From , large Tobacco Companies increasingly invested in snus, and more recently, tobacco leaf free nicotine pouches. For more information on these investments, see Cigarette Companies Investing in Snus. The European ban on snus sales has been repeatedly legally challenged by the industry, and a strong lobby from Sweden. Unlike cigarettes, snus does not produce secondhand smoke or carry a risk of causing accidental fires. Long-term prospective cohort studies have observed a lower risk of many tobacco-related diseases and overall lower mortality in snus users compared to smokers.
After 5 days, substantial reductions of most biomarkers, including nicotine, were observed, and toxicant exposures were similar to being tobacco abstinent. Compared to no tobacco use, use of snus does appear to carry some residual risks, albeit lower than for smoking, of pancreatic cancer, 6, 11, 12 and cardiovascular disease. In Sweden, among people who have ever smoked regularly, those who use snus are more likely to have quit smoking than those who do not.
Some health professionals do not feel that the existing epidemiological studies showing a lower risk of tobacco-related disease in snus users are sufficient to support snus use as a harm reduction strategy. Others are concerned that the difference in potential harm between snus and smoking has not have been fully described in existing studies. Some believe that any health risk from snus, no matter how small, is too great for its use to be encouraged. However, the difference in healthy life expectancy and overall mortality risk between smokers who quit all tobacco and smokers who switch to low nitrosamine smokeless forms appears to be small.
Whether the Swedish experience would transfer to Australia, which has never had a significant smokeless tobacco tradition, is uncertain. A growing smokeless tobacco market in Australia during the s was halted by the introduction of a commercial sales ban in , but it is unknown whether these products would have become widespread without the ban.
There are also behavioural aspects of smoking that may not be adequately replaced by snus use. For example, smoking offers something to do with the hands and is easy to do while engaging in other social activities such as drinking and talking. Snus is simply placed under the top lip and left there until it is removed. Talking and drinking while using snus requires more skill than smoking to keep the tobacco portion in place. The small bulge visible in the upper lip during snus use may also lack the supposed glamour of smoking.
Low nitrosamine smokeless tobacco products are not harmless and can be as addictive as smoking. Proponents of tobacco harm reduction with smokeless tobacco counter that it is unethical to deny smokers access to products with substantially lower risks than smoking and to deny them accurate information about the benefits of switching to them, particularly as cigarettes, the most harmful tobacco product, are readily available.
The lower harmfulness of low nitrosamine smokeless tobacco compared to cigarettes is likely to be an important motivator for smokers to switch products. For example, in a survey of Australian smokeless tobacco users, just over half stated they used smokeless tobacco because it was less harmful than smoking 30 and users of non-cigarette tobacco products are more likely to believe they are less harmful than cigarettes than non-users.
Using low nitrosamine smokeless tobacco products may reduce tobacco-related disease in individual smokers who make the switch, but widespread use could still result in population level harm in a number of ways.
Firstly, if these products proved more popular among non-smokers than smokers, then overall harm could increase. Secondly, their promotion could keep current smokers smoking instead of quitting or lead some non-smokers to commence smoking. This is the most likely way in which smokeless tobacco promotion could produce population harm because the large difference in health risk between smoking and use of low nitrosamine smokeless tobacco means that a very large number of non-smokers need to use these products to offset the health gain achieved from a smoker switching to them.
Tobacco manufacturers have argued that they should be able to market and promote reduced harm smokeless tobacco products in order to inform smokers of the benefits of switching. This is an important issue because if these products are to have a population-level benefit, a sufficient number of smokers need to make the switch.
However, promotion of smokeless tobacco via tobacco industry advertising may increase overall tobacco use, possibly including smoking among current non-smokers. In countries where tobacco advertising is allowed, cigarette manufacturers have promoted dual use of smokeless and smoked tobacco products as a way to get around public smoking bans.
Public smoking bans not only protect non-smokers from environmental tobacco smoke, but have the added benefit of encouraging smokers to quit due to the inconvenience these bans produce.
Some of these quitters may therefore be encouraged to keep smoking as they can get through the inconvenient times with a short-term alternative. In Norway, while current daily or former snus use is associated with quitting smoking, current occasional snus use is not.
Alternatively, these dual users may be in a process of gradually moving from one product to another or of quitting all tobacco use. In the US and Sweden, dual use of smoked and smokeless tobacco is uncommon and does not appear to be a stable pattern of tobacco use. Indeed, epidemiological evidence albeit with some limitations has suggested that dual use of snus and cigarettes might increase smoking quit rates.
Some tobacco control professionals view tobacco harm reduction with smokeless tobacco as a distraction from the main task of encouraging smokers to quit tobacco use and discouraging uptake.
Supporters of harm reduction argue that it offers an additional strategy that may hasten the decline in smoking and may reach those smokers who have been resistant to traditional tobacco control strategies or have been unable to quit tobacco use despite repeated efforts.
Long-term use of nicotine replacement therapy NRT products, such as gum, lozenges or inhalers, has also been suggested as an alternative to smoking. Because these present lower risk than smokeless tobacco, it has been argued that there is no need for smokeless tobacco products as a harm reduction alternative. This argument ignores the possibility that smokeless tobacco may be more attractive to smokers than NRT. Smokeless tobacco is a purely recreational tobacco product that can deliver nicotine in similar amounts to the user as smoking.
It may, therefore, be a better substitute for cigarettes for smokers who want to continue using tobacco recreationally. NRT is also primarily marketed as a medicine for short-term assistance during cessation. Pharmaceutical companies may also be concerned that long-term use of high-dose nicotine products may carry a higher health risk than short-term use of low-dose NRT, which has been established as safe.
In , former smokers in Sweden were significantly more likely to use smokeless tobacco than never smokers. Using NRT to quit smoking may also be stigmatised by some smokers who see the use of a medication to quit as a sign of drug addiction.
As uptake of NRT in Australia remains relatively low, 60 a product that may be more attractive to smokers and more effective, even if marginally riskier, could increase the number of quitters and therefore produce a greater population level benefit. Smokeless tobacco products appear to be less effective at reducing withdrawal symptoms than cigarettes. When presented with a range of hypothetical policy options, a sample of Australian smokers stated they would be more likely to quit if smokeless tobacco were made less expensive than cigarettes and if there were a substantial price increase on cigarettes, than if there were a cigarette price increase alone.
These results suggest that a lower tax on smokeless tobacco compared to smoked tobacco could produce a greater reduction in the number of smokers than simply increasing cigarette taxes. Similarly, a Californian survey found that smokers with greater intentions of quitting were less likely to be interested in switching to smokeless tobacco, but smokers who were trying to cut down their cigarette intake and smokers who had made unsuccessful quit attempts were more likely to be interested in switching to smokeless tobacco.
The authors suggest that the harm reduction effects observed in Sweden may have limited generalisability to other countries.
Another clinical trial in the US compared abstinence outcomes among smokers who were randomised to receive free samples of snus versus not. Overall, wide-scale provision of snus to smokers not ready to quit resulted in minimal uptake, and appeared to undermine quit attempts.
There were no differences between groups on abstinence. Snus manufactured for oral use is a moist ground tobacco of Dark Kentucky or Virginia species mixed with an aqueous solution of water and other blending ingredients. This form of snuff is found in two types: 1 loose and 2 portion-bag-packed. These are the most widely used. The majority of snus users place the quid in the vestibular area of the upper lip, and the prevalence among persons 15 years of age or older in The pH of snus has declined from a previous range of to a range of 7.
The results confirmed and extended previous studies that found most smokers quit unassisted. In addition, snus was the most frequently reported cessation aid among male smokers, whereas usage of pharmaceutical nicotine was more prevalent among females. Use of snus at the latest quit attempt appeared to be associated with a significantly higher success rate among males. The authors concluded that longer-term studies were warranted to test efficacy for long-term quit rates.
The results in this study were biologically verified. A review [ ] of smoking prevalence, snus use and associated effects on public health in Sweden suggested that the low rate of male smoking combined with high rate of snus use indicated the displacement of smoking by snus. The authors concluded that snus use prevents rather than promotes smoking and has contributed a net public health benefit in Sweden.
However, the SCENIHR report [ 23 ] and the Cochrane review [ ] concluded there was insufficient evidence to determine whether snus could aid long-term smoking cessation. The SCENIHR report was published prior to the seven studies cited above and was based on US research and the Cochrane review only included the Swedish Match sponsored trial when reviewing the effectiveness of different smoking interventions.
This review found that the health risks associated with snus use, where nicotine is decoupled from harmful tobacco smoke, are considerably lower than those associated with smoking cigarettes. Further, snus appears to be a viable alternative to smoking tobacco, is acceptable to consumers and does not act as a gateway product to smoking cigarettes.
Snus should therefore be regarded as a reduced risk product relative to cigarettes. These findings are in keeping with those reached recently by the UK Royal College of Physicians [ 25 ]. Snus as an alternative to cigarettes has the potential to deliver enormous harm reduction benefits as demonstrated in Sweden, particularly in reducing the incidence of lung cancer and cardiovascular disease of which smoking is a known cause, where the product can be marketed and sold to adult smokers widely.
This review also shows that since the European Union implemented a ban on the sale and marketing of snus in , a substantial and independent scientific evidence base has confirmed the harm reduction potential of snus.
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