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A recent Industry Watch (Tobacco Control; 2001;10:253–7) explored an “experiment in progress”—the use of snus (oral snuff) by Sweden's males as a possible substitute for cigarette smoking and as a way to reduce male lung cancer. A recent study commissioned by the Massachusetts Department of Public Health and conducted by the American Health Foundation found that levels of tobacco specific nitrosamines (TSNAs), the principal class of carcinogens in snuff, were only 1.8 μg/g for ETTAN, the most popular Swedish brand versus 41.1 μg/g for Copenhagen the most popular US brand. Swedish Match selects special tobacco blends and employs a new fermentation process to prevent formation of TSNAs. It could be argued that the low levels in Ettan make it “safer”. However, the Ettan levels (1800 parts per billion) are still hundreds of times greater than what would be allowed in regulated products; for example, the limits for NDELA, another, non-tobacco nitrosamine in bacon and beer, are 5 and 10 parts per billion respectively.
The prevalence of daily smoking among Sweden's males has fallen from 36.3% in 1980 to 17.1% in 1998. However, male snus use increased only modestly during the period from 16.6% to 18.2%, making it difficult to attribute the decline in male smoking to smokers switching to snus.
Sweden has been one of the most progressive European nations in curbing smoking through bans on advertising, taxation, and treatment of tobacco dependence. The US experience has shown that such comprehensive efforts contribute to large declines in tobacco use. The states of California and Massachusetts have conducted well funded comprehensive tobacco control campaigns. Both campaigns have aggressively passed tobacco control policies including taxation, eliminating public smoking, aggressive counter-advertising, crackdowns on tobacco sales to minors, and treatment of smokers. In 1998, the male smoking rate for California was 15.1% and Massachusetts 15%. In 1999, male use of chewing tobacco and snuff was only 2.4% in California. Massachusetts stopped measuring snuff use when it fell below 1% in 1993.
Swedish Match has recently introduced a new brand of oral snuff called Exalt into two test markets in the USA, Ohio and North Carolina, and is advertising the product on its website. It is a teabag pouch of oral snuff that has low levels of TSNAs and the user doesn't have to spit. The website is marketing the product not as a complete substitute for cigarette smoking, but as a temporary replacement where smoking is banned—airlines, worksites, theatres, and homes. There is little or no information in the site on the dangers of smoking, how to quit smoking, or the differences in health risks between smoking and smokeless tobacco use. Clearly, the product is being marketed as a complement to continued smoking.
Two US companies, Star Scientific and US Smokeless Tobacco Company, are about to launch similar low TSNA, spitless tobacco products. Swedish Match's strategy may be appealing to cigarette manufacturers since it does not promote quitting and may counteract the cessation effects generated by clean indoor air laws. Also, the product is cheap, costing a fraction of the price of nicotine gum or patches. This price difference may result in the pharmaceutical industry reducing their promotion of cessation medications if potential quitters turn to “safe” snuff rather than nicotine gum.
Another possible unintended consequence of a “snus experience” could be youth initiation into smoking. In the 1980s, the United States Tobacco Company targeted non-smoking young males with low nicotine, snuff starter products. The company employed a “graduation” strategy that intended new users to “graduate” up to higher nicotine brands over time. Among US 17–18 year old males, oral snuff use soared from 0.3% in 1970 to 2.9% in 1985, an eightfold increase. A Washington State study found that snuff became a nicotine entry product for young males who switched to cigarette smoking as they grew older.
Tobacco companies—Swedish or American—want to make money and the health of people is not part of the bottom line. The Swedish experiment could become an “increased harm experiment” where continued smoking is supported, clean indoor air laws weakened, and pharmaceutical companies that promote cessation products driven out of the marketplace. Since tobacco products are not regulated, we should be very cautious in arguing that one product is “safer” than another. It is a dynamic environment where all tobacco manufacturers will work together to promote each other's products and addiction to nicotine. We should be very careful in choosing our tobacco bedfellows.
All articles written by David Simpson unless otherwise attributed. Ideas and items for News Analysis should be sent to David Simpson at the address given on the inside front cover.