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What do we know about snus?

What is snus?

Snus is a moist, smokeless powdered tobacco. It is sold as a loose powder or pre-packaged in a small sachet (a bit like a mini tea bag). It contains ground tobacco, salt and may contain food-grade smoke aroma flavourings, such as citrus, bergamot, juniper, herb or floral flavours. Most Scandinavian snus is produced in Sweden where it is regulated as a food under the Swedish Food Act. The nicotine content varies among brands.

Is snus an appropriate and acceptable harm reduction product?

Snus fulfils the criteria for a tobacco harm reduction product. It is a low risk nicotine product and delivers acceptable doses to those who use it. In countries in which it is allowed it is popular and has contributed to declines in smoking and smoking related diseases.

How does snus differ from other oral tobaccos?

Snus is a smokeless tobacco. Unlike some other smokeless tobacco types, Swedish snus is not fermented and is pasteurised, which inhibits the growth of bacteria that help the formation of tobacco-specific nitrosamines (an important group of carcinogens in tobacco products). Snus is refrigerated in order to inhibit the growth of toxins.

How is snus used?

Snus is placed between the upper lip and gum. The nicotine is released into the saliva, with the rate of release affected by the amount of saliva. New users experiment (titrate) to find the best rate of nicotine release. http://www.wikihow.com/Use-Snus

Is there a quality standard for snus?

The Gothiatek standard, a voluntary quality standard for snus products, has maximum levels for constituents, including nitrosamines, metals, nitrite, agrochemicals, mycotoxins and aldehydes.
https://www.swedishmatch.com/Snus-and-health/GOTHIATEK/GOTHIATEK-standard/

Is snus safe and are there any long-term health effects?

Snus is considered by scientists to be 95%, and possibly closer to 99%, less risky than smoking.

Snus poses no respiratory risk. Respiratory diseases, predominantly lung cancer, chronic obstructive pulmonary disease (COPD) and pneumonia account for 46% of deaths due to smoking, according to the Scientific Committee on Emerging and Newly Identified Health Risks, 2008.
http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_013.pdf

Individual studies can produce contradictory findings so evidence must be sought from overviews of key studies and pooled results. A recent systematic review and meta-analysis examined the evidence relating to snus and health across six major Swedish, Norwegian, Danish and Finnish studies, up to 2010. This concludes that the evidence provides scant support for any major adverse health effects of snus: snus is not associated with cancers of the oropharynx, oesophagus, pancreas, or heart disease or strokes. Compared with smoking snus poses about 1% of the risk of cancer or cardiovascular disease. https://www.ncbi.nlm.nih.gov/pubmed/21163315

Snus and lung cancer in Sweden

The rise in the use of snus has resulted in Sweden having the lowest lung cancer mortality and tobacco-related mortality in Europe. It is estimated that if the Swedish smoking prevalence was extrapolated to the rest of the EU, there would be a 54% reduction of male mortality from lung cancer. (Rodu B. and Cole, P. 2009. “Lung Cancer Mortality: Comparing Sweden with Other Countries in the European Union.” Scandinavian journal of public health 37(5):481–86.)
http://journals.sagepub.com/doi/abs/10.1177/1403494809105797

Health effects of switching to snus

Given the lower risk profile for snus it has been calculated that the life expectancy of smokers who switch from smoking to snus is little different to the life expectancy of those who stop smoking altogether. The authors of this study conclude that: ’Individual smokers who switched to snus instead of continuing to smoke and new tobacco users who only used snus rather than smoking would achieve large health gains compared with smokers’.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60677-1/abstract

This finding is confirmed by a recent analysis of six major studies which found that switching from smoking to snus is associated with major reductions in morbidity and that switching to snus appears to have much the same reduced health risk as quitting smoking.
http://europepmc.org/abstract/MED/23454227

Does snus pose a risk to others?

Snus poses no risk to others, such as work colleagues and family members as there is no combustion and consequently no ‘second hand’ smoke and no risk of fire.

Snus and stopping smoking

Snus is now the most popular product for smokers in Sweden and Norway when they wish to stop smoking and the success rate is higher when using snus than when using pharmaceutical Nicotine Replacement Therapy products.
https://academic.oup.com/ntr/article/14/10/1221/1749452/Association-Between-Willingness-to-Use-Snus-to

Has snus replaced smoking in Sweden and Norway?

Consumers in both Sweden and Norway are choosing to use snus rather than to smoke. There has been a major increase in the use of snus and a concomitant decline in the smoking of tobacco. In Sweden, snus overtook cigarettes in 1996; In Norway the rise of snus and the decline in smoking resulted in male use of snus overtaking cigarettes by 2006. This happened despite snus use in Sweden and Norway occurring in a context where active promotion of the product was banned and health authorities warned smokers against snus use.

What are the levels of smoking in Sweden?

The prevalence of current adult smoking in Sweden in 2014 was 11% and Sweden now has the lowest prevalence of smoking in the EU. In the same survey in 2014 the prevalence of adult current smoking in the UK was 22% (European Commission. Attitudes of Europeans towards Tobacco and Electronic Cigarettes. European Commission; Brussels, Belgium: 2015. Special Eurobarometer 429).

‘Daily smoking’ is even lower in Sweden at 8% compared with 19% in the UK in 2014.

Smoking is fast disappearing in some groups of Swedish men: in 2016 in the 30 to 44 years age group only 5% are daily smokers, less than a quarter of the level in the UK men. https://www. folkhalsomyndigheten.se/ documents/statistik- uppfoljning/enkater- undersokningar/nationella- folkhalsoenkaten/2016/ Tobaksvanor-nationella- resultat-tidsserier-2016.xls

How does the use of snus reduce smoking?

Snus is used to avoid the uptake of smoking, to stop smoking, and to reduce smoking.

The decline in Sweden and Norway has come about by smokers using snus to avoid smoking, and by the fact that younger nicotine users are choosing to use snus rather than to smoke, and that the uptake of snus does not lead to tobacco smoking.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245639/  and https://www.ncbi.nlm.nih.gov/pubmed/27834883 )

Overall in Sweden and Norway the total level of tobacco use has remained stable or slightly declined – what is important is that there has been a major shift away from smoking.

Snus can therefore be considered protective against smoking.

Might other factors in Sweden account for the switch to snus?

No. Sweden has implemented fewer tobacco control measures than the UK. Laws on tobacco use and promotion are less strict that in the UK. They don't have a fully 'comprehensive' smoking ban. Smoking is allowed in designated purpose built smoking rooms in some workplaces and some public places like airport terminals. Smoking is also permitted in designated smoking areas outside in train stations and bus terminals. They don’t have especially high tobacco taxes. There is a ban on tobacco advertising and promotion, but advertising and promotion is allowed at points of sale, as are tobacco product displays. There are total restrictions on tobacco sponsorships.

The clear difference between Sweden and the UK is due to snus. Overall the UK ranks number 1 in implementing tobacco control measures, whilst Sweden ranks joint 9th in 2016. http://www.tobaccocontrollaws.org/legislation/country/sweden/summary Sweden gets better results with fewer controls on smoking.

What does the Royal College of Physicians, Tobacco Advisory Group say about snus?

‘The availability and use of an oral tobacco product known as snus in Sweden, documented in more detail in our 2007 report…demonstrates proof of the concept that a substantial proportion of smokers will, given the availability of a socially acceptable and affordable consumer alternative offering a lower hazard to health, switch from smoked tobacco to the alternative product. Particularly among men, the availability of snus as a substitute for smoking has helped to reduce the prevalence of smoking in Sweden, which is now by far the lowest in Europe…Trends in snus use in Norway are similar to, and perhaps stronger than, those in Sweden, and there the use of snus is strongly associated with quitting smoking.’ Royal College of Physicians, Tobacco Advisory Group (2016). Nicotine without smoke: Tobacco harm reduction

Legal status of snus

Snus is banned from sale in the EU (except in Sweden).

The UK Tobacco and Related Products Regulations 2016 and EU Tobacco Products Directive 2014 on which it is based states that ‘no person may produce or supply tobacco for oral use’. Tobacco for oral use is defined as:

A tobacco product which is –
(a) intended for oral use, unless it is intended to be inhaled or chewed; and
(b) in powder or particulate form or any combination of these forms, whether presented in a sachet portion or a porous sachet, or in any other way’.

How did snus come to be banned?

In 1989 the UK Oral Snuff (Safety) Regulations were passed in response to the introduction of the moist snuff marketed as ‘Skoal Bandits’. This ban was quashed on appeal by the manufacturer.

In the EU, Directive 92/41 banned sales of snus, to harmonise rules in that three member states had already banned tobacco for oral use.

In 1995, on accession to the EU, Sweden obtained an exemption from the ban.

In 2001 the Tobacco Products Directive continued the ban.

The ban was also continued in the 2014 Tobacco Products Directive.

The legal challenge

The Swedish Match legal challenge against the ban on snus

Swedish Match – the main manufacturer of Swedish snus – has brought a challenge in the UK High Court against the ban of the sale of snus. Their legal argument is that the law discriminates against snus compared with cigarettes and with lower risk nicotine products, that the ban is disproportionate, is against the principle of subsidiarity in removing national regulatory discretion, breaches the duty to give reasons for the ban, and is an unjustified restriction on the free movement of goods.

The NNA legal challenge against the ban on snus

NNA asked the High Court to be joined to the case as an ‘intervenor’. NNA is acting as a third party in the public interest, and brings added facts and argument to the case.

NNA argues that the ban is (a) disproportionate, and (b) contravenes the right to a high level of health protection.

Significantly, for the first time in a challenge against UK (and EU) tobacco legislation, NNA argues that the ban infringes human rights. NNA argues that the ban contravenes the EU Charter of the Fundamental Rights vis Art 1 ‘human dignity’, Art 7 ‘respect for private and family life’, and Art 35 ‘health care’.

Art 35 stipulates that a high level of human health protection shall be ensured in the EU policies and activities. NNA argues that the ban is inappropriate as it prevents smokers from having access to a safer product and is an unsuitable means for achieving a high level of health protection.

Progress with the case

The High Court agreed on Jan 26th 2017 that there was a case for a review of the legislation. Because the UK Tobacco and Related Products Regulations 2016 are based on the EU Tobacco Products Directive 2014, the case was referred to the European Court of Justice, on 9 March 2017.

Implications of the case

The ECJ ruling will apply across the EU.

Why did NNA get involved in this case?

NNA sees access to all safer nicotine products as important in helping provide smokers with lower risk alternatives to smoking – so lo-tech snus is important as well as hi-tech e-cigarettes. NNA contends that snus fulfils the criteria for a tobacco harm reduction product and that it should be available in the UK.

 

pdfDownload this as a PDF here 

 

Testimony to the Norwegian Parliament on the relative risk of snus from Professor Anders Milton, ex President of the World Medical Association.

 

More from the NNA on snus:

Leading experts implore the Swedish government to back snus at COP7

NNA goes to the High Court to challenge the ban on snus

Snus ban challenge, NNA media releases, 26th January 2017

Update on the challenge to the ban on snus – next step, the European Court of Justice

NNA snus ban challenge - update May 2017

NNA snus ban challenge - the legal case

Snus and the right to health