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When enough is enoughspeccomm | August 30, 2017

The continued call for more evidence about the relative risks of “tobacco” productspresents a risk in its own right.

By Marina Murphy

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Anyone who reads this magazine and takes an interest in the vapor industry will befamiliar with phrases like “more research needed” and “not enough evidence.” But when isenough evidence, enough evidence? I ask this because there is another product that hassuffered from the “more research needed” mantra: snus. Despite extensive evidence thatsnus is harm reducing, it remains banned in the European Union. And as we listen tocontinued calls for more research on e-cigarettes and other alternative tobacco andnicotine products, these categories risk becoming another “snus.”

In the last issue, I discussed snus and the legal challenge being brought against the EUban (see “No entry,” Vapor Voice, Issue 3, 2017). But I think it is worth revisiting this issuebecause—guess what—there is new evidence of the advantages of snus! In June, newdata was released and suggested that around 320,000 men would not die prematurelyfrom smoking-related diseases every year in the EU if snus were available and use levelsmirrored those in Sweden.

Now, it is highly unlikely that use levels in other European countries would mirror those ofSweden anytime soon, if ever, but if snus were available, it would add to an ever-increasing arsenal of potentially safer nicotine and tobacco products in the EU. This couldonly be a good thing for smokers looking for an alternative to conventional cigarettes.Because after all, we’re all different, and one size does not fit all. A wider range ofalternative tobacco and nicotine products gives more choice to the consumer. And if thesealternatives have the potential to present reduced risks in comparison with smoking, whyshouldn’t they be available to those who want to use them?

Snus, Sweden and Scandinavia

At some stage, somebody somewhere decided that snus should be banned in the EU,which it duly was in 1992. Now this ban may have been barely noticed in EU countrieswithout an oral tobacco tradition, but in Sweden, snus had been popular for around 200years. Snus has also been long used in neighboring Norway and Finland.

When Sweden and Finland joined the EU in 1995, Sweden applied for and received awaiver on the EU’s existing snus prohibition. This meant that Swedes could continueproducing and selling snus in their country. In contrast, Finland accepted the ban, leavingFinnish consumers without a legal source of snus in their own country. Norway neverjoined the EU, so snus remained available, and it remains available and popular today.

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So, what happened to smoking rates in these countries after 1995? A study by JenniferMaki from the Center for Healthcare Economics and Policy compared the smoking rates inthese countries and found that in both Sweden and Finland there had been a steadydecline in smoking until the mid-1990s. After 1995, the decline in smoking leveled off inFinland but continued in Sweden, even though smoking rates in Sweden had been farlower in the first place. “In the post-ban period, smoking increased in Finland by 3.47percentage points relative to Sweden. … This estimate can be interpreted as an increasein the smoking rate relative to what it would have been in the absence of the ban,” saysMaki (see Figure 1).

Figure 1

When Finland is compared with Norway over the same period (see Figure 2), the declinein smoking rates in the two countries is similar prior to 1995. However, after 1995, therates diverge, with the decline in smoking rates in Norway similar to that observed inSweden, albeit less significant.

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Creating momentum

Figure 2

Snus today

In June, Lars Ramstrom, of the Institute for Tobacco Studies in Sweden, presented newdata at the Global Forum on Nicotine conference in Warsaw, Poland, suggesting thataround 320,000 men over the age of 30 would not die prematurely every year fromsmoking-related diseases in the EU if snus were available and used like it is in Sweden.

“This new analysis reveals the true human cost of the European snus ban,” says GerryStimson, who is on the board of directors of the New Nicotine Alliance, one of the groupschallenging the EU ban. “Snus is at least 95 percent safer than smoking. … This ban onthe sale of snus contravenes a fundamental principle that EU law should be based on ahigh level of health protection.” Overall tobacco use in Sweden (including smoking, snusand other tobacco products) is higher than in many other countries in the EU. What makesSweden different is that most tobacco use, at least for men, is in the form of snus. Swedenhas the lowest smoking rates in Europe. According to the 2017 Eurobarometer survey,only 5 percent of men in Sweden are daily smokers compared with a European average of24 percent. Swedish men have Europe’s lowest level of tobacco-related mortality: 152 per100,000 compared with the European average of 373 per 100,000 (see Figure 3).

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If you look at tobacco-related mortality in the EU 28 plus Norway (Figure 3), Sweden is atthe very bottom, where it has been for many years. The death rate in Sweden is less thana fourth of the top rate and less than half of the EU average. And who is keeping Swedencompany in the lowest positions? Norway and Finland.

In Norway, there is also lots of snus use because Norway is not in the EU and snus wasnever banned there. According to Ramstrom, snus use in Norway has become prevalentenough to have a significant impact on smoking rates; so perhaps it’s not surprising thatNorway is close to the bottom of the chart. But what about Finland? Although snus wastraditionally used in Finland, it is now banned. But there are indications that snus use isstill prevalent, with reports of a black market worth in the range of €50 million a year. The2017 Eurobarometer survey results also suggest high levels of smokeless tobacco use inAustria, which also features at the bottom of the chart.

Not so surprising

While the data might be new, the knowledge is not; we already knew that snus presentsconsiderable opportunity for harm reduction. There are decades of data in respect of snususe from Sweden. And those in the know have come to call the phenomenon of highersnus use and lower smoking rates, along with lower incidences of some cancers andassociated death rates, the “Swedish experience.” A parallel “Norwegian experience” isincreasingly being recognized as well.

Despite all this evidence, snus researchers are in the position of having to prove theirpoint over and over again. When is enough evidence, enough evidence?

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Marina Murphy is head ofscientific media relations atBritish American Tobacco.

As long as local regulators, the European Commissionand many in the public health community fail toacknowledge such an encouraging example of success,it’s hard to see how newer products are going to makesignificant inroads.

We hear the phrase “more research needed” a lot in thevaping world, too. But there is a risk that this phrase isbeing relied on far too much and that it is becoming anempty cliche or cop-out for those who just don’t want tobelieve what the science is already telling them.

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