Objective: To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden. Method: Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden. Results: Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use. Conclusions: Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

Objective: To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking. Methods: Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001-2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures. Results: 15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum. Conclusion: Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking.

Successful tobacco control may result in a higher dependence among the remaining smokers (due to selective quitting by low-dependent smokers). The remaining highly dependent smokers may need more intensive treatment.

Rationale:This statement is an updated version of one released by the same authors in February 2003. The statement was produced to follow up the Royal College of Physicians (RCP) Tobacco Advisory Group report “Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority”,1which argued for an evidence based regulatory approach to smokeless tobacco and harm reduction and posed a series of questions that regulators must address in relation to smokeless tobacco.The purpose of this statement is to provide arguments of fact and principle to follow the RCP’s report and to outline the public health case for changing existing European Union (EU) regulation in this area. A review of regulation in relation to harm reduction and regulation of tobacco products other than cigarettes is required in Article 11 of EU directive 2001/37/EC,2and this is a contribution towards forming a consensus in the European public health community about what policy the EU should adopt in the light of this review, or following ongoing legal action that may potentially strike out the existing regulation altogether.Public health case:We believe that the partial ban applied tosomeforms of smokeless tobacco in the EU should be replaced by regulation of the toxicity ofallsmokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a “gateway” it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco—the alternative being to “quit or die”… and many die. While nicotine replacement therapies (NRT) may have a role in harm reduction, tobacco based harm reduction options may reach more smokers and in a different, market based, way. Chewing tobacco is not banned or regulated in the EU but is often highly toxic, and our proposal could remove more products from the market than it permitted.Regulatory options:We believe that the EU policy on smokeless tobacco should adapt to new scientific knowledge and that the European Commission should bring forward proposals to amend or replace Article 8 of directive 2001/37/EC with a new regulatory framework. Canada has developed testing regimens for tobacco constituents and these could be readily adapted to the European situation. A review of EU policy in this area is required no later than December 2004, and we believe the Commission should expedite the part of its review that deals with harm reduction and regulation of tobacco products other than cigarettes so as to reconsider its policy on smokeless tobacco. We held this view before Swedish Match brought its legal proceedings to challenge EU legislation and we will continue to hold these views if its action fails.

There has been concern that the availability of alternative less harmful forms of nicotine might inhibit smoking cessation and/or encourage those who would not otherwise have smoked to do so. The plausibility of such effects can be best assessed by looking at population trends in use of smoking in relation to alternatives. This paper looks at the relationships between snus use and smoking in Sweden. Analyses are based on a data set for the period January 2003 to February 2011 from a long-term study covering nationally representative samples of the Swedish population aged 18-79, with a total study population of 60,675 individuals. Questionnaires made it possible to identify detailed tobacco use categories and use trajectories. The results showed that uptake of snus use is much more common in males than females. Those who began daily tobacco use using snus were much less likely to subsequently take up smoking than those who had not, both among males (17.6% vs. 45.9%), and females (8.2% vs. 40.2%). Further, among those who started using snus after starting as smokers, 76.3% of men and 71.6% of women had stopped smoking completely, including 31.5% of the men and 28.6% of the women who had quit all forms of tobacco. Indeed, those who were primary snus users were also more likely to have quit altogether than those who only ever smoked. Snus was also reported as the most common smoking cessation aid among men and yielded higher success rates than nicotine replacement therapy and other alternatives. As conclusions, snus has both contributed to decreasing initiation of smoking and, when used subsequent to smoking, appears to facilitate smoking cessation. All these effects suggest that the availability and use of snus has been a major factor behind Sweden's record-low prevalence of smoking and the lowest level of tobacco-related mortality among men in Europe.