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A group of internationally renowned nicotine and tobacco experts including our Chair, Gerry Stimson, have written to the Swedish Government asking it to present the evidence on the opportunity that snus represents, to reduce the harm of tobacco smoking:
Snus and Sweden’s unique responsibility and opportunity
We are writing as independent public health specialiststo noteone of Sweden’s great health successes and indicate the urgency to communicate this internationally. That success is the widespread use of low‐risk oral tobacco (snus) to quit smoking and as an alternative to high‐risk tobacco in cigarettes. To external observers, Sweden has achieved notable success in reducing tobacco-related harm.
Given its contribution to better public health in Sweden, evidence-based information on snus should be shared. States which have ratified the WHO Framework Convention on Tobacco Control gather soon at the biennial Conference of Parties (COP7) in New Delhi, November 7-12, 2016. This is an opportunity for the Swedish government delegation to lead the discussion onpractical ways of further reducing the harms caused by smoking cigarettes.
Sweden’s unique health success. Swedenhas the lowest rate of smoking in Europe at 11%, compared with the EU average of 26% [1]. The recent UK Royal College of Physicians report [2] notes the contribution of snus to reducing smoking prevalence in Sweden. The mortality attributable to tobacco among men is lower in Sweden than in any other EU Member State and the use of snus has been an important contributor to this situation [3,4]. The risks associated with snus are of the order of 95% to 99% lower than for smoking, hence the reduced burden of tobacco related disease (cancers, COPD, cardiovascular disease).
Tobacco harm reduction. Snus is a popular and acceptable alternative to smoking tobacco among Swedish men. It is a proof of the concept that safer nicotine products are attractive to smokers, and that tobacco harm reduction approaches have a significant role to play in helping people to switch from smoking, or to avoid smoking in the first place. It complements other tobacco control initiatives. Data from Norway show similar health gains since snus has become popular [5].
Harm reduction is mandated in the Framework Convention on Tobacco Control.Three separate strategies are mandated in the English original of FCTC Art 1d [6] which states that “tobacco control” means a range of supply, demand and harm reduction strategies’. So far, Harm Reduction has been neglected by the WHO FCTC secretariat and member states. Promoting complete bans on smokeless products and other nicotine products, or overly restricting and regulating them, as seems to be the current ambition of the COP/FCTC, will cause harm instead of reducing harm.
Swedish snus can be produced at a fraction of the cost of other reduced risk nicotine products such as e-cigarettes. This indicates the very large potential for this intervention to reduce smoking in Low and Middle Income Countries. It isregrettable that at the last Conference of the Parties in 2014 (COP6), Sweden signed a declaration that incorrectly equates the dangers of Asian and Africansmokeless products (which can pose serious health risks though less than those of smoked tobacco)with the significantly saferSwedish snus.
As external experts we are surprised by the reluctance of the Swedish government to acknowledge the contribution of snus to improving public health. It is in the interest of public health to provide accurate information to smokers that if they switch to snus, they will dramatically reduce risks to their health [3]. We encouragethe Swedish medical communities and the Public Health Agencyto publicise the Swedish experience and encourage the Swedish government at COP7 to present the evidence that snus represents animportant and possibly unprecedented opportunity to reduce the toll of smoking related death and disease.
Despite current tobacco control efforts, smoking is increasing globally. The Swedish government has the opportunity in New Delhi to show that there are effective and acceptable alternatives that can be used to help bring about an end to smoking.
References
[1] Eurobarometer (2014) Special Eurobarometer 429. Attitudes of Europeans towards Tobacco (Published May 2015)
[2] Royal College of Physicians (2016) Nicotine without smoke: Tobacco harm reduction
https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0
[3] Gartner CE, Hall WH, Vos TH, Bertram MY, Wallace AL, Lim SS (2007) Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet, 369: 2010-2014. 10.1016/S0140-6736(07)60677-1.
[4] RamströmL, Wikmans T (2014)Mortality attributable to tobacco among men in Sweden and other European countries: an analysis of data in a WHO report,Tobacco Induced Diseases, 12:14
[5] Lund I, Lund KE (2014) How Has the Availability of Snus Influenced Cigarette Smoking in Norway? Int J Environ Res Public Health. 2014 Nov; 11(11): 11705–11717.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245639/
[6] World Health Organization (2005) Framework Convention on Tobacco Control http://www.who.int/fctc/treaty_instruments/en/
Authors
Anders Milton
Past Chair of the Swedish Medical Association and the World Medical Association, past President of the Swedish Red Cross and the Swedish Confederation of Professional Associations, Stockhol, Sweden
Gerry V. Stimson
Emeritus Professor, Imperial College, London; Honorary Professor, London School of Hygiene and Tropical Medicine, United Kingdom
Ron Borland
The Nigel Gray Distinguished Fellow in Cancer Prevention at The Cancer Council Victoria, Australia
Karl Fagerström
Principal Investigator, Fagerström Consulting, Helsingborg, Sweden
Coral Gartner
Senior Research Rellow, The University of Queensland, School of Public Health, Brisbane, Australia
Martin Jarvis
Emeritus Professor,Department of Epidemiology and Public Health, University College London, UK
Lynn T. Kozlowski
Professor of Community Health and Health Behavior, School of Public Health & Health Professions, University at Buffalo, State University of New York, USA
Jacques Le Houezec
Consultant in Public Health, Tobacco dependence, Rennes, France
Karl E Lund
Research Director - Tobacco, Department of Substance Use, Norwegian Institute of Public Health, Norway
Lars Ramström
Principal Investigator, Institute for Tobacco Studies, Täby, Sweden
David Sweanor
Adjunct Professor, Faculty of Law, University of Ottawa; Centre for Health Law, Policy & Ethics, University of Ottawa; Honorary (Consultant) Assistant Professor, University of Nottingham. UK; Legal Counsel, Non-Smokers’ Rights Association, 1983-2005. Canada
Peter Hajek
Professor of Clinical Psychology
Queen Mary University of London, United Kingdom
Jean-François Etter
Professor of Public Health, Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland
David Nutt
Professor, Edmund J Safra Professor ofNeuropsychopharmacologyHead of the Department ofNeuropsychopharmacology and MolecularImagingImperial College London,United Kingdom
Riccardo Polosa
Professor of Internal Medicine, Director of the Institute for InternalMedicine and Clinical Immunology,University of Catania, Italy
Konstantinos Farsalinos
Onassis Cardiac Surgery Greece, Department of Pharmacology, University of Patras, Greece
Clive Bates
Director, Counterfactual Consulting Limited; Former Director Action on Smoking and Health UK (1997-2003), London, United Kingdom
Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.
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NNA snus ban challenge - update May 2017
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