Swedish Snus: A Reply to Professor Tomar

Professor Scott Tomar (University of Florida) has made a couple of comments to my January 10th posting about the IARC report on smokeless tobacco. As these require a slightly lengthier response than a brief comment, I’m doing it here.

Dr Tomar presented some data showing the quit ratio for specific age groups of ever smokers (including ever occasional smokers). The age groups stop at age 64. My view is that snus availability has helped addicted (i.e. daily) smokers to quit. I doubt it would make much difference to occasional smokers, many of whom can quit if they want to without the need to use snus or NRT. That’s why most of those analyzing this issue have focused on daily smokers. In the Swedish government’s most recent report on tobacco use (2007) on p34 there is a diagram (#10) that presents data on the quit ratio by age and gender, based on ever daily smokers. The quit ratio is similar for men and women up to age 54 (around 30% in 2004-5). Thereafter there are large differences e.g. 50% of 65-74 year-old male ever daily smokers have quit, compared with 29% of female ever daily smokers.

So why the similar quit ratios below that age? In some respects women are not a perfect “control” or comparison group as they experience certain sex-specific life events in their younger years that men don’t (e.g. pregnancy) that are frequent triggers for quitting. Another factor is that across the age range female smokers tend to have a lower cigarette consumption. In the late 70s and early 80s Swedish men had a consistently higher smoking prevalence than women, and over the past 15 years Sweden is the only country in Europe to have male smoking prevalence consistently lower than women. Sweden is also the only EU country where snus can be legally sold and 24-30% of male ex smokers have quit smoking by switching to snus. I interpret this as evidence that snus has helped many Swedish smokers to quit smoking. This really shouldn’t be very surprising as NRT helps people to quit smoking, and snus contains the same active ingredient as NRT, but delivers it in higher quantities (nicotine) and is used for a longer time. This isn’t rocket science.

I’d also like to address the last point in Dr Tomar’s comment in which he stated that he is trying to reconcile my public statements that:
(a) Clinicians should NOT recommend that their patients who smoke try using smokeless tobacco to quit , and
(b) castigate the public health community for not promoting these products (snus) for harm reduction.

The statement (a) above is an accurate representation of my position. However, statement (b) is entirely inaccurate. Many members of the public health community see the potential for snus to have a positive impact on public health by competing with a far more dangerous product: cigarettes. In deed, this was proposed for further exploration in the recent Royal College of Physicians report (and the RCP has a good reputation on getting it right on the science of tobacco and health). I have never suggested that the public health community should “promote” smokeless tobacco. That is not our job. What I have criticized is the banning of a much less harmful product while giving the most dangerous product (cigarettes) a monopoly in the tobacco market in those countries (e.g. Australia or the EU apart from Sweden). Similarly, I have criticized members of the public health community who have misinformed the public by suppressing valid comparisons between the health risks of smoked and smokeless tobacco, or by giving inaccurate statements about the relative harmfulness of cigarettes and smokeless products like snus. I believe that the most basic requirement of public health workers is to provide the public with the most accurate information on the relative risks of competing behaviors or products. When we misinform the public we invite criticism and deserve it.

As an example, former U.S. Surgeon General Carmona (who was an excellent Surgeon General and leader in public health) gave testimony to congress in 2003 including the following statements:

“I cannot conclude that the use of any tobacco product is a safer alternative to smoking”

“There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes”

“smokeless tobacco is not a safer substitute for cigarette smoking.”

Each of these statements misinformed the public (and Congress) about the relative risks from smokeless tobacco and smoking cigarettes. It is entirely accurate to say that smokeless tobacco is not safe, that it can cause various diseases and that it is better to quit smoking completely without using smokeless tobacco. It is simply false to say that smokeless tobacco is not safer (or less harmful) than smoking. Two of the major causes of death from smoking are lung cancer and chronic respiratory disease and neither are caused by smokeless tobacco. Again, this is not rocket science.

So I am surprised that Dr Tomar is claiming that I have castigated the public health community for not promoting smokeless tobacco. This is a misunderstanding on his part. Just to be clear about this, here are some quotes from an article that Professor Lynn Kozlowski and I published in the Lancet in 2007, in response to another paper in the same issue that:

“ challenges the wisdom of bans on snus where cigarettes are widely used and also encourages public health professionals to disclose accurate health information on the relative risks of snus as compared with cigarettes. We are not suggesting that clinicians should advise their smoking patients to switch to snus, where safe and effective medications are available to treat cigarette dependence. Nor do we agree with Gartner et al’s suggestion that health departments should promote snus. On the contrary, we recommend that clinicians advise their smoking patients on more flexible ways to quit smoking using existing approved medicines, rather than snus.”

The rationale for this was described as follows:

“Public health is largely determined outside of clinical settings. Price, advertising, legal restrictions and availability of alternatives all have a large influence on health behavior. Public policy should aim to strongly discourage highly dangerous behaviors, and provide appropriate information and warnings regarding lower risk behaviors.”

Our main point was that:

“It is a perverse public health policy that makes an addictive drug widely available in its most harmful form, yet bans or fails to properly inform consumers of availability of that drug in a much less harmful form (for both the consumer and those around them)15.”

The basis for my position on Swedish snus is also described in three published papers that can be downloaded directly from the following link (Foulds et al, 2003; Ramstrom and Foulds, 2006 and Chapter 8 of the 2007 Royal College of Physicians Report):

It may be surprising or confusing for members of the public to see two so-called “experts” review similar data but come to such different conclusions. In fact this is more common than you might think. It doesn’t mean that we are both wrong or that we don’t respect each other’s opinions (Professor Tomar is one of the leading experts on oral public health in the country). It just means that we take a different perspective on the data – partly based our personal experiences and backgrounds. Professor Tomar’s background is as a dentist and public health specialist in the United States. He will have seen smokeless tobacco users who developed oral cancer, which is a truly horrific disease. In the United States he has also observed the leading smokeless tobacco manufacturer aggressively market its addictive product to young people. My background is as a clinical psychologist working in smokers clinics in Europe and observing many addicted smokers fail to quit and subsequently die of smoking caused diseases. I have also observed male smoking rates drop remarkably in the one EU country where snus is legal. Both of us hold our opinions based on our experiences as well as on the data we have seen. I suspect that we think its worth arguing about because the outcome of the (wider) debate may influence the direction the tobacco industry takes (or is forced to take) and may affect the lives and deaths of millions of people.
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About the Author

MA, MAppSci, PhD

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