Science & Research
Health Effects of Smokeless Tobacco Products - The 2008 EU SCENIHR Report
In 2005, the European Commission's Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) was asked to prepare a scientific report on the health effects of smokeless tobacco products, with particular focus on Swedish snus.
The SCENIHR report was published on 18th February 2008. The report reaches a number of significant conclusions:
- Marketed STP (smokeless tobacco products) varies considerably in form and content of toxicants, including nicotine, and thereby in associated health effects.
- Snus use is not a risk factor for oral cancer.
- Snus use poses significantly fewer, and less severe, health risks than cigarette use.
- The availability of snus has had a positive impact on public health in Sweden.
- Snus use among youth and adult users is not a significant predictor of future smoking.
- Snus use may help some smokers quit cigarette smoking.
There were five scientific 'opinions/questions contained within the SCENIHR report.
Question 1 : Adverse health effects of smokeless tobacco products.
In answering this question, the SCENIHR committee considered scientific evidences relating to the use of a variety of smokeless tobacco products from several countries. With respect to snus, most of the data considered originated from studies in Sweden and Norway (where snus is also available). The report acknowledges that snus use is in the order of 90% less harmful than smoking. It concludes that, based on current scientific evidences, snus use:
- does not increase the risk of oral cancer,
- does not increase the risk of lung cancer,
- does not increase the risk of cancers of the head and neck,
- does increase the risk of pancreatic cancer,
- does increase the risk of death after a heart attack (but not of heart attack itself) and
- may cause temporary localized (non-cancerous) lesions in the mouth.
The conclusion that snus use increases the risk of pancreatic cancer is based on two Scandinavian studies which report a 1.6 to 2-fold increased risk among snus users compared to non-users. Although these studies suffer from methodological weaknesses, these figures, if correct, should be taken into context. Cigarette smoking is associated with a 2.5 to 2.8-fold increased risk of pancreatic cancer, which is clearly higher than that associated with snus use.
Likewise, the conclusion that snus use increases the risk of death after heart attack should be taken into context, as also this risk is significantly lower than the one associated with cigarette smoking. It should also be noted that the conclusion concerning snus was mainly driven by one study (the Swedish construction worker cohort) in which it was not possible to rule out that other factors than snus contributed to the observation.
The report concludes that, for those people who switch from cigarette smoking to STP use, the overall benefits outweigh the risks. In agreement with this, the Swedish National Board of Health, in its Public Health Report (2005), states that "the net effect of using snus as a means of giving up smoking may be positive, since smoking is much more hazardous to health than snus use."
Unfortunately, this harm reduction potential, in comparison to smoked tobacco products, has not been fully addressed in the abstract or executive summary. However, in the main body of the report it is stated that, "While there is no doubt that complete abstinence from tobacco use would be the safe and preferred option for all of these snus users, the pragmatic argument is that if in practice the alternative for them would be to smoke tobacco, then if snus use is less hazardous than tobacco smoking, substitution of snus for smoking may be beneficial to individual and public health..." (p. 112).
Question 2 : What is the addiction potential of smokeless tobacco products?
The SCENIHR report notes that all smokeless tobacco products contain nicotine, and are thus capable of generating dependence (addiction) among users. The report also notes that snus users typically take up, into their bodies, comparable amounts of nicotine to cigarette smokers. However, due to differences in the speed of nicotine absorption (smoking = fast, oral tobacco = slower), the report concludes that the level of nicotine dependence among snus users may be somewhat lower than that among smokers. This is because the speed of nicotine delivery into the body is believed to be an important factor in the resulting degree of nicotine dependence; faster delivery = higher dependence potential. It should also be noted that it is precisely the nicotine content of smokeless tobacco that has made it an acceptable alternative to smoking among many smokers who have quit.
Question 3 : Use of smokeless tobacco as a smoking cessation aid compared to pharmaceutical nicotine replacement products.
The report also acknowledges that, in Sweden, snus is generally preferred over medicinal nicotine products as a smoking cessation aid. Recently published official statistics from Norway came to the same conclusion. However, the report correctly notes that no controlled clinical trials have been undertaken to assess the relative efficacies of snus and medicinal nicotine in successful smoking cessation.
Question 4 : Impact of smokeless tobacco use on subsequent initiation of smoking.
The report concludes that the use of snus in Sweden is not a significant predictor of future smoking (i.e. snus is not a gateway to smoking in Sweden). This is true both for youth and adult snus users.
Question 5 : Extrapolation of the information on the patterns of smokeless tobacco use,smoking cessation and initiation from countries where oral tobacco is available to EU-countries where oral tobacco is not available.
In essence, this question is impossible to answer under the current EU ban; the only way to gather evidence about the impact of STP use outside of Sweden would be to legalize its sale and monitor the subsequent patterns of use over time. Indeed, the SCENIHR report concludes that "due to societal and cultural differences" it is not possible to extrapolate the 'Swedish experience' to new markets. The report does not, however, provide any evidence to suggest that the impact on smoking rates in new markets would be different to that seen in Sweden. While it is quite possible that the 'Swedish experience' would not replicated in all new markets, it is possible that the effects would be similar, at least in direction if not in magnitude. No evidence is presented in the report that other countries would be completely different.
By upholding the EU ban, and not considering a revision to the tobacco products directive, it may be argued that individuals are being denied the right to a less harmful tobacco product, which may encourage less use of smoked tobacco products. Although there are differences between populations, more weight should be given to the 'Swedish experience' than is currently given.
In summary, it is the opinion of ESTOC that the current EU ban on oral smokeless tobacco products, such as Swedish snus, is scientifically unsupportable and inappropriate. As highlighted above, the ban was instigated on the belief that the use of such oral tobacco products was a significant risk factor for cancer, particularly oral cancer, and that they were particularly appealing to youth. The SCENIHR report finds no scientific evidence, in particular with respect to the use of Swedish snus, to support either of these claims. Therefore, the ban is unjustified and should be removed.
ESTOC believes that the EU ban should be replaced with a regulatory framework that is based on accurate scientific evidence. To this end ESTOC is proposing a new regulation for smokeless tobacco products (snus, chewing tobacco, oral and nasal snuff), which is science-based, addresses consumer protection and has food regulation as its guiding principle