Snus, and particularly its use in Sweden, is one of the best examples of the tobacco harm reduction approach. Snus is a form of snuff, but it’s more readily comparable to chewing tobacco in terms of its use. The finely-ground, moist tobacco powder is contained in a pouch, which is placed under the upper lip by users (although “loose” snus is also available). It’s a popular alternative to smoking in Sweden, primarily composed of air-cured tobacco, water and salt, with flavorings and additional ingredients to do things like modify the pH and increase its shelf-life. Because users do not combust tobacco, the vast majority of the harmful components of tobacco smoke are avoided, and thus it aims to reduce the harm caused by smoking.
History of Snus
Snus (pronounced to rhyme with “goose”) begun as nasal snuff, and can be ultimately be traced back to Christopher Columbus and his crew witnessing Native Americans inhaling powdered tobacco through a reed. After being introduced to Portugal, Jean Nicot is credited to bringing nasal snuff to the rest of Europe, and also supposedly cured the Queen of France’s headaches by suggesting a powdered tobacco treatment. Soon after this, snuff became popular across the continent.
The first documented evidence of snus in Sweden comes from the mid 17th century, and it was used nasally until the early 19th century, when it begun to be used by placing a pinch under the upper lip. This form of use became popular, and was introduced to America through emigration in the late 19thand early 20th centuries. After the First World War, cigarettes became popular in Sweden, and it wasn’t until around 1970 when the growing interest in reduced harm tobacco products brought about a revolution in snus. In addition, this is when the pouch was first introduced, making the practice more user-friendly and causing another surge in popularity.
Potential Health Effects of Snus
Snus is a reduced harm tobacco product, and is intended for use by adult smokers wanting to reduce the risk resulting from their nicotine addiction. It contains nicotine, which is an addictive substance, but has only minor risks when not consumed as part of combusted tobacco smoke. There are still some health concerns with regard to snus use, but since the renewed interest in the late 20th century, there has been a great deal of research conducted on their safety. Much of the concern comes from the presence of tobacco-specific nitrosamines (which are carcinogens) and the resulting potential for oral cancer, but other issues such as cardiovascular risks, gastrointestinal cancers and the risk during pregnancy have also been investigated.
Research into Snus
- Oral cancer – Several studies have investigated the risk of oral cancer, and this has been the primary area of interest given the method of consumption. Systematic reviews of this evidence have consistently concluded that the risk of oral cancers in snus users is very low. There is an increase in risk resulting from the use of snus, but this appears to be smaller in snus produced in Sweden. Case-control studies conducted there have found no increase in the rates of oral cancer, and most increased risk detected comes from studies of American snus conducted before 1980. In any case the increase in risk is very minor (around a 15 percent increase compared to non-smokers), and is much smaller than that from smoking. Research on rats uses an invasive model (which is currently being revised), but Swedish-made snus still showed no increase in oral cancer risk, even at high doses. There is evidence that some snus users develop lesions in the mouth, but none that these then become malignant. In addition, these are reversible if snus use is stopped.
- Pancreatic cancer – The research into the risk of pancreatic cancer among snus users is still fraught with uncertainty, but a 2008 systematic review of the evidence on the topic concluded that – at most – snus use is associated with a minor increase in pancreatic cancer risk. This is extremely likely to be less than that from smoking, but more research is required to precisely determine the size of this increase, or indeed whether a significant one exists at all.
- Other cancers – Several other cancers (including esophageal/stomach, kidney, bladder, skin and lung cancer) have been investigated, and no increase in risk has been observed overall from snus use. One piece of research observed increased stomach cancer risk, but further investigation is required to determine whether this was just a single chance result or whether the risk genuinely exists. Studies looking at the risk of all cancers show that snus usage is not a significant risk factor. This assumed to be minimized with Swedish snus, but larger with products from places like Southeast Asia due to differing ingredients and manufacturing processes.
- Cardiovascular disease – A 2007 systematic review of the health effects of snus from the Department of Public Health at the University of Christchurch (New Zealand) looked at six studies relating to cardiovascular disease. In five of these, there was no increase in risk observed for cardiovascular disease in snus users compared to the general population. However, one large study on construction workers (which begun in the 70s) found a 40 percent increase in risk of death (in comparison to non-tobacco users) from cardiovascular and cerebrovascular disease in snus users, but these risks were greatest in men aged 35 to 54. This may be related to the group studied or the older products involved, but an increase in risk is still expected by researchers. This, again, is smaller than the increased risk associated with cigarette smoking.
- Toxicological studies – Toxicological research conducted in vitro (“in glass,” using extracted samples or cultured cells) is available on snus, but there is limited data and the studies look at a variety of issues. The evidence supports the conclusion that snus (at least Swedish-produced snus) is not genotoxic, and one study reported that it wasn’t mutagenic, cytotoxic or clastogenic. However, some evidence suggests that snus may inhibit the immune response from oral mucosa, and the data on its effects on cell growth and division is inconsistent.
- Other conditions – The risk of numerous other conditions has been investigated with respect to snus use, including peptic ulcers, ulcerative colitis, diabetes and strokes. In most cases, there is no observed increase in risk for snus users compared to non-tobacco users. One “descriptive” study found an increase in type 2 diabetes risk in snus users, but other data comes to the opposite conclusion using a more objective methodology. Additionally, individual findings have suggested in an increase in a risk in a specific type of stroke and metabolic syndrome, but these need to be further investigated in order to determine whether the findings are due to chance.
Snus Impact in Sweden
In Sweden, more men use snus than smoke tobacco, and the country has one of the lowest smoking rates in the world overall. Sweden also has one of the lowest cancer mortality rates in the world, the lowest lung cancer rate in the industrialized world and in general, low rates of all tobacco-related illnesses. Researchers have determined that if the men in all EU countries smoked in the same proportion as those in Sweden, there would be 200,000 fewer deaths each year. This shows the potential value of tobacco harm reduction approaches for public health.
Legal Status of Snus
In the EU, oral tobacco is banned unless it is intended to be smoked or chewed, and so snus is technically illegal in EU member states. However, due to the country’s long history with snus, Sweden was exempted from this ban upon its entry to the EU in 1995. Norway, as a non-EU member state, also allows snus, and the product is still used in America and other countries. However, snus is also banned in Australia.
Resources for Snus
- Swedish Match – Research on Snus
- Environ International Corporation – Review of the Scientific Literature on Snus
- Broadstock, M; (2007); Systematic review of the health effects of modified smokeless tobacco products
- Rodu, B.; Jansson, C.; (2004); Smokeless tobacco and oral cancer: a review of the risks and determinants.
- Weitkunat, R.; Sanders, E.; and Lee, P.; (2007); Meta-analysis of the relation between European and American smokeless tobacco and oral cancer
- Hansson, J. et. al.; (2009); Use of snus and risk for cardiovascular disease: results from the Swedish Twin Registry.
- Sponsiello-Wang, Z, Weitkunat, R. and Lee, P; (2008) Systematic review of the relation between smokeless tobacco and cancer of the pancreas in Europe and North America.
- OECD iLibrary – Adult Smoking Population Daily
- OECD iLibrary – Mortality from Cancer
- Rutqvist, L.; The Swedish Experience
- Rodu, B. and Cole, P.; (2004); The Burden of Mortality from Smoking: Comparing Sweden with Other Countries in the European Union. (via For Smokers Only)