Quit Smoking with Swedish Snus

98% less harmful than cigarettes

About 90% of the smokers who try to quit smoking fails and the biggest reason are because of the addiction to nicotine. A cigarette delivers a higher initial nicotine kick than Snus but overall you get more nicotine from Swedish Snus. Snus is therefore a better alternative than both nicotine gum and nicotine patch when trying to quit smoking. Order our starting kit for snus use beginners with a unique selection of good beginner brands.

When thinking of tobacco, one thinks of cigarettes. Cigarettes are the most commonly used tobacco product in the world. Global consumption of cigarettes has been steadily rising since cigarettes were launched widely at the beginning of the 20th century. Today, there are approximately 46 million daily smokers in the U.S. and 1.2 billion daily smokers in the world. Cigarettes are considered to be responsible for the deaths of half of all lifetime smokers. In the U.S., 400,000 smokers are estimated to die annually due to cigarette smoking. However, the tobacco consumption pattern in Sweden is unique. The monopoly of cigarettes as the major tobacco product used has been broken among adult males in Sweden. There has been an interesting transformation during the past 50 years in Sweden.

Among adult males, Sweden has:

- Europe’s highest per capita consumption of smokeless tobacco

- Lowest cigarette consumption in Europe

- Lowest lung cancer mortality rate in Europe

- Among the lowest oral cancer mortality rate in Europe

- Lowest percentage of smoking-related deaths among developed countries

- Total tobacco consumption similar to neighboring countries (Norway, Denmark and Finland)

This bar chart shows Lung Cancer and Oral Cavity cancer in different countries throughout the world.

Smokeless tobacco products

There are a great variety of oral tobacco products around the world, many of which differ widely in chemical composition. The most unwanted constituents in all tobacco products are the Tobacco-Specific Nitrosamines (TSNA). The International Agency for Research on Cancer (IARC) classifies two of the tobacco-specific nitrosamines, NNN and NNK10, as possibly carcinogenic to humans. Hence, it is essential to eliminate or minimize the levels of these hazardous constituents in tobacco.

A study by Nyren11 states, “The smokeless tobacco used in the Third World may contain considerably higher levels of carcinogenic substances. A recent comparison between Swedish moist snuff and Sudanese toombaak reveals that the levels of NNN, NNK and NAT, respectively, were 100-200-fold, 600-4000-fold and 10-60-fold higher in the latter”.

Cigarette smoking in Sweden

Sweden was the first and only country in the western world to reach the World Health Organization’s (WHO) goal of reducing the percentage of smokers in the adult population (men and women) to below 20% by 2000. This is mainly due to the fact that the Swedish male population smokes considerably less than the male populations in other European countries as shown in Figure 1.

Figure1: Smoking Prevalence (%) Among Men, 2002-2003

SOURCE: Joossens, L. 2004. Effective tobacco control policies in 28 European countries. Presented at The Open Forum – Health in the enlarged Europe, Brussels, 17 May 2004. European Network for Smoking Prevention.

The following statistics and scientific studies from Sweden demonstrate how this unique tobacco consumption pattern can have a positive impact on cigarette consumption and tobacco-related diseases.

This data offers an explanation for the fact that the incidence of bronchus and lung cancer is lower among Swedish men than among men in most other developed countries. Figure 2 below presents the Lung Cancer Death Rates, Men age 40+, Europe 2002.

Figure2: Lung Cancer Death Rates, Men Age 40+, Europe 2002

SOURCE: WHO-IARC Worldwide Cancer Mortality Database.

Figure 3 illustrates that the risk of dying from a smoking related disease is very low for Swedish men compared to men in other western countries.

Figure3: The Risk, at the age of 35, of Dying from a Smoking Related Disease before the age of 70

SOURCE: Peto et al, Mortality from Smoking in Developed Countries 1950-2000. Oxford University Press

Rodu and Cole (2004)1 developed a systematic approach for estimating smoking prevalence and its impact on mortality in all EU countries. They conclude that 200,000 smoking related deaths would be avoided if all EU males smoked at the age-specific prevalence rates of Swedish men.

Rodu, et.al. (2002)2, Foulds, et.al. (2003)3, Rodu, et.al. (2003)4, Henningfield and Fagerstrom (2001)5, and Ault, et.al. (2004)6 have suggested that the low prevalence of smoking in Sweden is directly related to the availability of Swedish snus. Figure 4 shows the sales of snus and cigarettes as a function of time.

Figure4: Sales of Snus and Cigarettes in Sweden 1916-2001

SOURCE: Swedish Match 2001

Smokeless tobacco in Sweden - Snus

Swedish snus is a traditional product in Sweden, dating back to the early 1800s. Swedish snus is a ground, heat-processed (non-fermented), spit-less, oral tobacco product. It is used by placing a pouch between the upper lip and gum.

Snus use is more common than cigarette smoking among Swedish men, 22% vs. 14% in 20047. Approximately 50% of the snus users today in Sweden are ex-smokers. In the case of oral cancer, smoking (and alcohol) is a well-established risk factor. Several studies conducted in the 1990s, Schildt, et.al. (1998)8 and Lewin, et.al. (1998)9, found no evidence of an increased risk of oral cancer among users of Swedish snus. These findings offer an explanation why the incidence of oral cancer, as shown in Figure 5, is very low among men in Sweden compared with that in other countries, despite the high rate of snus use in Sweden. (Swedes are the only ones using smokeless tobacco extensively in Europe).

Figure5: Age-Standardized (World) Incidence Rates in Males of Oral Cancer (ICD 141; 143-145 per 100,000.

Source: Extract from Cancer Incidence in Five Continents, Volume VII, IARC Sci. Publ. 143, Lyon, France, 1997

The risk for Swedish females of dying from a tobacco-related disease is in line with the risk for women in the rest of the Europe. Their tobacco consumption pattern is also in line with the general tobacco consumption (cigarette smoking) pattern among European females.

The stop smoking - start using snus snus kit

MEDICAL REPORTS COMPARING SMOKING WITH SWEDISH SNUS

Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden.Lindström M.

Department of Clinical Sciences, Malmö University Hospital, Lund University, 205 02 Malmö

OBJECTIVES: The strategies used to support smoking cessation among quitters were investigated according to year of smoking cessation and sociodemographic characteristics. METHODS: The 2004 public health survey in Skåne, Sweden, is a cross-sectional study. A total of 27,757 people aged 18-80 answered a postal questionnaire. The participation rate was 59%. Different strategies to support smoking cessation--that is, no therapy, nicotine replacement (NRT), professional therapy and snus (snuff) use, were investigated among quitters according to year of smoking cessation, and demographic and socioeconomic characteristics. RESULTS: 14.9% of the men and 18.1% of the women were daily smokers. The prevalence of daily snus use was 19.5% among men but only 2.3% among women. Stratifying the data according to year of smoking cessation (1938-2004) revealed a significant increase in active smoking cessation strategies such as NRT, professional therapy and snus use. NRT was more common among women (23.6%) than men (14.8%) among smokers who quit in 2000-4, but snus use was more common among men (30.4% versus 8.7%). No replacement or other therapy at all was significantly more common among women (63.6%) than men (52.1%). People aged 35-80 years used more nicotine replacement than people aged 18-34, while men aged 18-34 used snus to quit smoking significantly more than men aged 55-80. CONCLUSIONS: Snus is used commonly among men as a support for smoking cessation in Sweden. Women use pharmacological NRT to a greater extent, but this can probably not compensate for the much higher extent of snuff use as a cessation strategy among men.

Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study.Gartner CE, Hall WD, Vos T, Bertram MY, Wallace AL, Lim SS.

School of Population Health, The University of Queensland, Herston, Queensland, Australia.

BACKGROUND: Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus. METHODS: We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked. FINDINGS: There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. INTERPRETATION: Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.

Role of snus in initiation and cessation of tobacco smoking in Sweden.Ramström LM, Foulds J.Institute for Tobacco Studies, Stockholm, Sweden.

OBJECTIVE: To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking. METHODS: Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001-2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures. RESULTS: 15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum. CONCLUSION: Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking.

Cigarettes and oral snuff use in Sweden: Prevalence and transitions.Furberg H, Lichtenstein P, Pedersen NL, Bulik C, Sullivan PF.

Department of Genetics, University of North Carolina at Chapel Hill, NC 27599-7264, USA.

AIMS: To investigate the prevalence and patterns of transitions between cigarette and snus use. DESIGN: Cross-sectional study within the population-based Swedish Twin Registry. SETTING AND PARTICIPANTS: A total of 31 213 male and female twins 42-64 years old. MEASUREMENTS: Age-adjusted prevalence odds ratios (POR) and 95% confidence intervals (CIs) described the association between gender and tobacco use, while Kaplan-Meier survival methods produced cumulative incidence curves of age at onset of tobacco use. Life-time tobacco use histories were constructed using ages at onset of tobacco use and current tobacco use status. FINDINGS: Although more males reported ever smoking (64.4%) than females (61.7%), more males were former smokers (POR: 1.33, 95% CI: 1.27-1.39). Males were far more likely to use snus than females (POR: 18.0, 95% CI: 16.17-20.04). Age at onset of cigarette smoking occurred almost entirely before age 25, while the age at onset of snus use among males occurred over a longer time period. Most men began using cigarettes first, nearly one-third of whom switched to using cigarettes and snus in combination. While 30.6% of these combined users quit tobacco completely, only 7.4% quit snus and currently use cigarettes, while 47.7% quit cigarettes and currently use snus. CONCLUSIONS: Current cigarette smoking is more prevalent among Swedish women than men, while snus use is more prevalent among men. Among men who reported using both cigarettes and snus during their life-time, it was more common to quit cigarettes and currently use snus than to quit snus and currently use cigarettes. Once snus use was initiated, more men continued using snus rather than quit tobacco completely.

Health risks of smoking compared to Swedish snus.Daniel Roth H, Roth AB, Liu X. Roth Associates, Inc., Rockville, Maryland 20852, USA.

Interest in tobacco harm reduction strategies has raised the question of the comparative health risks of cigarette smoking and use of other tobacco products. Although there appears to be a general belief that a unique smokeless tobacco product called Swedish snus has fewer health risks than cigarettes, no one has systematically reviewed the literature and compared the data on health risks in a quantitative manner. We reviewed the literature to identify all analytic epidemiologic studies that provided quantitative risk estimates associated with Swedish snus and cigarette smoking in a single population, using a common reference group. Seven studies were identified that addressed eight health outcomes. Although few in number, these seven studies do provide quantitative evidence that, for certain health outcomes, the health risks associated with snus are lower than those associated with smoking. Specifically, this is true for lung cancer (based on one study), for oral cancer (based on one study), for gastric cancer (based on one study), for cardiovascular disease (based on three of four studies), and for all-cause mortality (based on one study). This review has likely omitted many of the adverse effects of cigarettes, but probably few of the potential health effects of snus. Continued investigation of the reduced health risks of Swedish snus compared to cigarette smoking is warranted.

The decline of smoking in northern Sweden.Stegmayr B, Eliasson M, Rodu B. Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.

For decades men in Sweden have smoked at far lower rates than those in comparable countries. Previous studies showed that snus use played a major role in low smoking rates among men in northern Sweden; daily smoking declined from 19% (95% CI 16-22%) in 1986 to 11% (CI 8.9-14%) in 1999. The prevalence of smoking among all men is now 9% (CI 7.0-11%) and only 3% (CI 0.1-5.4%) among men age 25-34 years; the prevalence of exclusive snus use is 27% (CI 24-30%) and 34% (CI 27-42%) respectively. Combined smoking and snus use, an unstable and transient category, was under 5% in all surveys and was 2.2% (CI 1.4-3.4%) by 2004. For the first time snus use is also associated with a decrease in smoking prevalence among women. These patterns of tobacco use have implications for all smoking-dominated societies.

The burden of mortality from smoking: comparing Sweden with other countries in the European Union.Rodu B, Cole P. Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL 35294-0007, USA.

We describe the mortality currently attributable to smoking in the European Union (EU), and the change that would result if all EU countries had the smoking prevalence of Sweden. Almost 500,000 smoking-attributable deaths occur annually among men in the EU; about 200,000 would be avoided at Swedish smoking rates. In contrast, only 1100 deaths would be avoided if EU women smoked at Swedish rates. The low smoking-related mortality among Swedish men probably is due to their use of snus (Swedish smokeless tobacco).

Effect of smokeless tobacco (snus) on smoking and public health in Sweden.Foulds J, Ramstrom L, Burke M, Fagerström K. University of Medicine and Dentistry of New Jersey- School of Public Health, Tobacco Dependence Program, New Brunswick, New Jersey 08852, USA.

OBJECTIVE: To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden. METHOD: Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden. RESULTS: Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use. CONCLUSIONS: Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

Should the European Union lift the ban on snus? Evidence from the Swedish experience.Fagerström KO, Schildt EB. Smokers Information Center, Fagerstrom Consulting, Helsingborg, Sweden.

The very low smoking prevalence in Sweden has received considerable attention. Sweden was the only country in Europe to reach the World Health Organizations' goal of less than 20% daily smoking prevalence among adults by year 2000. Only 17% of Swedish men smoke. Some have argued that this has been achieved because Swedes use another form of tobacco instead. Sweden has a high level of use of a moist snuff product called 'snus'. Nineteen per cent of adult men and 1% of women are daily users and the trend is increasing. Epidemiological studies have failed to find evidence that snus causes cancers, including oral cancer. Its adverse effects on the cardiovascular system are debated, but are certainly less than those of smoking. Recent studies among former smokers indicate that many men have quit smoking using snus. Forty-seven per cent of current snus users are former smokers and 28% of ex-smoking used snus at their last attempt to stop smoking. The association between high snus consumption and low smoking prevalence has been debated and challenged. It has been argued that snus may be a gateway to cigarette smoking. Recent data has found that among those starting tobacco use in the form of snus, 20% later go on to smoking while the same risk for those not starting with snus is 43%. On balance, there is reason to believe that having snus available to the Swedish population has been of benefit to public health. Repealing the ban on snus in the rest of the European Union might also have some positive effect, depending on the marketing.

Harm reduction, public health, and human rights: smokers have a right to be informed of significant harm reduction options.Kozlowski LT. Department of Behavioral Health, Pennsylvania State University, University Park, PA 16802, USA.

Public health policy needs to be assessed for effects on human rights as well as public health. Although promoting harm reduction products to cigarette smokers might lead to greater total public health harm, if the products become too popular, human rights issues also need to be considered. Avoiding, or objecting to, the fair presentation of information on effective harm reduction products to smokers to allow them to make an informed choice to reduce health risk can represent a violation of a human right - the right to information. The necessary conditions are not met for protecting public health by restricting information on certain risk reduction products. As examples, based on current evidence, smokers have a right to information on snus (Swedish moist snuff) and medicinal nicotine as harm reduction options that would reduce substantially the risk of death to individuals. Smokers also have a right to truthful information about lower-tar cigarettes that have been erroneously promoted as risk reducing.

EU committee confirms health benefits of Swedish snus

The scientific committee (SCENIHR, Standing Committee on Emerging and Newly Identified Health Risks) has been assigned by the European Commission to evaluate the health effects of smokeless tobacco products including Swedish snus. The committee has now presented the final version of its findings to the Commission.

- The committee confirms the significant health benefits of Swedish snus relative to cigarettes. The report therefore constitutes a reevaluation of Swedish snus within the European Union where the product is currently banned, except in Sweden, says Lars E Rutqvist, MD, Ph D, Vice President for Scientific Affairs, Swedish Match AB, Stockholm, Sweden, previously Professor of Oncology at the Karolinska Institute in Stockholm.

- The scientific debate about snus within the EU has come to an end, and the politicians must now decide on whether it is reasonable to continue to deny European smokers access to a dramatically less hazardous alternative to cigarettes, Rutqvist concludes.

The SCENIHR report implies that there is no longer a scientific basis for a continued ban of snus within the European Union because the committee unanimously says that (page references to the report within parentheses):

Swedish snus has dramatically less adverse health effects than cigarettes (p. 113-114)

A smoker who switches to snus substantially reduces his or her risk for tobacco-related disease (p. 115-117)

The availability of snus as a substitute for cigarettes has had positive effects on Swedish public health (p. 116-117)

Swedish data contradict the hypothesis that snus is a gateway to smoking (p. 108, 116, 121)

It is, however, regrettable that these conclusions from an unanimous committee are not mentioned in the summary of the report which instead concludes that smokeless tobacco products contain nicotine which make them potentially addictive in the same way as cigarettes, that the nitrosamines in tobacco can be carcinogenic, and that the lack of controlled clinical trials of smokeless tobacco as a smoking cessation aid precludes firm conclusions, although it is noted that Swedish snus has been effective among Swedish male smokers (p. 110).

The committee finds it difficult to extrapolate the positive effects of snus on Swedish public health to other European countries. The potential net effect depends on the balance between the number of smokers who are able to quit with the aid of snus, and the number of non-tobacco users who take up snus unnecessarily (that is, smokers who would have quit anyway, or those who would not have used tobacco in any form). Although it is likely that the positive effects of snus on public health probably would be far more prominent (p. 117), the Committee feels that a lifting of the snus ban requires a more strict regulation of the whole tobacco area within the Union.

- It is not unexpected that the report mentions a number of potential negative aspects of smokeless tobacco products, says Rutqvist. Nobody has ever claimed that tobacco in any form is a health product. But what is striking is that the Committee so definitively and unanimously concludes that Swedish snus is dramatically less hazardous to health than cigarettes. This means that the scientific part of the debate about snus in the European Union now has come to an end. The next step is for the politicians decide whether it is reasonable to continue to deny European cigarette smokers access to an alternative that the Union’s own scientific expertise has concluded is much less hazardous. It is absurd that the most dangerous form of tobacco - cigarettes - continues to be freely sold all over the Union whereas the product with the least health effects - Swedish snus - is banned.

- This is probably only the first step in a long political process, says Rutqvist. There are strong forces within the European public health establishment that - irrespective of what the science says about Swedish snus - do not want to change their 30 year old message to the public about smokeless tobacco. But this final report includes so much scientific data about the relative benefits of snus which cannot be ignored in the debate about tobacco and public health. I remain optimistic that many decision-makers will take note of the Committee’s conclusions. Current tobacco policies within Europe are clearly inadequate as more than 700,000 EU citizens die prematurely every year as a result of cigarette smoking, Rutqvist concludes.

Harm reduction Cigarette smoking imposes a major public health burden on the world.

The tobacco harm reduction strategy proposes that individuals who cannot or are not willing to give up smoking can substantially reduce their health risks by switching to a smokeless tobacco product, such as snus. Opponents of the harm reduction approach argue that there could be unintended negative consequences of this approach, and that the only safe solution is to quit smoking without any aid or by using an approved nicotine replacement product.

What is the impact of smoking on morbidity and mortality?

The health risks associated with cigarette smoking are well known and the associated costs are enormous. The World Health Organization (2006) reports that half of all people who smoke (currently about 650 million people) will eventually be killed by their habit.

Recognition of this has led to increased efforts to encourage smokers to quit. While gains have been made, the majority of cigarette smokers are either unable or unwilling to quit their habit.

What is the tobacco harm reduction strategy?

The harm reduction approach grew from the recognition that the health hazards of cigarette smoking are primarily due to the burning of tobacco and its additives, and that smoking-related health hazards could be reduced by switching to "cleaner" sources of nicotine. This could be accomplished through either tobacco-based products (such as smokeless tobacco products or smoked products that have been modified to be less harmful) or through nicotine-replacement products (such as the patch or gum). There is some evidence that smokers may be more likely to accept the alternative tobacco products than the nicotine-replacement products, and thus have greater success quitting with the former.

Why do some researchers oppose this approach?

Opponents to the harm reduction approach argue that it could lead to unintended public health consequences. For example, an individual might begin using snus in an attempt to quit smoking, but end up using both products persistently (Henningfield et al. 2002). Alternatively, individuals who would never take up smoking might adopt use of snus, believing it to be without harm.

Critics of the harm reduction approach contend that the only risk-free solution is quitting tobacco altogether. They emphasize that snus may carry less risk than cigarettes, but that switching to snus is not without some risk of its own. Until the health consequences of long-term use of snus are known, they say that nicotine replacement therapy should be the aid of choice in smoking cessation.

What evidence is there that the health risks associated with use of snus are lower than those associated with cigarette smoking?

It has commonly been accepted, based on an observation of the "Swedish experience" that use of snus is associated with lower health risks than smoking. Swedish men have a low rate of smoking, but a high rate of snus use, and they also have very low rates of lung cancer and oral cancer. Numerous researchers have suggested that the low prevalence of smoking in Sweden is directly related to the availability of snus (e.g., Foulds et al. 2003, Henningfield and Fagerström 2001, Rodu et al. 2003).

More recently, researchers have attempted to quantify the difference in risks associated with cigarette smoking and use of snus. A quantitative analysis provided evidence that the health risks associated with snus are significantly lower than those associated with smoking for the following outcomes: lung cancer, oral cancer, gastric cancer, cardiovascular disease, and all-cause mortality (Roth et al. 2005). An expert panel concluded that mortality associated with use of low-nitrosamine smokeless (such as snus) is at least 90% lower than that associated with smoking (Levy et al. 2004).

What is the future for tobacco harm reduction?

It is undoubtedly an area that will continue to be controversial. However, many influential researchers believe that it would be unethical not to continue exploring the use of alternate tobacco products to cigarettes (Martinet et al. 2006). They note that it will be important to pursue this question in a scientifically based manner, and to consider all of the concerns mentioned above.

Smoking cessation There is a growing body of evidence that using Swedish snus can help some people quit smoking. Most cigarette smokers want to quit smoking, but few are able to do so. Many smokers say they need help to be able to succeed in quitting. Smoking rates among Swedish men have declined significantly over time as snus use has increased, suggesting that snus might be responsible for this decline. Epidemiology studies have shown that snus can serve as an effective smoking cessation aid, particularly among Swedish men. There are many benefits associated with using snus to quit smoking. There are also some public health implications, and some people have raised concerns that there could be unintended consequences.

Why would anyone consider using snus to quit smoking?

The vast majority of cigarette smokers want to quit smoking, and most who want to quit say they need help to do so, but only about 2% manage to quit each year (USDHHS 2000). Most believe they need support to be successful in quitting (Bolinder 2003). There is obviously a need for any method, especially an informal one, by which an addicted cigarette smoker could quit smoking.

What evidence is there that snus can lead to quitting smoking?

The pattern of smoking seen in Sweden over time is very different from that of other countries. During the past 20 years, smoking declined markedly while use of snus became more popular, especially among men. This striking inverse relationship suggested that Swedish men may have been using snus to quit smoking. An epidemiology study that specifically examined this hypothesis found that snus use was associated with smoking cessation (Furberg et al. 2005).

There is also evidence that the general public in Sweden recognizes snus as an informal way to quit smoking. Surveys show that many smokers stopped smoking when they started using snus (TEMO 2004). In addition, there is evidence that people who use snus are more likely to be successful in quitting smoking than those who use other aids, such as nicotine gum or the nicotine patch (Ramström and Foulds 2006).

Ultimately, additional data from the most rigorous studies (called controlled clinical trials) is needed to demonstrate that snus is an effective aid in quitting smoking.

What are the benefits of using snus to quit smoking?

There are several important benefits: snus is available without prescription, may be less expensive than traditional nicotine replacement therapies, and is associated with an immediate reduction in the health risks attributed to smoking. A quantitative analysis recently confirmed that the health risks associated with snus use are significantly lower than those associated with smoking (Roth et al. 2005).

Are there any risks to using snus to quit smoking?

There is some debate in the public health community about advocating using snus to quit smoking. Critics fear that there could be unintended consequences. For example, someone might plan to use snus for a limited period of time to quit smoking, but end up using both products indefinitely, or might quit smoking but continue using snus long-term. Others argue that the only risk-free solution is to quit all tobacco products; if an aid is required, they recommend use of an approved nicotine-replacement therapy. However, given the significant health hazards of long-term smoking, and the need for effective smoking cessation tools, many people believe that it is important to continue to investigate the potential use of snus as a smoking cessation aid.

Conclusion: Snus as an alternative to smoking

Is it true that the nicotine uptake from Snus is mucher higher than that from cigarettes and that Snus users are more addicted to nicotine than cigarette smokers?

No. Studies on Swedish Snus users have shown that they have about the same blood nicotine levels as cigarette smokers. One study showed that Swedish Snus users and smokers, who had the same blood nicotine levels, experienced the same degree of subjective nicotine dependence.

Do Snus users and cigarette smokers run the same health risk?

According to a report from the Swedish National Board of Health and Welfare, “Hälsorisker med Snus, 1997”, the health risks associated with Snus are in all probability lower than those associated with smoking. The Royal College of Physicians argues in a report from 2002 that it is 10 to 1000 times less dangerous to use smokeless tobacco products than to smoke cigarettes.

Is it more difficult to quit snus use than to quit smoking?

No. A recent study has shown that Snus users and cigarette smokers experience the same difficulties when trying to give up their tobacco habit.

Is it true that Snus use is a gateway to smoking?

No. A recently presented study has shown that Snus use decreases the propensity to start smoking.

Is it true that it is more difficult to stop using tobacco products if you use Snus as a quit smoking aid?

Several studies have shown that Snus works as a viable alternative for those who want to stop smoking. Those, who then want to stop using tobacco, may gradually phase out the use of Snus or use any of the nicotine replacement products available on the market. How difficult it is depends on the individual’s nicotine dependence, motivation and other facors.

Has Snus had any role what so ever to decrease the rate of cigarette smoking in Sweden?

Isn’t it true that females have decreased their smoking rate without using Snus. Both males and females have decreased their smoking rate during the past decades. However, males have in comparison decreased their smoking rate to a larger degree than females and have started to use Snus instead. About half of those, who are Snus users today, have previously been cigarette smokers. Although, it is not possible to exactly specify the number of smokers, who has quit smoking with the aid of Snus, the statistics speaks for itself. Those, who look upon Snus as an alternative to cigarettes, have been far more successful to quit smoking than those who do not.