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
mb-sofs@dh.gsi.gov.uk
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
|
Notes
[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.
