New IARC monograph on smokeless tobacco

The latest report from the International Agency for Research on Cancer (IARC) was released at the end of 2007. (downloadable – though very large - at: ). This report is based on the opinions of an expert working group that met in Lyon, France in October, 2004. It is not clear why it took over 3 years for the report to become available, but one consequence of that delay is that some of its content (relating to Swedish snus) is already out of date and has been contradicted by subsequent evidence. However, the neutrality and balance of the report itself appears to have been undermined from the start, as indicated by some of the self-contradictory statements contained in it.

For example, on p35 in the intoductory remarks to the report it states:

“Some health scientists have suggested that smokeless tobacco should be used for smoking cessation, and claim that its use would reduce the smokers exposure to carcinogens and risk for cancer. They also attribute declines in smoking in Sweden to increased consumption of moist snuff in that country. However, as discussed in volume 1 of the monograph on smokeless tobacco, these claims are not supported by the available evidence.”

However, the section of the report that reviews the evidence (available in 2004) on snuff use in Sweden ends with the following sentence (p174):

“These findings suggest that snuff use may be associated with smoking cessation among Swedish men but not women.”

Later on in the monograph (p153) it gives another view of the relationship between snuff use and smoking in Sweden:

“ The exact role that snuff has played in reducing the prevalence of smoking in Sweden is unclear, but it has probably been overstated (Tomar et al. 2003).”
(Tomar was one of the IARC report authors).

But now that the report has been released in 2008, we have much more evidence on the relationship between snus use and non-smoking in Sweden, showing that it was unfortunately understated by the IARC expert group. Since 2003/4 (1) there have been subsequent publications that have confirmed that in Sweden, men who start using snus are less likely to become daily smokers, that men who smoke and then start using snus are more likely to stop smoking, and that a higher proportion of men than women in Sweden have quit smoking, with the difference largely attributable to snus use (2,3). It had previously been suggested that the men who quit smoking in Sweden are not the same ones who start using snus (and that snus use is therefore not involved in men quitting smoking) (4). However, studies have now verified that in fact a sizeable proportion (26-30%) of Swedish men who quit smoking use snus as a smoking cessation aid (2,5,6). The latest report found that 30.4% of Swedish men who quit smoking from 2000-2004 did so by switching to snus (compared to 14.8% who quit by using NRT) (6). In northern Sweden, where smokeless use is most prevalent, daily smoking prevalence among male 25-34 year-olds is down to 3%, while daily snus use is 34% (7).

It is now crystal clear (and was fairly clear in 2003) that their transfer of nicotine dependence onto snus has accelerated the rate of decline of smoking among Swedish men in substantial numbers. That transfer from an extremely harmful form of tobacco use (cigarette smoking) to a much less harmful form (snus) has contributed to a reduction in the rate of smoking-caused diseases in Swedish men. Of 100 geographic units (primarily countries) in Europe, Swedish men now have the single lowest rate of lung cancer, and less than a half of the rate of lung cancer in the rest of Europe (IARC).

1. Foulds J, Ramstrom L, Burke M, Fagerstrom K. The effect of smokeless tobacco (snus) on public health in Sweden. Tobacco Control 2003; 12:349-59.
Pdf available at:

2. Ramström LM, Foulds J. The role of snus (smokeless tobacco) in initiation and cessation of tobacco smoking in Sweden. Tobacco Control 2006 Jun;15(3):210-4.
Pdf available at:

3. Furberg Furberg H, Bulik C, Lerman C, et al. Is Swedish snus associated with smoking initiation or smoking cessation? Tob Control.2005; 14:422-424.

4. Tomar SL, Connolly GN, Wilkenfeld J, Henningfield JE. Declining smoking in Sweden: Is Swedish Match getting the credit for Swedish tobacco control’s efforts? Tobacco Control2003; 12:368-59

5. Gilljam H, Galanti MR. Role of snus (oral moist snuff) in smoking cessation and smoking reduction in Sweden. Addiction 2003;98:1183-9.

6. Lindström M. Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden. Tob Control. 2007 Dec;16(6):410-6.

7. Stegmayr, B., M. Eliasson, and B. Rodu, The decline of smoking in northern Sweden. Scand J Public Health, 2005. 33(4): 321-4

For further information on smokeless tobacco check out:
Marlboro Snus: what is it? 6/10/07

Why did Philip Morris’s new smokeless tobacco product (“Taboka”) deliver almost no nicotine? 6/12/07

Carcinogens from smoking and smokeless tobacco use (1). 8/27/07

Smoking, smokeless tobacco and cancer (2). 8/28/07
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About the Author

MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.