Snus: a compelling harm reduction alternative to cigarettes

Abstract

Snus is an oral smokeless tobacco product which is usually placed behind the upper lip, either in a loose form or in portioned sachets, and is primarily used in Sweden and Norway. The purpose of this review is to examine the reported effects of snus use in relation to specified health effects, namely lung cancer, cardiovascular disease, pancreatic cancer, diabetes, oral cancer and non-neoplastic oral disease. The review also examines the harm reduction potential of snus as an alternative to cigarettes by comparing the prevalence of snus use and cigarette smoking, and the reported incidence of tobacco-related diseases across European Union countries. The scientific literature generally indicates that the use of snus is not a significant risk factor for developing lung cancer, cardiovascular disease, pancreatic cancer or oral cancer. Studies investigating snus use and diabetes have reported that high consumption of snus (estimated as being four or more cans per week) may be associated with a higher risk of developing diabetes or components of metabolic syndrome; however, overall results are not conclusive. Snus use is associated with the presence of non-neoplastic oral mucosal lesions which are reported to heal rapidly once use has stopped. The most recent Eurobarometer data from 2017 reported that Sweden had the lowest prevalence of daily cigarette use in the European Union at 5% whilst daily “oral tobacco” use was reported to be 20%. European data published by the World Health Organisation in 2018 indicated that Sweden had the lowest rate of tobacco-related mortality and the lowest incidence of male lung cancer. Overall, prevalence statistics and epidemiological data indicate that the use of snus confers a significant harm reduction benefit which is reflected in the comparatively low levels of tobacco-related disease in Sweden when compared with the rest of Europe. The available scientific data, including long-term population studies conducted by independent bodies, demonstrates that the health risks associated with snus are considerably lower than those associated with cigarette smoking.

Risk Perceptions of Low Nicotine Cigarettes and Alternative Nicotine Products across Priority Smoking Populations

“…Other studies report substantial misperceptions concerning snus, with people incorrectly believing that using snus is equally or more harmful than smoking cigarettes [36][37][38]. However, the epidemiological data from Sweden indicate the people who use snus have substantially lower risks of developing tobacco-related diseases compared to people who smoke cigarettes [39]. If people who are unable to stop using nicotine believe ANDS products, such as e-cigarettes and snus, are equally or more harmful than cigarettes, then they may not make the switch, thereby reducing the public health impact of the nicotine-focused framework.…”

Swedish snuff (snus) and risk of cardiovascular disease and mortality: prospective cohort study of middle-aged and older individuals

“…Consequently, strategies to reduce cigarette smoking are of great importance globally. There is considerable discussion regarding the effectiveness of nicotine replacement therapy, and safety of the alternative nicotine delivery products such as smokeless tobacco, especially among those who are less likely or unwilling to quit smoking [ 9 , 10 ].…”

Chemical characterization of tobacco-free “modern” oral nicotine pouches and their position on the toxicant and risk continuums

“…In Sweden, overall tobacco product use is similar to that in other European countries (Clarke et al 2019), but the incidence of smoking-related mortality is among the lowest in Europe (Ferlay et al 2013, Swedish Match 2020. This is because the majority of Swedish tobacco consumers use 'snus', a moist oral smokeless tobacco product (STP), rather than cigarettes (EC 2017, Clarke et al 2019, WHO 2019. In 2017, the population incidence of daily cigarette smoking was reported as approximately 5% in Sweden versus a European average of 25%; in contrast, daily snus use in Sweden was 20% (EC 2017, Clarke et al 2019.…”

“…Since then, several studies have explored the 'Swedish experience' (Swedish Match 2020) as a potential factor in tobacco harm reduction (e.g., Gartner et al 2007, Clarke et al 2019. In Sweden, overall tobacco product use is similar to that in other European countries (Clarke et al 2019), but the incidence of smoking-related mortality is among the lowest in Europe (Ferlay et al 2013, Swedish Match 2020. This is because the majority of Swedish tobacco consumers use 'snus', a moist oral smokeless tobacco product (STP), rather than cigarettes (EC 2017, Clarke et al 2019, WHO 2019.…”