Snus Effect on Newborn Birth Weight: Very Small

Three years ago I discussed several Swedish studies reporting that pregnant women who use snus are at risk for (1) slightly smaller babies and premature delivery and preeclampsia (here); and (2) premature birth and stillbirth (here).  Although the risks were lower than those from smoking, I advised that “pregnant women should refrain from using all tobacco products.” 

A new Swedish study confirms that the effect of snus use on birth weight is small, but the researchers made a gross oversight in their journal article.

The new study was conducted at Lund University and was based on over 900,000 births chronicled in the Swedish Birth Registry from 2002 to 2010.  It looked at the effect of snus use on birth weight with a conventional analysis and with a special analysis in which mothers had used or not used snus during two different pregnancies (a “sibling analysis”).    

Conventional analysis found that snus users’ babies weighed a statistically significant 47 grams (about 1.7 ounces) less than those of never users.  This is approximately the same magnitude found in the earlier study I discussed (here).  However, there was only a 20 gram reduction in the sibling analysis, which was not significant. 

The Lund authors emphasize: “Our findings should not be interpreted as suggesting that the use of snus is a healthier alternative to smoking during pregnancy…”  This might be an appropriate statement, but for the fact that the researchers report no attempt to compare and analyze the data they held on the births experienced by more than 100,000 smokers.

Exaggerating small risks but failing to directly compare smokeless tobacco users with smokers seems to be endemic among many scientists with anti-tobacco leanings.  Datasets from the Karolinska Institute and the American Cancer Society contain risk information for both smokeless users and smokers, but staff at these organizations refuse to report comparable risks for these two groups.

The Lund University study appears in PLoS (Public Library of Science) One (here).  The publisher banned studies funded by the tobacco industry, a policy I labeled as unscientific three years ago (here).

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

   

Tobacco Harm Reduction: Hope in the U.S., Despair in Europe

In my commentary, “The Electronic Future of Cigarettes,” published last week in The Atlantic,  I described “…a radical transformation in the way our society uses tobacco…as tobacco consumers switch to smoke-free products like smokeless tobacco and e-cigarettes.”  One of my longstanding goals has been to correct decades of misinformation about nicotine and tobacco, in order to introduce safer smoke-free products to millions of smokers. 

The Atlantic article, available here and reproduced below, conveys a hopeful message, but optimism in the U.S. is offset by depressing events in Europe.  The British Government two weeks ago decided to regulate e-cigarettes as medicines (here), a move that will likely deter wider e-cig adoption by smokers.  The European Union continues to move forward with its tobacco directive, which denies vastly safer snus to all but Swedish smokers and places further restrictions on e-cigarettes. 

A blistering public health critique of the European Commission, the European Council and the Irish Presidency, the World Health Organization, the European public health lobby and various governmental health organizations is offered by Clive Bates in his recent web post (here).  

The Electronic Future of Cigarettes

Aiming for a tobacco-free society is myopic. Embrace the safer alternative.

Brad Rodu

The Atlantic, June 20, 2013

We are on the cusp of a radical transformation in the way our society uses tobacco. Cigarette consumption is in substantial, protracted decline as tobacco consumers switch to smoke-free products like smokeless tobacco and e-cigarettes.

This isn't America's first large-scale change in tobacco habits; in the early 1900s, cigarettes replaced chewing tobacco. This is, however, the first shift with a promising public health outcome. The reason is simple science: Smoke-free tobacco and nicotine products are around 98 percent safer than traditional cigarettes. 

The evidence has been mounting for a long time. I published my first scientific studies on vastly safer smoke-free cigarette substitutes almost 20 years ago. Britain's Royal College of Physicians, one of the world's oldest and most prestigious medical societies, reported in 2002: "As a way of using nicotine, the consumption of non-combustible [smokeless] tobacco is on the order of 10-1,000 times less hazardous than smoking, depending on the product." The report continued with an even bolder statement, acknowledging that some smokeless manufacturers may want to market their products "as a 'harm reduction' option for nicotine users, and they may find support for that in the public health community."

In 2007, the Royal College challenged governments to consider "...that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved."

Big tobacco companies are already adapting to the demand for smoke-free tobacco. Altria, the largest American cigarette manufacturer, will sell e-cigarettes throughout Indiana in August. Number two Reynolds American believes that "governments, public health officials, tobacco manufacturers and others share a responsibility to provide adult tobacco consumers with accurate information about the various health risks and comparative risks associated with the use of different tobacco and nicotine products." Reynolds sells Snus, a smokeless tobacco product that has produced an extraordinarily low smoking rate in Sweden, under its flagship Camel brand. Reynolds also introduced dissolvable tobacco products, and it owns a pharmaceutical company that sells nicotine gum. In July Reynolds will start selling its Vuse e-cigarettes in Colorado.

Lorillard, the nation's third largest cigarette maker, is taking an aggressive smoke-free posture in the public policy arena as it promotes its Blu e-cigarette brand. Lorillard CEO Murray Kessler wrote, "We see e-cigarettes as a product that has the potential to play a critical role in the national harm reduction discussion and affords our company a seat at the table in this debate."

Sadly, the potential of tobacco harm reduction is threatened by opposition from many major medical organizations and government agencies. Obsessed with a myopic vision of a tobacco-free society, they have transformed a legitimate war on smoking into a moral crusade against tobacco, a mistake that was tragically made with alcohol almost 100 years ago.

Congress has prohibited tobacco marketers from any communication with smokers regarding safer alternatives without the express approval of the FDA. So far, the agency has taken a hard line, claiming, falsely, that, "To date, no tobacco products have been scientifically proven to reduce risk of tobacco-related disease, improve safety or cause less harm than other tobacco products." The agency is defying a key element of its stated mission - "to provide the American public with factual and accurate information about tobacco products."

In an effort to kill the nascent smoke-free market, the FDA is slow-walking development of necessary regulations. In March 2012, it signaled the extraordinary lengths that companies will have to go to in order to have a product accepted as "modified [i.e., reduced] risk. In essence, the agency will require dozens of new studies on minute product details and human effects, which will likely take a decade or more.

This is regulatory fundamentalism, a bureaucratic maze that will condemn e-cigarettes and smokeless tobacco products, and therefore tobacco harm reduction, to purgatory. With this delay, cigarettes will continue to dominate the American tobacco market, and 440,000 more Americans will die from smoking-related disease every year.

One thousand two hundred and five deaths. Every. Single. Day.

The body of highly credible research and roster of public health experts endorsing tobacco harm reduction continues to grow, providing more science-based support for smokers to switch. In the absence of rational FDA regulation, nicotine-addicted smokers would do well to quit cigarettes and avail themselves of the many smoke-free harm reduction products that are currently on the market.

Alternative Tobacco Products Aid in Smoking Cessation

In May Dr. Lucy Popova and Dr. Pamela Ling coauthored “Alternative Tobacco Product Use and Smoking Cessation: A National Study.”  It appeared in the May issue of the American Journal of Public Health (abstract here).

The authors are members of the Center for Tobacco Control Research and Education at the University of California, San Francisco, which is a staunch opponent of tobacco harm reduction.  So it is unsurprising that their conclusions about safer smoke-free products were almost entirely negative:

“Alternative tobacco products are attractive to smokers who want to quit smoking, but these data did not indicate that alternative tobacco products promote cessation.  Unsubstantiated overt and implied claims that alternative tobacco products aid smoking cessation should be prohibited.”

But these data DID indicate that alternative products promote cessation. 

The authors used a Knowledge Network survey in 2011 of 1,836 current or former smokers who quit less than two years before.  The survey asked participants about use of chewing tobacco, moist snuff, snus, dissolvable tobacco and e-cigarettes. 

Drs. Popova and Ling provide the percentages of the 1,527 smokers who had been successful and unsuccessful in quitting and who had used these products, but they either didn’t see or completely ignored these important results:

Successful Quitting Among Knowledge Network Survey Participants, 2011
Product	Ever Users (n)	Percentage Successful Quitters
Chewing tobacco	221	32
Moist snuff	232	29
Snus	205	26
Dissolvable tobacco	44	20
E-cigarettes	323	23
All participants	1,527	28

Over 300 survey participants had used e-cigarettes, and over 200 had used snus, moist snuff or chewing tobacco.  Importantly, a significant percentage of ever users of all smoke-free products were successful quitters. 

Popova and Ling close with this: “Explicit or implied claims that alternative tobacco products are smoking cessation aids should be prohibited in the absence of a body of scientific evidence showing such an effect.”

It is ironic that their paper adds to the body of scientific evidence that smoke-free products are smoking cessation aids.

Note: Thanks to Dr. Joel Nitzkin for noticing this discrepancy.