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For harm reductionists in some countries, smokeless tobacco can be used as a small backfire to help control a larger, more deadly forest fire. For tobacco prohibitionists, smokeless itself is too evil to use even as a tool. For some anti-tobacco scientists, the necessary data may still be lacking. The low tar cigarette disaster seems to have made some policy makers act as if, having been fooled once, their greatest goal is to avoid the shame of being fooled twice.
From Foulds and colleagues’1 excellent review, proponents of smokeless tobacco for harm reduction will find useful evidence. Opponents will still question, even if there may be a positive effect in Sweden, whether it can or should be exported. They will disagree with Bates and colleagues2 on ending the snuff ban in the European Union. Opponents will proliferate “what ifs” (for example, what if snus is a gateway to cigarettes). They will demand science based regulation (as do harm reductionists). They will say that clinical trials must be completed before taking action (forgetting perhaps that randomised controlled trials were not a requirement to prove cigarettes a cause of premature death).
We doubt that any feasible clinical trial in another country can provide us with better evidence on the possible individual and societal effects of snus. Controlled experiments can be instructive, but the Swedish example is priceless. Physicians and public health professionals are not always the key players in tobacco control—consumers appear to be active participants in the process. The Swedish effects do not appear to have arisen from physicians systematically giving advice to their patients (as a clinical trial might simulate), or from the public health community campaigning to persuade smokers to switch to the safer product, or from manufacturers’ advertising.
We agree with the conclusions of this review, …
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