The Swedish Snus Experience Isn’t Finnished

Despite the wealth of evidence demonstrating that snus has helped thousands of Swedish men and women avoid the ravages of smoking, the European Union continues to enforce an irrational ban on snus beyond Sweden’s border. 

I have documented that smoking deaths in Sweden are significantly lower than in all other EU countries (here and here).  A new study clearly demonstrates the differences in smoking rates when snus is available and when it is banned (abstract here).

Snus has been popular in Sweden for 200 years, but it was also used in neighboring Norway and Finland.  In 1995, Sweden and Finland joined the EU.  Sweden applied for and received a waiver on the EU’s existing snus prohibition, thereby allowing Swedes to continue producing and selling within the country.  In contrast, Finland accepted the ban, denying its snus consumers a legal source.  Norway never joined the EU, so snus remained available.

Dr. Jennifer Maki, an economist with the Center for Healthcare Economics and Policy, compared the smoking rates in these three countries before and after 1995.  Maki's figure above shows the rates among men in Sweden and Finland.  Clearly, a decline in smoking levels off in Finland after 1995, while the decline in Sweden continues, despite the fact that it was far lower over the entire period.  As Maki writes, “…in the post-ban period, smoking increased in Finland by 3.47 percentage points relative to Sweden…this estimate can be interpreted as an increase in the smoking rate [in Finland], relative to what it would have been, in the absence of the ban.”

The comparison of Finland and Norway, seen in Maki's chart on the left, also shows the effects of snus use on smoking.  According to Maki, “the smoking rate [decline] in Norway is similar to that in Finland prior to 1995, after which point the rates diverge. Using Norway in place of Sweden as a control produces a result similar to, but not as drastic as, [the Swedish comparison].”

Maki’s conclusions illustrate the impact of snus in Sweden, the impact of the snus ban in Finland, and the utter failure of EU policy:

“The smoking rate among Swedish males is remarkable [sic] low, and continues to decline; given Sweden’s low smoking rate pre-1995, the ability to achieve further reductions post-1995 is notable… The findings presented in this paper provide support for the viability of a harm reduction approach to smoking cessation and suggest that the Swedish Experience could be replicated elsewhere… It may have been underway in Finland prior to the implementation of the ban.  These results are not only meaningful within Finland, but may be applicable to the entire EU.”

Note: I am especially proud of Jennifer’s contribution.  She contacted me when she was a doctoral student at North Carolina State University; I provided materials on tobacco harm reduction, reviewed and critiqued early versions of her thesis and helped her search for Swedish and Finnish datasets.  Her mentor, Professor Barry Goodwin, sponsored my guest lecture at NC State, and I hosted a visit by Jennifer to the University of Louisville so that she could present her work.   

What the EU Snus Ban Means: 290,865 Casualties Per Year

A November 12 e-cigarette summit at the Royal Society in London featured a range of views on European prospects for these new products (information here). 

Tobacco harm reduction proponents included Clive Bates, Robert West, Jacques Le Houezec, Konstantinos Farsalinos, Jean Francois Etter and Antoine Flahault.  One presenter summarized the Swedish experience with snus as population-level proof that safer smoke-free products save lives.  He used my published study (abstract here) showing that there were 172,000 deaths from lung cancer – the sentinel disease of smoking – in the European Union in 2002.  If all men in the EU had smoked like Swedes, there would have been only 80,000 lung cancer deaths.

A summit attendee asked if I could update that analysis with more recent data.  In fact, the World Health Organization and the International Agency for Research on Cancer now have 2009 lung cancer mortality information for 27 of the 28 EU countries (Cyprus is the only exception).  I have calculated the number of lung cancer deaths among men that would have occurred at Swedish smoking rates for all of these countries.

Sweden’s lung cancer rate is still the lowest in the EU by a long shot, at 68 deaths per 100,000 men age 45+ years.  Finland’s is the next lowest at 102, which is interesting because snus is still used in some parts of that country, despite its prohibition.  In contrast, Hungary and Poland have the highest rates, at 278 and 222 respectively.

For perspective, two non-EU countries are worth mentioning.  The lung cancer mortality rate in Norway, where snus has contributed to reduced smoking (discussed here and here) was 121, which would have been fourth in the EU. The rate in the U.S., where tobacco harm reduction has been trashed by prohibitionists, was 138, which would have placed it tenth, behind Sweden. 

In the EU, the 2009 Swedish lung cancer rate was 12% lower than in 2002.  This is consistent with declines in most countries’ rates, ranging from -3% in Hungary (from 287 in 2002 to 278 in 2009) to -20% in Estonia (from 227 to 181) and Malta (from 158 to 126). 

While the declines may appear modest or even impressive, the lung cancer death toll among European men of 183,423 is intolerable.  The EU continues to ban snus everywhere except Sweden.  The price for this appalling policy: 99,086 avoidable lung cancer deaths per year, plus more from other smoking-related diseases.

Considering that 91% of lung cancer deaths are attributed to smoking, and lung cancer accounts for only 31% of all smoking-attributable deaths among men in the EU, the toll from smoking among men in these EU countries is 538,435.

At the Swedish rate, the toll would be 247,570.  That makes the net cost of the EU snus ban 290,865 deaths (assuming that all EU male smokers would adopt snus as successfully as Swedish males).

Recently the European Parliament voted on a new tobacco directive; the results make smokers both losers and winners.  Parliament continued the snus ban but struck down a provision that would have suppressed e-cigarette access.  As Clive Bates noted (here), “…the snus ban tells us that evidence, analysis and even concern for human life are not always that influential in way the EU makes policy.”     

The EU snus ban is indefensible and immoral. 

Lung Cancer Mortality Rates*, Numbers of Deaths, and Numbers Expected at Swedish Rates Among Men 45+ Years in 27 European Countries, 2009
Country	Rate*	Deaths	Deaths at Swedish Rate
Austria	120.3	2,360	1,334
Belgium	176.8	4,851	1,866
Bulgaria	157.8	2,633	1,135
Croatia	213	2,153	687
Czech Republic	176.7	3,950	1,520
Denmark	129.8	1,859	974
Estonia	180.6	475	179
Finland	102	1,426	951
France	152.9	21,983	9,777
Germany	126.8	28,839	15,466
Greece	176.6	5,280	2,033
Hungary	277.8	5,605	1372
Ireland	124.4	1,055	577
Italy	139.8	25,146	12,231
Latvia	192.5	833	294
Lithuania	188.6	1,139	411
Luxembourg	145.7	154	72
Malta	126	124	67
Poland	221.8	16,250	4,982
Portugal	105.3	2,646	1,709
Romania	182.7	7,528	2,802
Slovakia	167.6	1,567	636
Slovenia	157.5	723	312
Spain	157.9	17,061	7,347
Sweden	68	1,820	1,820
The Netherlands	156.8	6,368	2,762
United Kingdom	120.9	19,595	11,021
All		183,423	84,337

*Deaths per 100,000 men per year, age-adjusted to the World Standard Population.
Note: Croatia was not an EU member in 2009.  

Censorship by the Norwegian Health Directorate

Global health authorities have zero tolerance for tobacco use. Worse, they have zero tolerance for any rational discussion of tobacco harm reduction. 

Last year, the health directorate of Norway, which, like Sweden, has benefitted from snus-driven tobacco harm reduction (discussed here and here), removed an invited commentary from the Norwegian Health Directorate’s prevention website, http://www.forebygging.no/ .

The commentary was written by Dr. Lars Erik Rutqvist, former professor at the Karolinska Institute and now senior vice president for scientific affairs at Swedish Match.  He is a highly respected Swedish scientist and expert on tobacco harm reduction.

In April 2012, a column by Dr. Rutqvist on using snus as a means to quit smoking appeared in the Norwegian national newspaper Aftenposten.  Subsequently, the Health Directorate invited him to write an expanded piece, which they published on their prevention site in June.  Two months later, the piece was erased from the site.   

Dr. Rutqvist described the obvious censorship in an interview with a Norwegian financial newspaper in September:

“I got a call from the [prevention website] editor who explained that the Norwegian Directorate of Health wanted the article removed.  I`ve been working with research and have written debate contributions for many years. Never have I come across anything like this. It is quite strange for the Directorate of Health to censor what a specialist website regards as good.”

The Health Directorate’s censorship is appalling.  I asked Dr. Rutqvist for an English translation of his blacklisted commentary.  It is outstanding and deserves wide circulation.  It appears unedited below.

Sacrificing lives for the sake of morals

Opponents of snus are dominating the Norwegian snus debate by manipulating facts, which are shoddy at best and fatally immoral at worst.

Discussion of snus in Norway is characterised by a debate where the end justifies the means and where the facts are manipulated to make snus look far more harmful than it is. In this debate there are several key questions: Is snus carcinogenic?  Can snus help people stop smoking?  Is it immoral to recommend snus to those who want to give up cigarettes?

One example: The usually meticulous Norwegian Institute of Public Health recently issued a report claiming that using snus as an adolescent increases the likelihood of starting to smoke.  The basis for this was an interview of adolescents first in 2001 followed by another interview in 2004, the purpose of which was to track how their habits evolved.  Of the only 90 (!) persons that the Institute chose to present as a representative sample to draw conclusions from regarding snus, 25 had started to smoke casually.  Almost just as many – 22 – had quit snus altogether.

So, you could just as easily conclude that it is just as likely for snus users to quit snus as it is for them to start smoking – yet this is not stated in the report.

When, added to that, there is so small a sample such a categorical conclusion can only be politically motivated.  Besides, there are a number of reports, including from SIRUS [Norwegian Institute for Alcohol and Drug Research] and the EU [European Union], that conclude that snus is the way out of smoking, and not the way in.

Is snus carcinogenic?

The reason why snus is so controversial is that it contains tobacco, among other things. Tobacco in itself is so negatively charged that just discussing it is a problem. Few to none of the Norwegian politicians or experts want to appear overwhelmingly positive about snus, so those who are after banning it often get to dominate the arena by playing with the facts.

Let’s look at some facts: Snus is a pleasure product, and should be used in moderation. Nicotine in all forms, meaning snus along with pharmaceutical products containing nicotine, should be avoided during pregnancy.  There is scientific agreement that nicotine affects the development of the foetus.  It is also a known fact that nicotine affects blood pressure.

On the other hand, the existence of a connection between snus and cancer that is supported by science is nothing but a myth.  On the contrary, the past 30 years of research shows that it is the burning process in cigarette smoke that causes the well-documented relationship between cigarettes and cancer.  There is no burning involved in the process of using snus, which is why snus gives no indications in generally accepted lab tests that measure cancer risks associated with chemical substances.  Neither have epidemiological studies been able to conclude any real increase in the risk of any form of cancer, including oral cancer, cancer of the oesophagus or pancreatic cancer.  Yet despite the lack of a scientific basis, snus opponents gladly shout about cancer risks, most probably because just the word ‘cancer’ is enough to stir up negative associations.

Although there are traces of substances classified as carcinogenic (such as nitrosamines) in the tobacco used in snus, the levels are so far below WHO’s [World Health Organization] recommended limits that snus is not so different from any of the usual food products for which the regulating authorities have specified values in terms of undesired substances.

That some epidemiological studies have indicated a marginal increase in risk for snus users fails to establish a pattern, and goes further in proving randomness or methodical errors than anything else.  It is a huge problem that in a number of these studies, the effects of smoking are confused with the alleged effects of snus use.

One of the reasons for this is that a number of snus users today have previously been smokers.  If any of them gets cancer, is it because of smoking or is it because of snus?  Because the risk of cancer from smoking can manifest itself long after you’ve quit, it is easy to mistakenly see snus as the cause.

There is therefore a huge gap between what is presented as fact in Norway, and the results we’re finding through scientific studies.

In June this year, the Norwegian scientist and doctor, Tom K. Grimsrud said to the Cancer Registry for women’s portal, Kvinneguiden:

“…Based on what we know today, snus seems to have many of the same harmful effects as smoking.”

And Professor Maja-Lisa Løchen went even further to say to VG in April: “…Snus also increases the risk of dying of a heart attack, and the risk of three serious forms of cancer; oral cancer, cancer of the oesophagus and pancreatic cancer.  The risk of getting these types of cancer is almost the same as if you smoke…”

These claims are so grossly misrepresentative and false that Grimsrud and Løchen appear to be completely ignorant of the scientific literature available on the subject.  In the scientific community it is generally known that snus is at least 90 per cent less harmful than cigarettes, as determined by the EU’s own health authorities, SCENIHR [Scientific Committee on Emerging and Newly Identified Health Risks] and the Royal College of Physicians in London.  Any real connection with oral cancer, cancer of the oesophagus and pancreatic cancer cannot be found if looking at cumulative research in the field, and not just presenting marginal risk increases from a few studies, which seems to be Løchen’s modus operandi.  At the same time, it is quite clear that snus does not result in any increased risk for heart attacks.

Yet despite the scientific facts, snus opponents keep on talking about the conceivable health risks.  Such allegations ironically enough lead to more people continuing to smoke, in essence - the exact opposite of what we want.

What does science say?

Already as far back as 2001, SCENIHR concluded that snus is not carcinogenic and that there is no connection between Swedish snus and oral cancer.  The same conclusion was carried forward in 2008.  This conclusion was also the basis for removing the cancer warning from snus boxes in 2003.

The alleged connection between smoke-free tobacco and pancreatic cancer was rejected in 2011 by a major international study composed of a team of renowned scientists from 12 different universities (PanC4).  The team claimed that earlier Scandinavian studies, whose purpose it was to prove a connection, had not conducted their analyses in a scientifically correct manner which compromises the results of those studies.

This rejection was no great surprise, because the claim is based on an old study which proposed a marginal increase in a rare form of cancer among a group of smokers and snus users.  This could also help explain the Swedish results since there is a clear connection between smoking and pancreatic cancer.

Still, in the debate it is often stated that WHO has classified snus as a carcinogen.  This is an extreme case of oversimplifying the facts.  It is correct that WHO finds there to be a connection between smoke-free tobacco and cancer; nor is this any big surprise.  Several African and Asian varieties of smoke-free tobacco, which have far more users than the Swedish variety, are extremely carcinogenic.  The concentration of certain chemical substances can be thousands of times the levels found in Swedish snus, which are currently well below WHO’s recommended levels.  Several of the Indian and African smoke-free products contain highly carcinogenic substances that are not found in Swedish snus.

The simple truth of the matter is that the uniquely low levels of undesired substances in Swedish snus have been put forward in scientific reports, including from WHO, as an example of what it is possible to achieve if you want to make a product of the highest possible quality and the lowest possible risk.

Can snus help people stop smoking?

So, when you know how much less harmful Swedish snus is compared to cigarettes, it begs the question: Can snus be an effective way to get people to stop smoking?

In 2008, 30 per cent of Norwegian youth in the 16 to 24 age group were smokers, of which 16 per cent were regular smokers.  According to Statistics Norway, currently 11 per cent of this group are smokers.  This positive trend can naturally be attributed to the fact that knowledge of the harmful effects of cigarettes has become a matter of course for youngsters.  But, this picture is complemented by snus.  Because in the same period this age group also shows an increased use of snus; from 11 per cent being daily users in 2008 to 18 per cent in 2011.

Regardless of personal beliefs about snus; if this trend continues fewer are at risk of contracting lung cancer and other cigarette-related forms of cancer in Norway.

It is also interesting to observe that tobacco habits in Norway today are evolving in the same way as they did in Sweden in the 70s.  Total consumption remains constant, but the way in which tobacco is used is changing.  Snus is growing in popularity while smoking is shrinking.  Swedish men, which represent the largest group of long-term snus users, have among the lowest occurrence of cancer in Europe.

In science, replacing smoking with snus is called “Harm Reduction.”  You continue to use nicotine but reduce its harmful effects.  Some find this to be immoral.  Their utter hatred for anything and everything called tobacco blinds them to finding effective alternatives for reducing the impact on public health that the fatal cigarette represents.

Both observational studies and controlled clinical trials show clearly that snus is an effective means to stop smoking.  The same is confirmed by studies conducted by SIRUS in Norway.  Snus is the most commonly used product to stop smoking, perhaps exactly because it is not made as a pharmaceutical NRT [nicotine replacement therapy]?  An observational study by SIRUS from 2012 showed 45.8 per cent of men below [age] 45 who had used snus in their last attempt to quit smoking were currently non-smokers.   Of those that had used NRTs only 26.3 per cent were currently non-smokers.

What is morally correct?

As an oncologist with years of experience in cancer care and researching the harmful effects of tobacco, it is a pleasure to know that snus, which is far less harmful, is getting a foothold at the expense of cigarettes.  I myself stopped smoking with the help of snus, and recommended it to patients when all other methods had failed.  If all the tobacco that is smoked today was consumed in the form of snus, tobacco would cease to be a public health issue of any great import.  If you in addition have personal experience with the harm caused by smoking, it becomes a simple ethical choice – even for a doctor.

Moralism rules the debate on snus.  Let it be said.  The healthiest option is to abstain from tobacco altogether, but to deny that snus can help so many smokers to a better life is no moral high ground.

It is much rather fatally immoral.

Lars Erik Rutqvist
Cancer Specialist and Research Advisor for snus, Swedish Match