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.   

Oral Cancer Scaremongering by Public Health Officials

A range of public health leaders, who should know better, have rushed to repeat and, with their stature, endorse the apparently unfounded claim by baseball great Curt Schilling that his mouth cancer was caused by smokeless tobacco.

Claims about cancer causation can significantly influence national health policy; when made by recognized authorities, they should be based on scientific and medical facts.

While I fully sympathize with Mr. Schilling, his claim of causation has no on-the-record support from his medical team. That has not stopped the anti-tobacco establishment from rushing to the media.

In remarks trashing smokeless tobacco, Schilling’s oncologist, Dr. Robert Haddad of the Dana-Farber Cancer Institute, made no comments specifically connecting his patient’s cancer to use of smokeless products.

Regardless, in short order, the FDA Center for Tobacco Products repeated Schilling’s causation claim on Twitter (here), and the presidents of the Massachusetts Medical and Dental Societies (here) and the director of the Arizona Department of Health Services (here) gave it further credence.

I don’t question Schilling’s belief that smokeless tobacco caused his cancer.  However, before endorsing his statements, public health officials should address several points:

1.  Where, specifically, was the “mouth cancer”?  According to this National Cancer Institute monograph (here), almost all cases of mouth cancer attributable to smokeless tobacco occur in the location where it is used.  That is also my experience in 30 years as an oral pathologist.  In addition, the cases of mouth cancer that I have seen are almost always in users of dry powdered snuff, and they occur in the gum-cheek area.  Schilling hasn’t disclosed the location of his cancer, which he blames on moist snuff.  Users of that product are not protected from mouth cancer, but epidemiologic studies show that they are not at higher risk than nonusers.

2.  Other risk behaviors.  It can be uncomfortable, but doctors need to know about all risk factors for oral cancer. Those at higher risk are individuals who smoke and drink, a combination that tends to be associated with cancers in the throat as well as the mouth.  Human papillomavirus infection is an emerging risk factor, especially for throat cancer.  Schilling disclosed that his cancer was discovered as a “lump” in his neck; this presentation is more common with a throat cancer than a mouth cancer.  Schilling hasn’t disclosed information on his other risk factors.

It is inappropriate for the FDA, presidents of medical societies and other public health authorities to blindly endorse unvalidated medical claims.  Hundreds of thousands of former smokers in the U.S. use smokeless tobacco.  Dreading the prospect of getting mouth cancer, they might be motivated by these authorities’ pronouncements to start smoking again, not knowing that the latter significantly increases their mouth, throat and lung cancer risks.  Public health advocates should stick to the facts, not engage in scaremongering.

New England Journal of Medicine Downplays Its Error in Exaggerating Youth E-Cigarette Data

Last week the New England Journal of Medicine inflated a study of mouse brain activity with nicotine into a gateway-to-cocaine claim (here).  This week I report that the journal never properly fixed an error it made regarding e-cigarette use among children.

I reported on April 9 that “the New England Journal of Medicine and authors of a commentary on e-cigarette use ignored our call for correction of a substantial error regarding e-cigarette use among American schoolchildren in 2011 and 2012.” (here). 

The following day, Dr. Fairchild, first author of the commentary and professor of sociomedical sciences at Columbia University, emailed me: “We have, in fact, been talking with NEJM about the graph. I’ll let you know what happens.” 

No further communication was received from Dr. Fairchild, but on June 12 the journal published its idea of a correction in the form of a revised bar chart, which appears on the left.  The revision involved changing a stacked bar chart to a side-by-side chart, with the entirely insufficient note that “some students may have been included in both categories.” 

May have been?  It is clear from the CDC reports (here and here) that the original article double-counted a large number of dual users of both e-cigarettes and cigarettes.  The journal should have corrected the error by issuing a chart we provided (the larger chart at left), illustrating the huge proportion of dual use. 

Why did the journal “revise” the presentation of data, rather than acknowledge and correct a significant error regarding dual use of e-cigarettes and cigarettes among American youth?  One could conclude that an anti-tobacco bias overrode standard editorial policy.

NEJM Irresponsibly Damns E-Cigarettes as Gateway to Cocaine, Based on Mouse Nicotine Studies

The New England Journal of Medicine today published an incendiary anti-e-cigarette article that tags nicotine as a gateway to cocaine use… in mice.  It’s another sad day for tobacco truth.

The authors are Drs. Denise and Eric Kandel, the latter a Nobel Prize-winner for his work on the physiological basis of memory storage in nerves.  Since 1975, Dr. Denise Kandel has aggressively promoted a gateway theory that adolescent use of legal drugs like alcohol and tobacco causes use of illegal drugs, starting with marijuana and progressing to cocaine and heroin.  The theory is highly contested among addiction research and policy experts because it is not supported by human studies.

The NEJM presents the Kandels’ laboratory data on how nicotine and cocaine affect the mouse brain at the cellular and molecular level.  Their experiments involved force-feeding nicotine to and injecting cocaine into mice.  Post-mortem studies on the rodent brains led the authors to conclude that nicotine/tobacco causes cocaine use. 

Following a nine-page technical discussion of their research that made no mention of e-cigarettes, the authors inserted a concluding three paragraphs claiming that smoking, vaping and even passive smoke are gateways to cocaine. 

In a crass attempt to heighten interest in the publication, the Kandels and the NEJM offered the media a press release with an attention-grabbing e-cigarette-bashing headline and inflammatory quotes that exceed and distort the authors’ scientific work.  

Shame on all parties for allowing marketing to trump the truth.