Learn about "the Swedish Experience" which it's called in the scientific community. It's the paradox that the male tobacco use in Sweden is the same as in the rest of Europe. However, the risk for men of dying from a tobacco-related disease is less in Sweden than the rest of Europe. Swedish men smoke much less than in other countries but instead use Swedish Snus.

THE SWEDISH EXPERIENCE

The prevalence of male tobacco use in Sweden is similar to that of many other European countries. However, the risk for men of dying from a tobacco-related disease is less in Sweden than in any other European country. In the scientific community this paradox has been referred to as “the Swedish Experience” and can probably be explained by the unique pattern of tobacco use in Swedish males. Swedish men smoke much less than in other countries but instead use Swedish Snus to a large extent. In fact, Snus use is as common as smoking.

However, the risk for Swedish females of dying from a tobacco-related disease is in level with the risk for women in the rest of Europe. The tobacco consumption pattern of Swedish females is in line with the pattern in other parts of Europe as Swedish females never used Snus to any large extent. This comparison between males and females speaks for the fact that snus is one of the major factors involved in the staggering harm-reduction statistics for Swedish men.

Facts:
• In 1998, 17.1 % of adult Swedish males smoked compared with an average of 32 % for Denmark and 33.7 % for Norway (1).
• In 1997, Swedish snus was used by 19 % of the adult male population. Swedish males are the only Europeans to extensively use Swedish snus (2).
• The per capita consumption of tobacco products, grams per person, 15 years +, in 1998 was: Sweden - 1400, Denmark - 1612 and Norway - 1304 (3).
• More users progress from smoking to Swedish Snus than from Swedish Snus to smoking (4).
• Sweden became the first and only country in the world to lower adult smoking prevalence below the WHO target level of 20 % before the end of year 2000 (5).
• In 1990, 11 % of all male deaths in Sweden were smoking-related compared with an average of 25 % in Europe (6).
• In 1990, the risk of a 35 year-old male dying from smoking-related illness before the age of 70 was 4 % in Sweden compared with 10 % in Denmark and 6 % in Norway in 1990. Sweden has an average incidence of smoking-related death amongst women in Europe (7).
The number in brackets refers to the list of references.

This evident difference in tobacco related health effects in Swedish males in relation to males in the rest of Europe implies that the health risks associated with Swedish Snus differ from those known to be associated with smoking. This difference has also been confirmed in recent scientific studies. Even if the studies do not clear Swedish Snus completely from potential negative health effects the reports show a very different picture of Snus related effects than those associated with smoking.

Facts:
• The incidence of lung cancer amongst Swedish males has dropped in the past 20 years. Females have shown an increasing trend on lung cancer (8).
• Two epidemiological studies recently performed in Sweden did not show any association between the use of Swedish Snus and oral cancer (9,10).
• Recent epidemiological studies on gastric cancer and esophageal cancer did not find any association between Swedish Snus and an increased risk of any type of those cancers (11,12)
• Cancer deaths are not raised amongst Swedish smokeless tobacco (Snus) users compared to non-tobacco users (13).
• The risk of myocardial infarction is not increased in Snus users (14).
• No significant elevation of diastolic blood pressure, hemoglobin concentrations, white cell count, serum cholesterol or triglyceride levels has been found in Snus users. This is in contrast with findings for cigarette smokers (15).
• Both Snus users and smokers face a higher risk of dying from cardiovascular disease than non-users. The risk for Snus users is lower than for smokers (13).
• The health risks associated with Snus are, with a high probability, less than the risks associated with smoking (16,17).
The number in brackets refers to the list of references.

In the Press

The Scientist, Volume 17 | Issue 6 | 22 | Mar. 24, 2003 (The Scientist is an international news magazine)
"The new, so-called harm-reduction products are getting mixed reactions from public health officials. These can include "safer" cigarettes, novel nicotine products, and smokeless tobacco, such as low nitrosamine Snus from Sweden. "Snus is the most interesting harm-reduction story in the world," says Kenneth Warner, director, University of Michigan Tobacco Research Network. Perhaps because of its low cost compared to cigarettes, almost 30% of Swedish men use Snus. "The Swedish government has studied this stuff to death, and to date, there is no compelling evidence that it has any adverse health consequences. ... Whatever they eventually find out, it is dramatically less dangerous than smoking," says Warner."

University of Minnesota Cancer Center
"Smokeless Tobacco Study: Alternative Nicotine Treatment Systems (ANTS)
This study examines the health effects of Swedish Snus and the nicotine patch. Snus is a Swedish smokeless tobacco product that contains less nitrosamines (cancer causing agents) than traditional American smokeless tobacco. The nicotine patch is a transdermal nicotine delivery system used to quit tobacco use."

Wall Street Journal Volume 34, 2001
"In week 34 of 2001 Wall Street Journal published an article about a laboratory test on tobacco snuff carried out by the health authorities in Massachusetts. Massachusetts is the state which have been working hardest to implement the toughest regulations against tobacco. What happen in this state is carefully monitored by federal authorities and the tobacco industry. In the examination the existence of carcinogenic nitrosamine substances were compared among five US brands together with the Swedish brand "Ettan snus". The result showed that Ettan snus scored lowest amount of carcinogenic nitrosamine substances, containing 2.8 per mil of weight, compared with 127.9 per mil of weight for the worst US brand. According to laboratory experiment on rats, nitrosamine substances have developed tumours. But to get the amount of nitrosamine substances that the rats were given, a man has to consume 1654 lb. - 750 kg (the weight of a small car) of the Swedish Ettan snus per day."

Journal of Internal Medicine
Volume 253 Issue 6 Page 660 - June 2003
doi:10.1046/j.1365-2796.2003.01143.x

Evolving patterns of tobacco use in northern Sweden
B. Rodu1, B. Stegmayr2, S. Nasic2, P. Cole3 & K. Asplund2
Abstract. Rodu B, Stegmayr B, Nasic S, Cole P, Asplund K (University of Alabama at Birmingham, Birmingham, AL, USA; Umeå Hospital, Umeå, Sweden). Evolving patterns of tobacco use in northern Sweden. J Intern Med 2003; 253: 660-665.

Background and objectives. Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999.

Design. This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999.

Results. Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05).

Conclusions. The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.

The University of Alabama at Birmingham
HOW SMOKELESS TOBACCO HAS SNUFFED OUT SMOKING IN SWEDEN
Impact of smokeless tobacco use on smoking in northern Sweden. Published in the Journal of Internal Medicine, Volume 252, pages 398-404, 2002. By Brad Rodu, Birgitta Stegmayr, Salmir Nasic and Kjell Asplund. (TRF)

For the past 50 years men in Sweden have among the lowest smoking rates of any developed country in the world. But they haven't given up tobacco entirely. Sweden also has the world's highest consumption of smokeless tobacco, in the form of moist snuff (called snus in Swedish).

Until now the fascinating tobacco use pattern seen in Sweden, called the Swedish model, has received very little attention. In 2002 Dr. Rodu spent six months in Umea, Sweden, working closely with Swedish researchers to investigate the role of smokeless tobacco in making smoking smoking history in that country. This study is the first product of that research effort, and it looks at tobacco use patterns, both snus use and smoking in northern Sweden from 1986 to 1999.

The popularity of snus among Swedish men has played a big role in low smoking initiation rates. For example, although 67% of men in this study have used some form of tobacco at some point in their lives, only 50% have ever smoked. Compare this with American men, among whom 65% have ever used tobacco and as many as 59% have ever smoked.

But the real benefit of snus is that it has helped smokers quit. For example, in 1986 19% of men smoked and 18% used snus, but by 1999 only 11% of men smoked and 27% used snus. The decline of smoking and increase in snus use was not coincidental. Our analysis shows that snus was the major factor in smoking cessation among men. Over the entire period of our study a higher percentage of women smoked than men. This is a reversal of the pattern in virtually every other society in the world, where smoking is generally much more common among men than women.

But the news for women is not all bad. In 1999 snus was used by 6% of women, a big jump compared to earlier years. It will come as no surprise that smoking among women, which was as high as 26% in earlier years, had dropped to about 20% in 1999.

The Swedish model of tobacco use shows that smokers have adopted safer tobacco products. The Swedish model is not the result of a governmental campaign or other public health strategy. It is the result of Swedes making educated choices about tobacco use.

University of Maryland School of Medicine, Jerome H. Jaffe
The current controversy surrounding smoking asks whether smokeless tobacco is less harmful to health than tobacco smoke. There is evidence that it is. Currently there is no data linking smokeless tobacco to the diseases attributed to smoking, including cancer, cardiovascular, and respiratory diseases. Cigarette smoke contains over 4000 compounds, 43 of which are toxic and/or carcinogenic. In smokeless tobacco products the major carcinogens are tobacco specific nitrosamines (TSNAs), which are associated with oral cancer.

There are many types of smokeless tobacco. Most contain dark tobacco varieties and come in a multitude of forms from powdered to stripped and packed. Most importantly, these products differ in their constituents of health concern. Among brands of smokeless tobacco, TSNA levels differ by more than one thousand-fold in poor nations and by several hundred-fold in advanced economies.

Swedish use of smokeless tobacco has provided data supporting the benefits of smokeless tobacco. Snus, a traditional form of oral smokeless tobacco, is now used by about 20 percent of men and 2 to 3 percent of women. During the past twenty-five years, the use of snus among men has increased while the rate of cigarette smoking has decreased. The smoking rate for men in Sweden is now the lowest in the developed world. Also, men with a history of snus use have a higher rate of quitting cigarette use.

For the last twenty years, Swedish snus has been prevented from containing high levels of TSNAs. Case studies have shown no significant increases in mouth cancer among snus users. These same studies found an elevated risk of mouth cancer among smokers and heavy drinkers. An Institute of Environmental Medicine study found that long-term use of snuff does not alter risk factors for cardiovascular disease. Furthermore, studies do not indicate that use of snus increases the risk of cancer. However, there is still insufficient evidence to completely exclude the risk of cancer. It is important to note that while snus use in Sweden is higher than in Canada, Denmark, France, or the United States, the death rate for smoking-related diseases and oral cancer is lower in Sweden than in any of these countries. The Swedish case is an example of the possibility of using smokeless tobacco to reduce the adverse health consequences of smoking.

Tobacco Reporter, 2003-03-31
SMOKELESS ALTERNATIVE / Recent studies suggest that using snus is less risky than smoking cigarettes.
As health activists debate their strategy, Swedish Match steps up production.

Intro: Sweden is the only country in the world to have reached the World Health Organization's (WHO) goal of bringing its share of smokers down to less than 20 percent of the population by 2000. Fewer than one in five adults still smoke. So what is the secret? The answer is moist snuff, or as the Swedes call it, "snus," and it is no secretit's tradition. Snus has more than 1 million users in Sweden alone, half of which are former smokers.

Brian Wicklin, senior statistician for the Swedish Statistical Bureau VECA, says, "Sweden maintains a low smoking profile and a high snus profile." According to a report published by the bureau in September, smoking prevalence among Swedish men decreased from 36 percent in 1980 to 17 percent in 1997. The figure for women went down from 29 percent to 22 percent during the same period.

Snus use, by contrast, increased from 562 grams per person (age 15 and up) in the years 1980-1982 to 796 grams per person in 1998-2000, according to VECA.

Tobacco Control Program, Massachusetts Department of Public Health, USA
A recent Industry Watch (Tobacco Control; 2001;10:253-7) explored an "experiment in progress"the use of snus (oral snuff) by Sweden's males as a possible substitute for cigarette smoking and as a way to reduce male lung cancer. A recent study commissioned by the Massachusetts Department of Public Health and conducted by the American Health Foundation found that levels of tobacco specific nitrosamines (TSNAs), the principal class of carcinogens in snuff, were only 1.8 µg/g for ETTAN, the most popular Swedish brand versus 41.1 µg/g for Copenhagen the most popular US brand. Swedish Match selects special tobacco blends and employs a new fermentation process to prevent formation of TSNAs. It could be argued that the low levels in Ettan make it "safer". However, the Ettan levels (1800 parts per billion) are still hundreds of times greater than what would be allowed in regulated products; for example, the limits for NDELA, another, non-tobacco nitrosamine in bacon and beer, are 5 and 10 parts per billion respectively.

The prevalence of daily smoking among Sweden's males has fallen from 36.3% in 1980 to 17.1% in 1998. However, male snus use increased only modestly during the period from 16.6% to 18.2%, making it difficult to attribute the decline in male smoking to smokers switching to snus.

Sweden has been one of the most progressive European nations in curbing smoking through bans on advertising, taxation, and treatment of tobacco dependence. The US experience has shown that such comprehensive efforts contribute to large declines in tobacco use. The states of California and Massachusetts have conducted well funded comprehensive tobacco control campaigns. Both campaigns have aggressively passed tobacco control policies including taxation, eliminating public smoking, aggressive counter-advertising, crackdowns on tobacco sales to minors, and treatment of smokers. In 1998, the male smoking rate for California was 15.1% and Massachusetts 15%. In 1999, male use of chewing tobacco and snuff was only 2.4% in California. Massachusetts stopped measuring snuff use when it fell below 1% in 1993.

Swedish Match has recently introduced a new brand of oral snuff called Exalt into two test markets in the USA, Ohio and North Carolina, and is advertising the product on its website. It is a teabag pouch of oral snuff that has low levels of TSNAs and the user doesn't have to spit. The website is marketing the product not as a complete substitute for cigarette smoking, but as a temporary replacement where smoking is bannedairlines, worksites, theatres, and homes. There is little or no information in the site on the dangers of smoking, how to quit smoking, or the differences in health risks between smoking and smokeless tobacco use. Clearly, the product is being marketed as a complement to continued smoking.

Two US companies, Star Scientific and US Smokeless Tobacco Company, are about to launch similar low TSNA, spitless tobacco products. Swedish Match's strategy may be appealing to cigarette manufacturers since it does not promote quitting and may counteract the cessation effects generated by clean indoor air laws. Also, the product is cheap, costing a fraction of the price of nicotine gum or patches. This price difference may result in the pharmaceutical industry reducing their promotion of cessation medications if potential quitters turn to "safe" snuff rather than nicotine gum.

Another possible unintended consequence of a "snus experience" could be youth initiation into smoking. In the 1980s, the United States Tobacco Company targeted non-smoking young males with low nicotine, snuff starter products. The company employed a "graduation" strategy that intended new users to "graduate" up to higher nicotine brands over time. Among US 17-18 year old males, oral snuff use soared from 0.3% in 1970 to 2.9% in 1985, an eightfold increase. A Washington State study found that snuff became a nicotine entry product for young males who switched to cigarette smoking as they grew older.

Tobacco companies Swedish or American want to make money and the health of people is not part of the bottom line. The Swedish experiment could become an "increased harm experiment" where continued smoking is supported, clean indoor air laws weakened, and pharmaceutical companies that promote cessation products driven out of the marketplace. Since tobacco products are not regulated, we should be very cautious in arguing that one product is "safer" than another. It is a dynamic environment where all tobacco manufacturers will work together to promote each other's products and addiction to nicotine. We should be very careful in choosing our tobacco bedfellows.

The Western Mail - The National Newspaper Of Wales

'Lift ban on nicotine alternative' Jan 7 2003

THE BEST hope of reducing the UK's growing cigarette death toll lies in an alternative tobacco product banned across Europe, a Welsh MP will claim today.

Paul Flynn is advocating the use of a cross between snuff and chewing tobacco - known as snus - for nicotine addicts as a less damaging alternative to cigarettes.

The Newport West MP believes the UK should follow the example of Sweden where one in five men use snus but lung cancer rates and other smoking-related diseases are the lowest in Europe.

And he will lead a debate in Parliament this afternoon, urging the Government to back a bid to over-turn the Europe-wide ban on snus.

"All the things we are currently doing to discourage people from smoking, such as the advertising ban and anti-smoking campaigns, are worthwhile but will have a limited effect," Mr Flynn said.

"But the impact of switching to a form of nicotine product that gives people who are addicted to nicotine the buzz they crave without the health risks has been proven over 100 years in Sweden.

"Tobacco is not the killer - smoking is. Nicotine is no more dangerous than caffeine.

"It's madness for us to continue to ban snus when it could well be a major lifesaver and save the NHS a fortune."

Snus is a form of moist ground tobacco that is placed between the lip and the gum and sucked rather than chewed. It has been manufactured and used in Sweden since 1822 but is banned in the rest of Europe.

About 20% of men in Sweden - which negotiated a special exemption from the ban on snus when it joined the EU - use snus, compared to 15% of men who smoke. Few women use snus and the female lung cancer death rate is comparable with the rest of Europe.

Sweden's lung cancer death rate is almost half of that in the UK and the lowest in Europe. The country is the only one to meet the World Health Organisation's target of less than 20% of the population being smokers.

A US study found that people who switched to snus from cigarettes had the same life expectancy as those smokers who gave up tobacco altogether.

And rates for oral cancer - commonly associated with the use of oral tobacco products - were found to be lower in snus users than cigarette smokers in a study published in the International Journal of Cancer in 1998.

The Swedish National Board of Health and Welfare also concluded there is "little evidence" for an increased risk of oral cancer among snus users.

The president of Swedish Match, the company that makes snus and is challenging the European ban, Lennart Sundén, said, "The ban on oral smokeless tobacco lacks adequate legal base and violates the principles of non-discrimination and proportionality.

"It does not even serve the purpose of promoting public health, but is in fact counter-productive to that purpose."

The idea of introducing snus as an alternative to cigarettes for nicotine addicts is also backed by anti-smoking group ASH.

"We have to be realistic that some people do not want to give up tobacco or nicotine and if there is a product they can use where the risk of cancer is cut dramatically then it would be reasonable to allow them to do that," said spokeswoman Amanda Sandford.

Professor Martin Jarvis, a clinical psychologist at University College, London, and a member of Cancer Research UK's health behaviour unit, said, "It's hard to offer a rational defence of the current ban on oral tobacco products as it manages not to ban the most harmful forms.

"Oral products such as Swedish snuff do not deliver any combustible products like you get from cigarettes, and where it is used instead of cigarettes in Sweden there are much lower rates of cigarette-related deaths.

"Why it should be banned is not at all clear. I don't think it should. But will people in a country like the UK use it? I'm not at all sure that we know the answer.

"The big challenge to any recreational nicotine producer is to give users nicotine in a way they find satisfying without harming their health."

But Dr Richard Walker, chief executive of the Tenovus Cancer Information Centre in Cardiff, said, "As far as I am concerned, any tobacco product exposes the user to carcinogens and I cannot emphasise enough the dangers people expose themselves to when using them.

"I would prefer to see the ban retained as I think it gives out the wrong message - there's no incentive to give up if would-be quitters are told there is a product out there that is not as bad."

From New Scientist magazine, vol 172 issue 2316, 10/11/2001, page 28
Clare Wilson is a medical journalist in London

My friend nicotine 10 Nov 01

Either quit or die, smokers are told. But Clare Wilson says this message is doing more harm than good

THE evil weed, cancer sticks, coffin nails . . . From the names smokers use to describe their habit it's obvious they know they should quit. Politicians and doctors agree. The orthodox view is that slowly and surely, via creeping prohibition, tax hikes, education and medical intervention, people must be weaned off their deadly addiction until eventually, one fine day, the last smoker stubs out their last ciggy-and we'll all live happily ever after.

Fat chance. Smoking is on the up worldwide and the trend shows no signs of slowing. There's about a 1 per cent increase in cigarette consumption every year, with the number of smokers worldwide now standing at about 1.1 billion and expected to rise to 1.6 billion by 2025. Small decreases in a few Western countries have been outweighed by people in developing nations taking up the habit with gusto. And even in much of the West, smoking among young people is rising, too.

The orthodox approach isn't working. Maybe it's time to think the unthinkable and accept that a tobacco-free world isn't going to happen. But learning to live with tobacco is not the same as leaving smokers to their fate. There are well-researched strategies to cut deaths from smoking that have little to do with propaganda or prohibition. They receive scant attention from governments because they're just not politically acceptable. But they work.

Take Sweden, for example. It was the only country to meet the World Health Organization's target of reducing smoking prevalence to 20 per cent of the population by 2000. Its success is all down to a strange cultural predilection for what might be called "sucking tobacco". No one's suggesting that the rest of us take up the habit, but Sweden points to a new way to save lives.

There's no doubt that smoking is a global health problem. Smokers are 25 times as likely to contract lung cancer compared with non-smokers, and run two to three times the risk of a heart attack. Half of smokers die prematurely as a direct result of their habit, 4 million a year worldwide.

Yet smokers aren't dying of ignorance. They understand the harm their habit is doing to their health. According to British anti-smoking group ASH (Action on Smoking and Health), two-thirds of smokers want to quit and half of these attempt to do so every year. But success rates are dismal. Of those who try using will power alone, only 5 per cent are sticking to their guns one year later, according to a 1999 review by England and Wales's Health Education Authority.

The problem is that nicotine is ferociously addictive (New Scientist, 13 August 1994, p 10). Once people get hooked, they find it nearly impossible to give up. Nicotine latches onto receptors in the brain, causing nerve cells to release the dopamine that produces a pleasurable high. This psychoactive effect makes users seek the drug out-a classic element of addiction. In terms of chemical dependence, doctors rank nicotine as more powerful than heroin and cocaine.

The orthodox response has been to classify smoking as a "disease" and try to cure it. In the past few years drugs companies have flooded the market with "smoking cessation products". Almost all of these are nicotine replacement therapies-chewing gum, skin patches, lozenges or inhalers designed to deliver a dose of nicotine large enough to kill cravings but too small to produce a high. The idea is that you use nicotine replacement therapy as a temporary pharmaceutical crutch to keep the pangs at bay while you kick the habit.

Replacement therapy is possible because nicotine itself is pretty harmless. True, it does have some stimulatory effects on the nervous system, leading to raised blood pressure and heart rate. It's also toxic, though you'd have to chew 20 pieces of nicotine gum simultaneously to risk a lethal dose. Perhaps more seriously, nicotine itself is a mild carcinogen (New Scientist, 2 December 2000, p 10) and promotes blood vessel formation, which can help the growth of existing tumours. But the consensus is that smokers aren't dying from what they are actually addicted to. It's all the other chemicals in tobacco smoke that do them in.

Burning tobacco gives off around 4000 compounds, at least 60 of which are known to cause cancer. Cigarette smoke also contains carbon monoxide, which reduces the blood's ability to carry oxygen and so puts a strain on smokers' hearts and lungs.

Finding new ways of delivering nicotine satisfies short-term cravings, but its success rate in getting people to quit smoking isn't good. Without additional support, such as weekly counselling sessions and telephone helplines, 90 per cent of people who try nicotine replacement therapy start smoking again within a year. Even with the most successful drug, GlaxoSmithKline's Zyban, around 85 per cent of quitters fail.

So how come Sweden does so well? The answer is that smokers there aren't faced with the quit-or-die dilemma. Instead of using a nicotine replacement therapy with the aim of quitting both smoking and ultimately nicotine, they can continue using tobacco as a recreational drug, safe in the knowledge that it probably won't kill them. It's all down to a product called "snus", a form of moist ground tobacco that you pop between your lip and gum. Snus comes in two forms, either loose or packed in small portions like miniature tea bags. Both deliver nicotine direct to the bloodstream.

Among Sweden's 3.4 million men, snus is more popular than smoking: about 19 per cent use snus and 17 per cent smoke. That's easily the lowest rate of smoking in Europe-half the rate of Norway, for example-and it translates into an excellent health record. Swedish men have the lowest rate of lung cancer in Europe, according to WHO figures, and the lowest risk of dying from a smoking-related disease-just 11 per cent compared with 25 per cent in Europe as a whole. Karl FagerstrÖm of the Helsingborg Smokers' Information Centre, a smoking cessation clinic, is in no doubt that snus should take the credit. "It's very hard to argue that there are other factors responsible," he says. "It's very common to switch from smoking to snus. If they can't give up smoking then I suggest snus because it's much less dangerous than setting fire to tobacco." Tellingly, about half of snus users are former smokers.

The evidence that snus improves public health becomes even stronger when you consider Swedish women. They hardly touch the stuff-only around 2 per cent use it-so act as a built-in control to the experiment. And their record on smoking-related diseases is nothing out of the ordinary. Swedish women are just as likely as any others to die from smoking, and their lung cancer rates are comparable with those of other Scandinavian countries.

Recreational drug

Snus isn't completely harmless. Users increase their risk of cardiovascular disease by 40 per cent. But that's lower than the risk among smokers. And crucially, snus doesn't seem to cause mouth cancer, which is a serious risk with other forms of oral tobacco. A long-term study of 135,000 Swedish men, published in the American Journal of Public Health in 1994, found that snus caused no increase in cancer risk at all. The reason is that snus is cured under conditions that inhibit the production of carcinogens.

Snus, in effect, is nicotine replacement without the therapy. It's a pleasurable, recreational drug, and users aren't under pressure to stop. Swedish Match, the Stockholm-based tobacco company that dominates the snus market in Sweden, explicitly promotes its product as a safer alternative to smoking.

The "Swedish experiment", as it has come to be known, has inspired some health campaigners to press for a more enlightened approach to the smoking epidemic. It's a concept they call "harm reduction". "If you look at Sweden, we have a living example of the concept in action," says Clive Bates, director of ASH.

Snus on its own will never be the answer. For one thing, few people outside Sweden have heard of it, though there's some tradition of use in Germany and Denmark. It's also illegal. The European Union banned it in 1992 as part of a general assault on oral tobacco. Sweden negotiated an opt-out when it joined the EU in 1995.

But the Swedish experiment does suggest that we could tackle smoking more creatively. In most countries, nicotine replacement therapies are tightly regulated, sold only in pharmacies as temporary aids for bona fide quitters. They're expensive-in the US, for example, one day's supply of nicotine replacement therapy can cost half as much again as a pack of 20 cigarettes-and product leaflets give strict warnings that using nicotine replacement therapy while still smoking could trigger a nicotine overdose, leading to dangerous heart problems. In other words, if you want to use replacement therapy to help you cut down, whittle down a 40-a-day habit in stages, or just get through a non-smoking transatlantic flight, you're in for an uphill struggle.

To many anti-smoking activists this is crazy. David Sweanor, legal adviser to the Canadian Smoking and Health Action Foundation, cites the example of a parent on a long car journey, desperate to avoid smoking as their child is in the back seat: "Cigarettes are readily available at their first petrol stop, but nicotine gum isn't." He believes that as well as being an aid to quitting, nicotine replacement therapies should be available as a consumer product.

But drug regulatory agencies are ultra-cautious. They're not convinced by the argument that chewing nicotine gum for half your life can't be as bad as smoking like a chimney, because it hasn't been tested in long-term clinical trials. "Going from a pack a day to half a pack a day is bound to make a difference to people's health," Sweanor says. "But until you can prove that, you can't get that licence."

Harm reduction, however, isn't the sole preserve of the drugs industry. Some tobacco companies have decided to take the matter into their own hands by developing safer cigarettes. Admittedly, they'll still probably shorten smokers' lives, but maybe by not quite as much-which must be better than leaving things as they are.

One safer cigarette currently being test-marketed is Eclipse, developed by US tobacco giant RJ Reynolds. It consists of a tube of tobacco with a heat source at one end. To "smoke" it you light the heat source and suck on the other end, which draws heated air through the tobacco and evaporates the nicotine in a similar way to hot water passing through coffee grounds. Most of the tobacco doesn't catch fire and the cigarette doesn't burn down. RJ Reynolds claims that the smoke contains lower levels of 14 known or suspected carcinogens than ordinary cigarette smoke.

Harm reduction cigarette
RJ Reynolds test-marketed a similar product, Premier, in 1988 but withdrew it because smokers didn't like the taste. Eclipse has a shot of tobacco in the heat source to produce a slug of real smoke, but it's still not certain that smokers will take to it.

Other tobacco companies are trying to make actual cigarette smoke safer, by reducing levels of carcinogens. One American firm, Star Scientific, is staking its future on a tobacco-curing process that it says reduces the levels of some carcinogens.

But again, there are regulatory problems. There's no point in tobacco firms investing money in safer products if they are not allowed to make health claims. And regulators take a dim view of using the words "safe" and "cigarettes" in the same sentence.

They've had their fingers burnt, so to speak, on this before, by low-tar cigarettes. Regulators were happy to accept health claims, only to find that "light" brands were actually more dangerous. Low-tar smoke is less irritable to the airways, so smokers inhale more deeply, exposing a greater proportion of their lung tissue to carcinogens. As a result, lung cancer rates actually rose after the introduction of low-tar cigarettes (New Scientist, 15 March 1997, p 8).

Despite the regulatory problems, there are signs that health authorities are starting to take harm reduction seriously. Earlier this year, the US Institute of Medicine published a report on "potential reduced-exposure products", including snus and nicotine replacement therapy. The key question was whether harm-reduction products save lives in the long run, or whether their benefits are outweighed by people staying addicted to nicotine when they might otherwise have quit-or even taking up smoking when they wouldn't have otherwise.

Backward step

The report was eagerly awaited by harm reduction advocates who hoped it would back their way of thinking. But they were disappointed. One of the main conclusions was that there's no evidence harm reduction improves public health, and might even damage it. Far from breaking new ground in tobacco policy, the report was widely seen by campaigners as a retrograde step.

Joint author Robert Wallace, an epidemiologist at the University of Iowa, defends the report, saying: "We don't want people to be misled into thinking they are taking a product that's less harmful to their health when what they should be doing is quitting. The long-term health effects of these products are not defined. They certainly should not be able to make claims that they're safer because there's simply no evidence."

Outside the US, however, harm reductionists are gaining ground. New legislation in the EU will soften the health warnings on snus, replacing "causes cancer" and "seriously damages health" with "can damage your health" and "is addictive". The same legislation, due to come into force next year, enjoins EU scientists to investigate reduced-risk tobacco products. Whether this will pave the way for snus to be legalised across the EU remains to be seen. But a showdown is likely when Swedish Match takes the German authorities to the European Court of Justice for trying to enforce the ban.

The WHO has gone even further. Its most recent report on regulating tobacco products, published in May, acknowledges that there is a need for new tobacco delivery systems, and even calls for "more progressive" regulatory methods.

No one sensible is suggesting that harm reduction should replace measures such as banning tobacco adverts or sales to children. And the single most beneficial thing an individual smoker can do is quit. But there might be real public health benefits from pursuing policies that encourage harm reduction when quitting isn't possible.

There are historical precedents. Needle-exchange schemes for heroin addicts sparked moral outrage when they were first introduced, but they are now seen as an invaluable tool in reducing the spread of HIV and hepatitis. Harm reduction for nicotine addicts also entails steps that some view as morally repugnant. Legislators and doctors will have to start working side-by-side with tobacco companies, having spent all their professional lives viewing them as agents of Satan. Perhaps they're taking the term "evil weed" too literally.

GOTHIATEK
Ever since the beginning of the 20th century the Swedish Snus has been of dominating kind - Swedish Snus made by Swedish Match. A strong driving force for Swedish Match has been the continual improvement of the products and introducing stricter quality requirements on raw materials, manufacturing and final products. Today this work has resulted in a standard – GothiaTek®. GothiaTek® is a system for a continual reduction of the harmful elements in Swedish Snus.

GOTHIATEK® of Swedish Match is the result of decades of research and development, a work that has led to unique products, produced in a unique manufacturing process.

In recent years a number of scientific reports on the health effects of Swedish snus have been published. The findings of these reports have helped to clarify some controversial health related issues. Importantly, Swedish researchers did not find any association between the use of snus and cancer or an increased risk of heart infarction.

The World Health Organization (WHO) has identified smoking as one of the largest public health threats in the world. In Sweden, however, snus has replaced cigarette smoking
to a large extent, particularly among men. Consequently, in an international perspective, Swedish males run a comparatively low risk of dying from a tobacco related disease. In the scientific community this circumstance has been named “the Swedish experience”.

Our quality standard GOTHIATEK® rests on three legs:

- Requirements on maximum permitted levels of suspected harmful elements that occur naturally in tobacco.

- Requirements on the manufacturing process and raw materials.

- Requirements on qualified product information to consumers.

The following pages will give you more details about Swedish snus by GOTHIATEK® (Swedish Match)

Philosophy
It is Swedish Match's belief that the adverse health effects of tobacco use, at least in the Western World, is primarily related to inhalation of smoke. Scientific data clearly demonstrate that the health risks associated with the use of Swedish Snus are significantly lower than those of cigarette smoking.

Data from Sweden show that snus favours smoking cessation. Swedish studies also show that the existence of snus has rather decreased smoking initiation rates. Swedish males have a record low risk of dying from a tobacco-related disease although the prevalence of male tobacco use in Sweden does not differ from many other countries.

We believe therefore that Swedish Snus by GothiaTek® can play a role in harm reduction strategies, as has been demonstrated by several Swedish studies. Snus provides a far more sensible alternative foremost because it is simply not smoked and consequently does not deliver toxic pyrolysis products.

We do not claim that the use of Swedish Snus could not have any adverse health effects and we do recognise that the use of snus raises serious questions that need to be addressed.

If one realises that the Tobacco Free World simply will not happen within a foreseeable future, a pragmatic harm reduction strategy needs to be developed. In such a strategy Swedish Snus by GothiaTek® can play an important and constructive role.

Swedish Match position paper on Swedish snus

Background
Swedish Match is a manufacturer of Swedish snus, a product category that substantially differs from many other smokeless tobacco products in the world.

The consumption of snus in Sweden has a very long tradition; it has been consumed for more than 200 years. Today over 20 % of adult males use snus and approx. 50 % of the consumers are ex-smokers. It can not seriously be disputed that the availability of snus and the consumer acceptance of snus as an alternative to cigarettes has substantially contributed to Swedish males having a record low smoking rate. Neither can its most favourable determined consequence be disputed, that Swedish males have a record low risk of dying from a tobacco related disease.

The Swedish example demonstrates the constructive role snus can play in a harm reduction strategy to cut down cigarette smoking by means of offering smokers a viable alternative to cigarettes.

Position on snus use
It is Swedish Match's belief that the adverse health effects of tobacco use, at least in the Western World, is primarily related to inhalation of tobacco smoke. We do not claim that the use of snus could not have any adverse health effects and we do recognize that the use of snus raises certain questions that need to be addressed, the youth issue being one, nicotine dependence being another. What we do claim, however, is that all scientific data clearly demonstrate that the health risks associated with the use of snus are significantly lower than those of cigarette smoking.

We believe that tobacco products, including snus, should only be available for adult consumers. We strongly enforce Under 18 No Tobacco Policy. We do not and will not target young people, directly or indirectly, in any marketing effort. The major target group for Swedish Match's snus products is adult cigarette smokers.

Position on regulation
Swedish Match is in favour of regulating tobacco products as long as regulation is fair, based on scientific evidence and proportional. The more severe health risks the more these products should be regulated. In Swedish Match's view the current EU regulation of oral tobacco is unfair and discriminatory, as it is not based on scientific evidence and is not proportional, allowing the most hazardous tobacco products to be sold and banning the less hazardous products.

We have for centuries worked in line with the precautionary principle. When scientists have identified undesired components in Swedish Match's products we have seen it as Swedish Match's responsibility to reduce or eliminate these components, if feasible. As part of a tobacco regulation we would welcome a list of maximum residue limits of undesired components and a list of permitted ingredients. In absence of legislative regulation we have created Swedish Match's own model (the GOTHIATEK®standard).

We believe the consumers must have the right to make informed choices; it is Swedish Match's firm position that relevant product information must be available to the public. In addition we want to state Swedish Match's support for marketing restriction and all other means where there are obvious risks that the public otherwise might be misled. Marketing regulation should be designed so that tobacco products are not easily accessible to minors.

Nicotine uptake from snus
Nicotine, which is present in concentrations of 0.5-1 % in Swedish snus, has well-documented pharmacological effects on the central nervous system. There is, however, no evidence of nicotine per se or any of its metabolites being carcinogenic (Adlkofer et al., 1995).
Both the dose and the uptake rate are of importance for understanding the biological effects of nicotine in humans. The amount of nicotine that is absorbed during snus use (nicotine dose) can be quantified by measuring the concentration of nicotine or its metabolites in different body fluids, i.e. blood, saliva and urine. The uptake rate can be estimated by monitoring the increase of the blood nicotine concentration over time. The nicotine uptake from Swedish snus has been described in five scientific publications of different objectives and design.

Important research results on Swedish snus:
• Less than half the amount of nicotine present in a pinch of snus is extracted during snus use.
• Only 10-20 % of the nicotine present in a pinch of snus is absorbed via the mucous membrane and reaches the systemic circulation. This means that only 1-2 mg of nicotine is absorbed into the blood from a one gram pinch containing ca 10 mg of nicotine.
• Nicotine is absorbed quite rapidly from Swedish snus but compared to cigarette smoking the uptake is slower.
• Studies on Swedish snus users have shown that the plasma steady-state levels of nicotine and its main metabolite, cotinine, are similar in Swedish snus users and cigarette smokers.
• Snus users and cigarette smokers, who have similar blood nicotine levels, have reported similar levels of subjective dependence on tobacco.
• The total nicotine uptake (dose) measured as the excretion of nicotine and its metabolites per 24 hours is similar in habitual snus users and cigarette smokers, i.e. 25 mg.
• In contrast to cigarette smokers, snus users do not compensate their nicotine uptake when switching to a low nicotine product. A decrease of the nicotine content of snus by 50 % results in a decrease of the nicotine uptake by about 50 %.

Effects on the oral mucosa
The use of Swedish snus and the occurrence of dental caries and periodontal disease and various non-carcinogenic oral conditions have been investigated in multiple studies. It is evident that Swedish snus possesses multiple physio-chemical properties such as pH, chemical composition, particle size and moisture content that can affect the oral mucosa and in certain cases cause snus lesions. Whether these lesions will result in cancer have attracted scientific attention for a long time.

Cancer
The use of snus was previously often associated with an increased risk of oral cancer. This position was based on results from epidemiologic studies dealing mainly with smokeless tobacco products from other part of the world than Sweden and on the fact that such products contain compounds that may cause cancer. Much discussed are the tobacco specific nitrosamines (TSNA), which can cause cancer in animals. Swedish snus contains TSNA, although in lower concentrations than in many other smokeless tobacco products. The incidence of oral cancer is relatively low in Sweden and the use of snus is a frequently occurring habit among men. Swedish scientists have therefore found it important to examine if there is an association between use of Swedish snus and cancer.

The scientific literature on the use of Swedish snus and its association with oral cancer comprises two recently published case-control studies. The association between snus use and oesophagus and gastric cancer has been examined in two case-control studies, and the mortality from cancer among snus users has been evaluated in a prospective cohort study.

Important research results on Swedish snus:
• Use of Swedish snus is not a risk factor for oral cancer.
• No association has been established between use of Swedish snus and neck and oesophagus cancer.
• There is no association between snus use and gastric cancer.
• The mortality from cancer is not increased among Swedish snus users.

Gastrointestinal diseases
Because saliva produced during the use of snus is often swallowed, it has been of importance to study the association between snus use and gastrointestinal diseases. The scientific literature comprises a descriptive study on the use of snus and general health, including heartburn and peptic ulcer, and a case-control study on the use of snus and risk of two different inflammatory gastrointestinal diseases, Crohn's disease and ulcerative colitis.

Important research results on Swedish snus:
• Use of Swedish snus does not increase the risk of peptic ulcer.
• Snus users have a significantly lower risk of heartburn than non-tobacco users.
• There is no increased risk of Crohn's disease or of ulcerative colitis for snus users, who have never smoked.

Cardiovascular disease
The relationship between the use of Swedish snus and cardiovascular disease has been examined in several studies. Due to the presence of nicotine, which is known to cause acute increases in heart rate and blood pressure, some scientists have assumed that the use of snus can affect the cardiovascular system.

The body of published literature examining the relationship between the use of Swedish snus and various measures of cardiovascular disease includes several descriptive studies, two case-control studies and a prospective cohort study. The outcomes studied include general health status, clinical risk factors for cardiovascular disease, development of atherosclerosis, elevated blood pressure, the risk of myocardial infarction and mortality from cardiovascular disease. The risk for type 2 diabetes has been examined in a population based study.

Important research results on Swedish snus:
• There exists a relationship between the use of snus and the acute effects on the cardiovascular system such as acute increase in blood pressure and heart rate.
• It remains unclear whether the use of snus is a risk factor for hypertension.
• There is no association between the use of snus and atherosclerosis or risk factors for atherosclerosis.
• There is no evidence of an increased risk of myocardial infarction in snus users.
• There are conflicting results whether the use of snus causes an increased mortality from cardiovascular disease.
• There may exist an association between high consumption of snus and the risk of type 2 diabetes.

References (The Swedish Experience)

1. Smoking and tobacco statistics 1970-1998. Statistical Report 1999-09-13, VECAHB Statistical Bureau, pp. 13, 66, 80.

2. www.tobaksfakta.org

3. Tobacco Statistics 1970-1998. Statistical Report 1999-09-13, VECAHB Statistical Bureau, pp. 61, 66, 75.

4. Ramström, L.M. Smokeless Tobacco: A Potential Gateway to Smoking. In: Durston, B., Jarnrozik, K. eds. Tobacco and Health 1990: The Global War. Proceedings of the 7th World Conference on Tobacco and Health, 1990. Perth: Health Department of Western Australia, 1991, 451-52.

5. Tobacco Statistics 1970-1999. Statistical Report 2000-09-18, VECAHB Statistical Bureau, p. 12.

6. Peto, R., Lopez, A.D., Boreham, J., Thun, M., Heath, C. Jr. Mortality from smoking in developed countries 1950-2000. Oxford University Press, 1994, p. A61.

7. Peto, R., Lopez, A.D., Boreham, J., Thun, M., Heath, C. Jr. Mortality from smoking in developed countries 1950-2000. Oxford University Press, 1994, pp. A60-61, A68-69.

8. Swedish Cancer Registry, 1998.

9. Lewin, F., Norell, S.E., Johansson, H., Gustavsson, P., Wennerberg, J., Björklund, A., Rutqvist, L.E. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck. Cancer, 82, 1367-75 (1998).

10. Schildt, E.-B., Eriksson, M., Hardell, L., Magnusson, A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int. J. Cancer, 77, 341-6 (1998).

11. Ye, W., Ekström, A.M., Hansson, L.-E., Bergström, R., Nyrén, O. Tobacco, alcohol and the risk of gastric cancer by sub-site and histologic type. Int. J. Cancer, 83, 223-9 (1999).

12. Lagergren, J., Bergström, R., Lindgren, A., Nyrén, O. The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardis. Int. J. Cancer, 85, 340-6 (2000). 13.

13. Bolinder, G., Alfredsson, L., Englund, A., de Faire, U. Smokeless tobacco and increased cardiovascular mortality among Swedish construction workers. Am. J. Public Health, 84, 399-404 (1994).

14. Huhtasaari, F., Lundberg, V., Eliasson, M., Janlert, U., Asplund, K. Smokeless tobacco as a possible risk factor for myocardial infarction: A population-based study in middle-aged men. J. Am. Coll. Cardiol., 34, 1784-90 (1999).

15. Eliasson, M., Lundblad, D., Hägg, E. Cardiovascular risk factors in young snuff-users and cigarette smokers. J. Int. Med., 230, 17-22 (1991).

16. Steen, T. Helserisikoen ved snusbruk. Tidskr. Nor. Laegeforen., 116, 625-7 (1996).

17. Ahlbom, A., Olsson, U.A., Pershagen, G. Hälsorisker med snus. SoS-rapport, 11, 28 (1997).