Thursday, January 16, 2014

Ban the Snus Ban

The European Union last year confirmed its irrational ban on smokeless tobacco, denying smokers safer products that are widely used in Sweden.  In October, shortly before the European Parliament extended the ban by supporting the revised EU Tobacco Directive, Europe’s leading tobacco research and policy experts expressed their support for tobacco harm reduction in a letter to the United Kingdom’s Parliamentary members and to UK Secretary of State for Health Jeremy Hunt (originally published here).  Their argument, brilliantly stated, should resonate with U.S. policymakers and public health practitioners.

To:         Rt Hon Jeremy Hunt MP
  Secretary of State for Health
              Richmond House
              London SW1A 2NS
CC:       UK Members of the European Parliament
From:    Specialists in tobacco and public health

Date:     7 October 2013

Dear Mr Hunt,
Re: Tobacco Products Directive and snus
We are writing to you as independent public health specialists to react to your letter to UK MEPs on the Tobacco Products Directive. We were disappointed that you declared support for banning snus outside Sweden, and believe the justification given is inadequate.  The position statement[1] argues that we would take a ‘backward step for public health by relaxing a ban on an existing category of tobacco’.  This reasoning is weak unless you plan an imminent ban on cigarettes.  In reality, it simply assists the most harmful form of tobacco, cigarettes, by banning a much safer alternative and causes ill-health by denying this option to smokers.  We disagree with the policy of banning snus and regard it as unscientific, unethical and far more likely than not to contribute to additional death and disease from smoking. This letter briefly explains why there is no justification for the ban, and why many leading experts have called for it to be lifted, for example in a letter from 15 experts to Commissioner Dalli in 2011[2].  Sadly, these well-informed and carefully argued views from public health experts were ignored when the Commission published its proposal for the revised directive in December 2012. In the case of snus, the Department of Health has not followed the logic of its own approach to ‘harm reduction’. The consequence is an unjustified and harmful ban based on a policy-making error made 25 years ago.  We hope this letter is sufficient reason for you to reconsider the issue of the snus ban with an open mind and fresh pair of eyes.

An unjustified ban on snus – misunderstood gateway effects.  Snus has been banned in the EU, other than in Sweden, since 1992.  The original reason for the ban was a fear that it could become a ‘gateway’ to smoking for young people. This risk was only ever hypothetical but the subsequent reality of snus use in both Norway and Sweden shows that it is, beyond doubt, a gateway out of smoking.  Snus is used as an alternative to smoking and as a means to quit. Further, snus is not increasing but rather decreasing onset of smoking in young people.   It is primarily because of snus use that Sweden and Norway have the lowest rates of smoking in Europe, by far.  It is sometimes claimed that snus should be banned because is not 100% safe. However, this misunderstands its impact: the overall effect of snus has been protective and highly beneficial to public health where it is on sale freely.  The original justification for the ban has been overturned by evidence from the real world, and there is now no justification to treat snus differently to any other smokeless tobacco. As with e-cigarettes, there are good reasons to carefully encourage its use as an alternative to smoking for people who cannot or do not wish to quit using nicotine or tobacco. 
Health potential of snus in the rest of Europe.  There has been a remarkable success for public health in Sweden and Norway that deserves more recognition.  According to the most recent Eurobarometer survey[3], adult smoking prevalence in Sweden is just 13%, far lower than the EU average of 28%. Nothing we consume can be 100% safe or pure, but the risks associated with snus use are of the order of 95-99% lower than for smoking[4]. This has resulted in substantially reduced burdens of tobacco-related disease (cancer, cardiovascular disease, emphysema). For example, the rate of lung cancer mortality in Sweden is half that of its neighbour Denmark[5]. Sweden also has significantly lower levels of oral cancer mortality. It is not enough to argue, as the Commission does, that snus is ‘toxic and addictive’: it is a very much less toxic and also less addictive than cigarettes but its effective nicotine delivery still makes it a viable alternative to smoking. This is the well-established idea of ‘tobacco harm reduction’ working for health here in Europe. More data are appended at the end of this letter.
An unethical ban.  When people use snus instead of smoking they are significantly reducing their own health risks, at their own expense, on their own initiative, and with no harm to anyone else.  On what basis can a government justify using the force of European law to prevent them doing this? The consequence, visible everywhere in the European Union outside Sweden, is more smoking and more death and disease than there would otherwise be. Even if a single user somewhere in Britain wished to use it, why should a European Union directive prevent them? Why should the UK wish to prevent someone using it in another country, such as Denmark? We can find no precedent for governments banning much safer alternatives to risky products. This highly irregular policy raises major ethical concerns and implicates the European Union and UK government in causing additional unnecessary harm.

Incoherent tobacco legislation brings the EU into disrepute. The approach to snus policy and legislation rests on a 25-year-old error that officials have refused to accept or correct[6]. There is no credible explanation for why the safest known form of tobacco in the world, snus, is banned when the most dangerous, the manufactured cigarette, is widely available.  No one can explain why smokeless tobacco placed in the mouth and chewed is permitted, but if sucked it is banned. How can a ban be consistent with the principle of free movement of goods, especially when we know the impact of the product is overall beneficial to health where it is not banned? These obvious contradictions disfigure such important legislation. All branches of the legislature have professional and legal obligations to take advances in scientific understanding into account, and this is especially important given the lives at stake.  It is now time face these responsibilities, and to correct the 25 year error behind the ban on snus.
Fixing the snus provisions in the tobacco products directive. There are three main options, which we list in order of preference, with the most strongly justified first.
1.      Treat snus like any other smokeless tobacco. The definitions in the directive can be amended to remove the arbitrary discrimination between snus and other smokeless tobaccos. This would be the simplest and best approach.
2.      Treat snus like a novel tobacco product. Snus products could go through the same process for introduction of novel tobacco products, such as those that heat tobacco, under Article 17 of the proposed directive. Given snus has not been present for at least 20 years outside Sweden, it is reasonable to treat it as ‘novel’.
3.      Allow an exception to the general ban where snus has traditional use. This would allow members states to determine that snus meets a traditional product demand, and to permit it.  
We also advocate a regulatory framework for all smokeless tobacco that would place limits on the toxic contaminants that potentially cause harm. The WHO’s expert group on smokeless tobacco recommended exactly this[7], and the approach is supported by the UK Royal College of Physicians and many other experts. 
There is no scientific, ethical or legal basis to ban snus, and we hope you will reconsider and change your position to support one of the three options listed above. In reality, you would be supporting better health and challenging the dominance of cigarette smoking, which is the most harmful and addictive form of tobacco and nicotine use.

Yours sincerely

Professor Martin Jarvis
Emeritus Professor of Health Psychology
Department of Epidemiology & Public Health
University College London, UK
Professor Peter Hajek
UK Centre for Tobacco and Alcohol Studies
Wolfson Institute of Preventive Medicine
Barts and The London School of Medicine and Dentistry Queen Mary, University of London

Professor Gerry Stimson
Emeritus Professor, Imperial College London; Visiting Professor, London School of Hygiene and Tropical Medicine
Professor John Britton
Professor of Epidemiology, 
Faculty of Medicine & Health Sciences, University of Nottingham

Prof. Riccardo Polosa, MD, PhD
Full Professor of Internal Medicine
Università degli Studi di Catania, Italy

Jacques Le Houezec, PhD
Consultant in Public Health, Tobacco dependence, France
Professor Dr Michael Kunze
Head of the Institute for Social Medicine
Medical University of Vienna
Karl Erik Lund PhD
Norwegian Institute for Alcohol and Drug Research, Oslo Norway
Professor Karl Olov Fagerström PhD
Emeritus Professor of Psychology
President Fagerström Consulting AB
Professor Tony Axéll
Emeritus Professor Geriatric Dentistry
Consultant in Oral Medicine
Dr Lars Ramström
Director Institute for Tobacco Studies
Stockholm Sweden
Clive Bates
Former Director,
Action on Smoking & Health (UK) 1997-2003

Dr Lars Ramström
Director Institute for Tobacco Studies
Stockholm Sweden
Clive Bates
Former Director,
Action on Smoking & Health (UK) 1997-2003


[1]      Secretary of State for Health, Letter to UK MEPs. Proposal for a revised tobacco products directive. September 2013 (undated) [link]
[2]      Axell T, Borland R, Britton J, Fagerström K, Foulds J, Gartner C, Hughes J, Jarvis M, Kozlowski L, Kunze M, Le Houezec J, Lund K, McNeill A, Ramström L, Sweanor D. (2011) Letter to Commissioner Dalli: Advancement of the scientific basis for the EU Tobacco Products Directive, May 2011  [link]
[3]      European Commission, Special Eurobarometer 385, Attitudes of European Citizens to Tobacco, March 2012
[4]      Phillips CV, Rabiu D, Rodu B. Calculating the comparative mortality risk from smokeless tobacco versus smoking. Am J Epidemiol 2006; 163: S189.
[5]      WHO / International Agency for Research on Cancer:  Cancer mortality database. Lung cancer is a good marker for all smoking related diseases as it is mostly (c. 85-90%) attributable to smoking.  
[6]      C Bates, L Ramström, A critique of the scientific reasoning supporting the proposed measures relating to oral tobacco, March 2013 [link]
[7]      WHO study group on tobacco product regulation (2009). Report on The Scientific Basis Of Tobacco Product Regulation: third report of a WHO study group. WHO technical report series; no. 955. WHO, Geneva. [Link]

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