/Africa/Zimbabwe/0,,2–11–1662_1720511,00.html (accessed July 13, 2005). Human Rights Watch. China and Tibet. 2005: http://hrw.org/doc/?t=asia_ pub&c=china (accessed Aug 4, 2005). Amnesty International. China. 2004: http://web.amnesty.org/report2004/ chn-summary-eng (accessed Aug 4, 2005). Eisenman J. Rising tigers roam in Harare. July 12, 2005: http://www. thestandard.com.hk/stdn/std/Focus/GG12Dh01.html (accessed Aug 4, 2005). Mde V, Brown K. Crunch for Mugabe as $1bn loan talks start. Aug 4, 2005: http:///www.businssday.co.za/articles/frontpage.aspx?ID=BD4A76617 (accessed Aug 4, 2005). Zimbabwe Association of Doctors for Human Rights. Appeal to the Zimbabwe Medical Association, the South African Medical Association, other national medical associations in Southern Africa and worldwide, health and human rights organisations, and the World Medical Association re: Operation Murambatsvina (sweep up the rubbish). July 4, 2005: http://www. zimbabwesituation.com/jul5_2005.html#link9 (accessed July 13, 2005).
Mixed feelings on snus 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.
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal
966
First, British American Tobacco (BAT) has testmarketed 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 www.thelancet.com Vol 366 September 17, 2005
Comment
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. Nicotinereplacement 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) nicotinereplacement therapy should hesitate over a tobaccocontaining cigarette-smoke substitute, on the grounds that tobacco contains carcinogens other than nitroswww.thelancet.com Vol 366 September 17, 2005
amines9 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. Nigel Gray Tobacco Unit, International Agency for Research on Cancer, 69008 Lyon, France [email protected] I declare that I have no conflict of interest. 1
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British American Tobacco. About smokeless snus-British American Tobacco. June 2, 2005: http://www.bat.com/oneweb/sites/uk__ 3mnfen.nsf/ vwPagesWebLive/DO6CPCXZ?opendocument&SID= 559F018C60E5F6974CC310A5202CB4C2&DTC=20050616&TMP=1 (accessed June 16, 2005). Ekman I. Fight? Swedes would rather switch. International Herald Tribune May 27, 2005: 1, 7. Bates C, Fagerstrom K, Jarvis MJ, Kunze M, McNeill A, Ramstrom L. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control 2003; 12: 360–67. Foulds J, Ramstrom L, Burke M, Fagerstrom K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control 2003; 12: 349–59. Cogliano V, Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F. Smokeless tobacco and tobacco-related nitrosamines. Lancet Oncol 2004; 5: 708. Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer 2005; 114: 992–95. Hughes JR, Adams EH, Franzon MA, Maguire MK, Guary J. A prospective study of off-label use of, abuse of, and dependence on nicotine inhaler. Tob Control 2005; 14: 49–54. Gray N, Boyle P. The future of the nicotine-addiction market. Lancet 2003; 362: 845–46. International Agency for Research on Cancer. Tobacco smoke and involuntary smoking. Lyon: International Agency for Research on Cancer, 2004. Weinstein ND. 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. Bethesda: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2001: 193–235.
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Human Rights Watch. The politics of food assistance in Zimbabwe. Aug 12, 2004: http://www.hrw.org/backgrounder/africa/zimbabwe/2004/zimbabwe 0804.pdf (accessed July 13, 2005). Amnesty International. Zimbabwe: unprecedented call for UN and AU action over evictions by 200 rights groups. June 23, 2005: http://news.amnesty. org/index/ENGAFR460172005 (accessed July 13, 2005). BBC. Africa rejects action on Zimbabwe. June 24, 2005: http://news.bbc. co.uk/2/hi/africa/4618341.stm (accessed July 13, 2005). Tibaijuka AK. Report of the fact-finding mission to Zimbabwe to assess the scope and impact of Operation Murambatsvina by the UN special envoy on human settlements issues in Zimbabwe. July 18, 2005: http:// www.un.org/ News/dh/infocus/zimbabwe/zimbabwe_rpt.pdf (accessed July 24, 2005). Hartnack M. IMF team arrives for Zimbabwe reassessment. August 22, 2005: http://www.businessweek.com/ap/financialnews/D8C4UEP80.htm?campai gn_id=apn_home_down&chan=db (accessed Aug 25, 2005). UNAIDS. Zimbabwe. 2005: http://www.unaids.org/en/geographical+area/ by+country/zimbabwe.asp (accessed July 13, 2005). UN Population Fund. State of the world population 2004—the Cairo consensus at ten: population, reproductive health and the global effort to end poverty. 2004: http://www.unfpa.org/swp/2004/pdf/en_swp04.pdf (accessed July 13, 2005). UN Office for the Coordination of Humanitarian Affairs. Doctors demand better pay as inflation bites. June 30, 2005: http://www.irinnews.org/ report.asp?ReportID=47896&SelectRegion=Southern_Africa&SelectCountry =ZIMBABWE (accessed Aug 1, 2005).
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Southern Africa Migration Resources. Zimbabwe coverage of brain drain. May 19, 2004: http://www.queensu.ca/samp/migrationresources/ braindrain/documents/zimbabwe.htm (accessed Aug 1, 2005). UN Office for the Coordination of Humanitarian Affairs. Zimbabwe: forced evictions could aggravate disease—health experts. July 6, 2005: http:// www.irinnews.org/print.asp?ReportID=48006 (accessed July 13, 2005). News 24.com. Zim doctors condemn clean-up. June 13, 2005: http://www. news24.com/News24/Africa/Zimbabwe/0,,2–11–1662_1720511,00.html (accessed July 13, 2005). Human Rights Watch. China and Tibet. 2005: http://hrw.org/doc/?t=asia_ pub&c=china (accessed Aug 4, 2005). Amnesty International. China. 2004: http://web.amnesty.org/report2004/ chn-summary-eng (accessed Aug 4, 2005). Eisenman J. Rising tigers roam in Harare. July 12, 2005: http://www. thestandard.com.hk/stdn/std/Focus/GG12Dh01.html (accessed Aug 4, 2005). Mde V, Brown K. Crunch for Mugabe as $1bn loan talks start. Aug 4, 2005: http:///www.businssday.co.za/articles/frontpage.aspx?ID=BD4A76617 (accessed Aug 4, 2005). Zimbabwe Association of Doctors for Human Rights. Appeal to the Zimbabwe Medical Association, the South African Medical Association, other national medical associations in Southern Africa and worldwide, health and human rights organisations, and the World Medical Association re: Operation Murambatsvina (sweep up the rubbish). July 4, 2005: http://www. zimbabwesituation.com/jul5_2005.html#link9 (accessed July 13, 2005).
Mixed feelings on snus 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.
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal
966
First, British American Tobacco (BAT) has testmarketed 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 www.thelancet.com Vol 366 September 17, 2005
Comment
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. Nicotinereplacement 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) nicotinereplacement therapy should hesitate over a tobaccocontaining cigarette-smoke substitute, on the grounds that tobacco contains carcinogens other than nitroswww.thelancet.com Vol 366 September 17, 2005
amines9 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. Nigel Gray Tobacco Unit, International Agency for Research on Cancer, 69008 Lyon, France [email protected] I declare that I have no conflict of interest. 1
2 3
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5
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British American Tobacco. About smokeless snus-British American Tobacco. June 2, 2005: http://www.bat.com/oneweb/sites/uk__ 3mnfen.nsf/ vwPagesWebLive/DO6CPCXZ?opendocument&SID= 559F018C60E5F6974CC310A5202CB4C2&DTC=20050616&TMP=1 (accessed June 16, 2005). Ekman I. Fight? Swedes would rather switch. International Herald Tribune May 27, 2005: 1, 7. Bates C, Fagerstrom K, Jarvis MJ, Kunze M, McNeill A, Ramstrom L. European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health. Tob Control 2003; 12: 360–67. Foulds J, Ramstrom L, Burke M, Fagerstrom K. Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tob Control 2003; 12: 349–59. Cogliano V, Straif K, Baan R, Grosse Y, Secretan B, El Ghissassi F. Smokeless tobacco and tobacco-related nitrosamines. Lancet Oncol 2004; 5: 708. Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer 2005; 114: 992–95. Hughes JR, Adams EH, Franzon MA, Maguire MK, Guary J. A prospective study of off-label use of, abuse of, and dependence on nicotine inhaler. Tob Control 2005; 14: 49–54. Gray N, Boyle P. The future of the nicotine-addiction market. Lancet 2003; 362: 845–46. International Agency for Research on Cancer. Tobacco smoke and involuntary smoking. Lyon: International Agency for Research on Cancer, 2004. Weinstein ND. 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. Bethesda: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 2001: 193–235.
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