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The complexity of ‘harm reduction’ with smokeless tobacco as an approach to tobacco control in low-income and middle-income countries
  1. Olalekan A Ayo-Yusuf1,2,
  2. David M Burns3
  1. 1Department of Community Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
  2. 2Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA
  3. 3UCSD School of Medicine, San Diego, California, USA
  1. Correspondence to Professor Olalekan A Ayo-Yusuf, Department of Community Dentistry, Faculty of Health Sciences, Oral and Dental Hospital, University of Pretoria, PO Box 1266, Pretoria 0001, South Africa; lekan.ayoyusuf{at}


Objective To review the implications of recommending smokeless tobacco (ST) use as a harm reduction approach for low-income and middle-income countries (LMICs).

Method Narrative review of published papers and other data sources (including conference abstracts and internet-based information) on the health risks posed by the use of ST products for individual smokers and for the population with a focus on their implications for LMICs.

Results Swedish snus has a relatively lower toxicity profile than ST products available in other markets, including older products used in the US and products used in Africa and Asia. The experience with snus in Sweden provides information on the effects of snus use in a population where cigarette smoking was already culturally ingrained. However, population effects are likely to be different in those LMICs where smoking is not yet the dominant culturally accepted form of tobacco use. The total effect may be negative in countries where locally-popular ST products have substantially higher disease risks than Swedish snus and where there is limited regulatory and tobacco use surveillance capacity.

Conclusions Issues relating to how populations in LMICs respond to marketing efforts, the risks of the dual use of ST and smoking, and the capacity to regulate ST products need to be considered in making decisions about harm reduction strategies in LMICs. The public health effects of supporting ST as a harm reduction strategy may vary substantively in countries with different pre-existing tobacco use patterns.

  • Harm reduction
  • public policy
  • nicotine products
  • smokeless tobacco
  • primary healthcare
  • traditional tobacco products
  • tobacco and African tradition
  • oral health
  • smoking caused disease
  • prevalence

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  • Competing interests DMB has testified extensively as an expert in litigation against the tobacco industry.

  • Provenance and peer review Commissioned; externally peer reviewed.

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